Quality Measures for Medicare’s Enhancing Oncology Model (EOM): New and Improved or More of the Same?

In July 2023, the Center for Medicare & Medicaid Innovation (CMMI) will be initiating the Medicare Enhancing Oncology Model (EOM). The EOM is intended to build on the Medicare Oncology Care Model (OCM) demonstration project that ran from July 2016 through June 2022.

EOM is cast from the same mold as OCM. Both models assess oncology practices’ ability to lower costs for six-month drug prescribing initiated episodes while maintaining or improving quality of resource utilization, patient experience, and clinical processes of care. Under EOM, the Monthly Enhanced Oncology Services (MEOS) payment amounts will be smaller compared to OCM, but EOM focuses episodes specifically on seven high-burden types of cancer and includes funding for treatment of patients dually eligible for Medicare and Medicaid. EOM participating practices will also continue to report on a set of quality measures and either be eligible for performance-based payments resulting from cost containment or be required to repay losses. However, unlike OCM, EOM emphasizes collection of patient-reported outcome data and requires practices to establish a health equity plan for vulnerable patients. CMS has higher expectations for EOM, anticipating that EOM will succeed in cutting Medicare spending and maintaining or improving quality for patients.

Oncologists who do not participate in EOM, which qualifies as an Advanced Alternative Payment Model for the Medicare Quality Payment Program, may still be subject to the Merit-based Incentive Payment System (MIPS), which adjusts clinician Medicare Part B payments for performance on quality, cost, Improvement Activities, and use of certified EHR technology for interoperability. For oncologist participation in MIPS, CMS has finalized an “Advancing Cancer Care” MIPS Value Pathway (MVP), a discrete set of measures and activities that are aligned with the care cancer providers deliver, which will be voluntary to report in 2023.

Ideally, Medicare’s quality measurement strategies for MIPS and EOM should be meaningful to clinicians and patients and aligned to amplify the quality signal. So, how do these new approaches stack up when it comes to truly understanding the quality of cancer care for Medicare beneficiaries?

CMS’ Efforts to Advance Cancer Quality Measurement

As CMS seeks to better incentivize quality and cost management through cancer value-based care, the agency is adding practice redesign activities and measures to EOM that were not included in OCM and adding quality and cost measures to MIPS.

For the EOM, CMMI is adding two new required enhanced practice redesign activities:

• Identify beneficiary social needs using a health-related social needs screening tool to target issues that can exacerbate health disparities if they are not addressed. As part of the model’s requirement to use data for clinical quality improvement, participants are also required to develop a health equity plan that “identifies where health disparities may currently exist in their care or patient population and describes strategies they will explore to address these disparities.”

• Gradual implementation of electronic patient-reported outcomes (ePROs) that help identify and address patient needs. Oncology practices participating in EOM will need to integrate ePROs in their electronic health records. The survey tools to collect the ePROs must focus on symptoms and/or toxicity, functioning, behavioral health, or health-related social needs.

To further alignment among Medicare quality measurement programs, EOM also includes measures that were not included in OCM but that are represented in other oncology quality reporting programs. For example, EOM-1 “Admissions and Emergency Department Visits for Patients Receiving Outpatient Chemotherapy” is also part of the Prospective Payment System – Exempt Cancer Hospital Quality Reporting Program.

CMS’ proposed Advancing Cancer Care MVP for MIPS relies on many measures that have been available for oncologists to select from since the beginning of the MIPS program. However, the proposed MVP includes a new focus on precision medicine by including several measures of appropriate biomarker testing. CMS is also exploring development of a cost measure focused on prostate cancer treatment episodes for inclusion in the MIPS program.

But What’s Still Missing?

Despite some effort to enhance Medicare oncology measure sets and alignment among the sets, CMS is essentially treading water when it comes to advancing quality measurement for cancer care. Innovation in treatment has rapidly outpaced innovation in measurement. Below, we discuss specific gaps in the design of the EOM measure set, and Medicare’s approach to cancer quality measurement more broadly.

Misalignment of Measure Sets

While measure sets among Medicare quality programs need not be identical, they should be aligned, particularly when there is overlap in the types of patients and providers. Oncologists who opt not to participate in the EOM will be subject to MIPS and may report through the Advancing Cancer Care MVP, which varies considerably from the EOM quality measure set. Both sets include measures assessing pain management, depression screening, and end-of-life care for hospice referrals and use of chemotherapy in the last 14 days of life. However, they differ in their use of tumor-specific measures. The MVP set includes measures for breast, colorectal, and prostate cancers—all of which will be represented in EOM episodes but not EOM measures. In addition, the MVP addresses appropriate biomarker testing and prescribing, an important quality concern that will not be assessed under the EOM. Further, while the EOM assess cancer care concerns through a model-specific patient experience survey, the MVP includes only the CAHPS for MIPS survey measure, which is for the general Medicare population.  

Patient-Centered Outcomes

In its Quality Measure Development Plan, CMS identified Person and caregiver-centered experience and outcomes as a high-priority domain for future measure development. Through the Medicare Access and CHIP Reauthorization Act (MACRA), CMS has grant funded the development of new cancer patient-reported outcome performance measures (PRO-PMs) that measure improvement in pain and quality of life. While these measures have been funded, it is unclear whether they will eventually be included in the EOM or the Advancing Cancer Care MVP, which does not currently include any incentives to collect or report oncology-related PROs.

EOM’s emphasis on implementation of ePROs is a step forward, but CMS will eventually need to specify which ePRO surveys participants will need to report to achieve standardization and comparability of data among practices. In the EOM, reporting ePROs is mandatory, but there is no specific survey tool that practices are required to use.  In the future, CMS may wish to tie ePRO collection to performance measures (PRO-PMs) to assess whether care delivery is leading to improved symptom management and quality of life. To accomplish this, CMS will ultimately need to standardize the collection tools.

Health Equity

EOM includes submission of a health equity plan, but the model does not include any measures that evaluate social risk screening or management, though such measures have recently been finalized or are under consideration for inclusion in hospital quality reporting programs (“Screening for Social Drivers of Health,” “Screen Positive Rates for Social Drivers of Health,” “Resolution of At Least 1 Health-Related Social Need”). And despite proposals to add the “Screening for Social Drivers of Health” measure to MIPS, it was not proposed for the Advancing Cancer Care MVP. This disconnect is particularly notable given its apparent misalignment with CMS’ Framework for Health Equity priorities, which includes expanding collection and reporting of data and assessing causes of disparities within CMS programs, both of which will be difficult to evaluate without including health equity quality measures in program sets.

Cost of Care and Utilization

Despite cancer costs being a central concern of Medicare (and a concern which the OCM did not significantly impact), cost incentives are misaligned because Medicare’s strategy for measuring value between programs remains inconsistent. While the EOM includes certain Part D costs, cost measures under the “Total Per Capita Cost” measure included in the MVP notably exclude Part D drug costs. The proportion of Part D drug spending on oncology drugs increased to 13.2% in 2020, demonstrating a need for inclusion of Part D costs in measures across Medicare models. These inconsistencies may lead to different prescribing trends between oncologists participating in EOM compared to oncologists participating in MIPS.

EOM focuses on episodes for seven cancer types: breast, chronic leukemia, small intestine/colorectal, lung, lymphoma, multiple myeloma, and prostate cancers. In 2022, the top 15 most frequently sold oral therapies for cancer treatment include indications across each of these diagnoses. Despite the potential for adverse events arising from oral therapy, the EOM only assesses rates of admissions and emergency department visits following infused treatment. Furthermore, for oral therapies, critical gaps remain in measures evaluating persistence or adherence to treatment.

What does EOM mean for cancer care quality?

Given the rapid pace of innovation, rising costs of treatment, and unique needs of patients with cancer, CMS’ cancer quality strategy is more important than ever. Alignment of measure sets and cost incentives across programs is essential to promote consistent care improvement for Medicare beneficiaries regardless of which value-based program their oncologist participates in. EOM’s steps toward patient-reported outcomes and health equity are movement in the right direction, but CMS’ overarching measurement strategy must follow suit to align incentives for quality improvement across Medicare oncology quality programs.

About the Quality Outlook Commentary Series

Breakthrough treatments in cancer care, including precision therapies tailored to specific patient factors, are driving rapid changes in the definitions of oncology quality and value. Efforts to implement value-based care models in oncology must meet the demands of evolving science, new best care practices, and shifting patient priorities. Quality measures must be up-to-date and relevant. Payment models must recognize the challenges and costs of managing complex patient populations with diverse needs. In this JCP blog series, Quality Outlook, Discern Health will explore key issues in oncology quality and value through posts focused on measurement, value-based payment, and quality improvement.

About Sarena Ho
Sarena Ho,  is a Project Analyst at Discern Health, part of Real Chemistry. With a background in public health and health policy, she brings strong research and policy analysis skills to the Discern team. Prior to joining Discern, Sarena worked on issues related to violence prevention and rehabilitation at Johns Hopkins School of Public Health as well as global health and immunizations at CDC. At Discern, Sarena supports efficient completion of client projects related to oncology, immunizations, behavioral health, and quality improvement. 

About David Blaisdell

David Blaisdell, a Director at Discern Health, part of Real Chemistry, leads and manages client projects, providing insight and subject matter expertise, particularly on quality landscape analyses and measure gap identification. David has led and contributed to projects focused on oncology quality measurement to identify key gaps in measures used in accountability programs and opportunities for measure development. Through this experience, David helps clients navigate measurement and value-based payments and define strategies for success.

About Tom Valuck, MD, JD
Tom Valuck is a Partner at Discern Health, part of Real Chemistry. He is a thought leader on health care system transformation and helps lead the firm’s focus on achieving better health and health care outcomes at a lower cost. Tom’s work at Discern includes facilitating the exploration of next-generation measurement and accountability models for health care delivery systems. He also helps clients develop strategies to achieve success within the value-based marketplace. 

About Discern Health
Discern Health, part of Real Chemistry, uses research and strategic advisory services to help our clients improve health and health care through value-based payment and delivery models. These models align performance with incentives by rewarding doctors, hospitals, suppliers, and patients for working together to improve quality while lowering total costs. Real Chemistry is an independent provider of analytics-driven, digital-first research, marketing services, and communications to the healthcare sector.