Fee Methodology – Healthcare Economist

Again in July, I offered an summary of the Enhancing Oncology Mannequin (EOM). In the present day I construct upon that put up focusing largely on CMS’s EOM’s Payment Methodology. I take advantage of a Q&A format as properly.

What’s the objective of EOM?

Based on CMS “EOM is a CMMI different cost mannequin designed to advance well being fairness, promote higher care coordination, enhance entry to care, scale back prices, and enhance outcomes for Medicare fee-for-service (FFS) beneficiaries with most cancers who obtain chemotherapy.”

Which most cancers sorts are eligible for EOM included?

There are seven most cancers sorts eligible for EOM: (i) breast, (ii) power leukemia, (iii) lung, (iv) lymphoma, (v) a number of myeloma, (vi) prostate most cancers, and (vii) small gut / colorectal most cancers.

Notice that low-risk breast most cancers (i.e., long-term oral endocrine chemotherapy) and low-intensity prostate most cancers (indicated by androgen deprivation and/or anti-androgen remedy with out chemotherapy) will not be included in EOM.

Does EOM solely contemplate chemotherapies?

No! Though all of the CMS language makes use of the time period “chemotherapy” often, EOM Initiating Therapies embrace not solely conventional chemotherapies (e.g., azacitidine, carboplatin, decitabine), however contains immuno-oncology therapies (e.g., nivolumab, pembrolizumab) and focused therapies (e.g., bevacizumab, osimertinib, sorafenib? A full checklist is on the market on the EOM web site here.

Cell and gene therapies–which CMS calls n Adoptive Cell Switch (ACT) remedy–are excluded from the EOM program. For example, CAR T-cell therapies are excluded from the EOM program.

How lengthy are EOM episodes?

6 months.

Episodes begin at a “set off occasion” which is the initiation of a Half B or Half D anti-cancer remedy. Beneficiaries who proceed to obtain chemotherapy after finishing a six month episode provoke a brand new episode. Notice, nevertheless, that “There isn’t any requirement {that a} chemotherapy-free interval exist earlier than the start of any episode.” The tackle the shortage of a ‘clear interval’ earlier than the set off occasion, CMS depends on threat adjustment.

How are episodes assigned to doctor observe teams?

That is based mostly on the oncology doctor group observe that both (i) offered the primary analysis and administration (E&M) service through the 6 month efficiency interval so long as they offered at the very least 25{a0a53df5b21b30f1dc707787012dfe5cf0092a60ed2df5b3ad9744fa4ff50b1c} of E&M providers within the episode, or (ii) the PGP with the plurality of E&M providers if the preliminary PGP didn’t attain the 25{a0a53df5b21b30f1dc707787012dfe5cf0092a60ed2df5b3ad9744fa4ff50b1c} threshold.

What kinds of funds can physicians group practices (PGPs) obtain?

Practices obtain the usual Medicare FFS billing. As well as, EOM has the choice to incorporate a Month-to-month Enhanced Oncology Providers (MEOS) cost, which may be considered a capitation cost. Base MEOS funds are $70 per thirty days however enhance to $100 per thirty days for dual-eligible beneficiaries. Primarily based on remedy value and high quality, PGPs have two-sided threat: high-quality/low value PGPs can earn a retrospective performance-based cost (PBP), however low-quality/high-cost PGPs can owe a retrospective performance-based recoupment (PBR).

PBP and PBRs rely upon the chance mannequin chosen. By default, EOM individuals and swimming pools are in RA1 except they request to be in RA2. The cost specs for RA1 and RA2 are beneath. RA1 requires PGPs to fulfill a bigger goal low cost (4{a0a53df5b21b30f1dc707787012dfe5cf0092a60ed2df5b3ad9744fa4ff50b1c}) however has a 2{a0a53df5b21b30f1dc707787012dfe5cf0092a60ed2df5b3ad9744fa4ff50b1c} most draw back threat; RA2 requires a smaller low cost (3{a0a53df5b21b30f1dc707787012dfe5cf0092a60ed2df5b3ad9744fa4ff50b1c}) however PGPs are accountable for extra optimistic and detrimental threat (most 6{a0a53df5b21b30f1dc707787012dfe5cf0092a60ed2df5b3ad9744fa4ff50b1c} draw back threat). By default, EOM individuals and swimming pools are in RA1 except they request to be in RA2.

What kind of expenditures are included in an episode?

All Medicare Half A and Half B FFS expenditures (funds) and sure Half D expenditures are counted as a part of the episode value. Particularly, EOM episodes solely embrace the Low-Revenue Value Sharing Subsidy (LICS) quantity and 80 {a0a53df5b21b30f1dc707787012dfe5cf0092a60ed2df5b3ad9744fa4ff50b1c} of the Gross Drug Value above the Catastrophic (GDCA) threshold. All different Half D expenditures will not be included in an EOM episode as a result of they’re paid on a capitated foundation by Half D plans.

How does EOM account for outlier episodes and variations in affected person traits?

To cut back the chance that a couple of very excessive or very low value episodes will result in a poor efficiency rating, CMS winsorizes episode expenditures on the fifth and ninety fifth percentiles.

Moreover, CMS threat adjusts episode prices based mostly on components akin to demographics (i.e., age, intercourse), revenue (i.e., twin eligibility, Half D LIS eligibility), comorbidities (autoimmune problems, COPD, dementia, endocrine problems, heard illness hematologic illness, hypertension), depend of different HCCs, receipt of particular providers (i.e., cancer-directed surgical procedures, bone marrow transplant, radiation), institutional standing, participation in a scientific trial, prior chemotherapy use, and episode size (e.g., if died or disenrolled)
weight problems. Danger adjustment relies 50{a0a53df5b21b30f1dc707787012dfe5cf0092a60ed2df5b3ad9744fa4ff50b1c} on nationwide cancer-specific value predictions and a mixture of regional and PGP particular value estimates with bigger PGPs having extra weight on their historic knowledge and smaller PGPs having extra weight on regional value predictions.

Extra particulars on how CMS calculates the goal quantities for EOM participant PGPs is beneath.

Does EOM account for tumor stage or tumor mutations?

Sure, however crudely. There’s a scientific adjuster if the affected person ever had metastatic illness (presently solely used for breast, lung and small gut/colorectal cancers), and a single biomarker is adjusted for (HER2+ sufferers with breast most cancers).

How does EOM cope with new therapies?

EOM may doubtlessly de-incentivize using clinically helpful however excessive value therapies. To not unduly disincentivize innovation, EOM features a new remedy adjustment the place oncology medicine are thought-about “new” for two years from FDA approval for that particular indication.

Does EOM account for high quality of care?

Considerably. EOM does this by way of Mixture High quality Rating (AQS). Briefly, PGPs are solely eligible to obtain bonuses in the event that they meet a minimal threshold on the AQS.

High quality of care contains sure actions (24/7 entry to care, affected person navigation, documented care plan, following scientific pointers, conducting health-related social wants screening, and use of licensed digital well being data expertise (CEHRT). The precise high quality measures are listed beneath based mostly on CMS’s Quality Strategy Webinar from August 25, 2022.

For extra particulars on EOM because it evolves, see the CMS’s EOM website.