Getting Real with the New Enhancing Oncology Model

Dawn Holcombe, MBA, FACMPE, ACHE
Editor-in-Chief
President, DGH Consulting, South Windsor, CT

We now know what will follow the Oncology Care Model (OCM). On June 27, 2022, the Centers for Medicare & Medicaid Services’ (CMS) Innovation Center announced the voluntary Enhancing Oncology Model (EOM). This new model will commence July 1, 2023, and continue for 5 years. Oncology practices across the country must now begin planning, analyzing, number crunching, and considering whether they want to, or can afford to, submit an application to participate in the EOM. Applications are due by September 30, 2022.

Early commentary on the announcement focused on the lower monthly per beneficiary payment set forth for participating practices (less than one-half of the monthly OCM payment) and the mandatory 2-sided risk model options for bonus payments. Now comes the hard work, which must be done individually by each practice. They will need to read the EOM Request for Applications (https://innovation.cms.gov/media/document/eom-rfa) in great detail, because the devil is indeed in the details, and then spend the rest of the summer performing deep analyses of past OCM and practice information to determine whether this new model will meet their needs or if it is something they will have to forego this time around.

In this article, I will discuss some highlights of the EOM that you may wish to consider. However, it is critical that you take the time to read the application details carefully to determine how they would apply to your particular practice.

Which Practices Will Qualify for the EOM?

The first hurdle that oncology practices must overcome, besides deciding whether they are interested in the program, is whether they even qualify. Participants must be a Physician Group Practice (PGP) as defined by CMS with at least 1 participating oncology physician who bills under the group tax identification number (TIN) and is on the PGP’s approved EOM practitioner list. Unlike the OCM program, there will be flexibility that allows physicians to also bill for a limited, minimal number of patients under the TIN of another entity. The term “limited” is yet to be defined but is intended to allow for cross-coverage of underserved rural areas and ease some of the challenges that were presented under the OCM requirements. If the providers of a given PGP bill a “high volume” of outpatient cancer-related professional services under the TIN of another entity, CMS will establish a mandatory pooling threshold, and require that both the PGP and the other entity enter a pooling arrangement in order to participate in the EOM. There are several identified accountable care organizations and other CMS payment models that may overlap with the EOM and affect an affiliated PGP’s ability to participate.

Limited and Reduced Beneficiary Pool

While the OCM applied to all Medicare beneficiaries attributed to a participating OCM practice, under the EOM, only 7 cancer types are being covered. These include breast cancer, chronic leukemia, small intestine/colorectal cancer, lung cancer, lymphoma, multiple myeloma, and prostate cancer. These types of cancer were chosen because CMS believes they occur in sufficient quantities to calculate episodic benchmarks at the individual cancer level, instead of the aggregated levels used for OCM calculations. CMS will also exclude low-risk breast cancer and low-intensity prostate cancer from the data. This is a major change and will require practices to review their previous OCM clinical and financial experience for just these 7 included cancers, as well as their current and projected cancer volumes and mix.

Additional Care Redesign Activities Beyond Those of the OCM

Practices implemented the OCM requirements in vastly different ways, leaving the door wide open (in the eyes of CMS) for considerable continued improvement. The 8 EOM participant redesign activities include 6 OCM requirements that have heightened expectations from the CMS regarding delivery. In addition, there are 2 new requirements that will be phased in, although practices will need to have a plan of action for them when submitting their application in September.

The original OCM requirements include the following (heightened EOM expectations are noted in parentheses):

  • Provide beneficiaries 24/7 access to a clinician who has real-time access to the medical records.
  • Provide patient navigation and significantly enhanced communication (minimum standards focus on coordination of timely appointments, maintaining communications even outside the office between visits, medical records in office at appointments, language interpreters/translators, linkages to numerous services and community resources, and access to clinical trials).
  • Document a 13-point care plan (and continually share the care plan with beneficiaries as part of ongoing shared decision-making at appointments).
  • Use data for continuous quality improvement (provide and request data from CMS, use CMS feedback to actively make changes in practice operations and patient interactions, moving toward tracked improvements in outcomes and patient feedback).
  • Treat only using nationally recognized clinical guidelines developed by clinicians with relevant disease expertise (now with an added health equity lens to deliver culturally competent care and show the plan for accomplishing that).
  • Use certified electronic health record technology.

The new EOM requirements (for which a plan needs to be articulated in the EOM application) include the following:

  • Identify EOM beneficiary health-related social needs (HRSN) using an HRSN screening tool, standardizing screening across all EOM participants, and focusing at a minimum on food insecurity, transportation, and housing. Other screenings could include social isolation, emotional distress, interpersonal safety, and financial toxicity.
  • Gradual implementation of electronic patient-reported outcomes (ePROs).

The challenge for aspiring EOM practices is that the legacy electronic health record platforms commonly used by practices do not encompass the advanced requirements for the 6 existing OCM components and are not well-equipped to support practices in the implementation and execution of the 2 new EOM requirements. Practices will need to seek new care partners before submitting their applications to achieve these requirements. One likely care partner, GoMo Health, shared how to achieve patient screening, tracking, navigation, and communication innovations in “Digital Therapeutics in the Oncology Outpatient Setting” in the March 2021 issue of Oncology Practice Management (www.oncpracticemanagement.com/issues/2021/march-2021-vol-11-no-3/2212-digital-therapeutics-in-the-oncology-outpatient-setting).

Focus on Health Equity

One important goal of the EOM program is to improve health equity and quality of care for all beneficiaries. Participants will be expected to recognize care equity differences in cancer prevention, screening, diagnosis, treatment, and health outcomes using sociodemographic factors such as race, ethnicity, socioeconomic status, and geography. Examples of disparity in cancer care include, but are not limited to, delays in initiation of chemotherapy, more advanced stage of diagnosis, underrepresentation in and limited access to clinical trials, decreased medication adherence, more frequent hospitalizations and intensive care unit admissions near the end of life, and lower enrollment in hospice. These will be new initiatives for many practices, requiring significant planning and new analytics, as well as complex population management approaches and care management strategies, adding hurdles to the consideration of whether to participate in the EOM.

The EOM program will promote health equity through the following:

  • Requiring practices to collect beneficiary-level sociodemographic data (eg, race, ethnicity, language preference, disability status, sexual orientation, gender identity) from beneficiaries willing to share this information and report the collected data to CMS.
  • Requiring practices to collect HRSN data (eg, food insecurity, housing instability, and transportation concerns) for use in patient care management, and potentially report this data to CMS later.
  • Requiring practices to execute patient navigation for services and resources outside the practice and develop relationships with community resources to bridge gaps in care and support.
  • Adding a payment methodology that responds to the greater resource needs of complex, underserved communities, adjusting payments and benchmarks for dual eligibility and low-income subsidy beneficiaries.
  • Emphasizing the requirement for 24/7 beneficiary access to a clinician with full medical records access and active shared decision-making using the 13-point care plan regularly with patients.
  • Requiring practices to develop and implement a health equity plan as part of their continuous quality improvement, using feedback and data from their own care delivery experience.
  • Requiring practices to review and improve their protocols to promote equity and remove barriers.

Payments Are Dropping, With More Intense Requirements and Analytics

The Monthly Enhanced Oncology Services (MEOS) payments in the EOM are less than one-half of those in the OCM ($70 vs $160 per beneficiary, respectively) and are not guaranteed as they were under the OCM. Practices may request up to 6 MEOS payments per 6-month episode but will only receive them if they are actively providing the required services of the EOM model. Practices may receive an additional $30 per beneficiary if they qualify as an underserved or dual-eligible beneficiary category. This will make the decision about whether to participate more challenging and will require deep data dives into past OCM beneficiary types to calculate the actual potential payments that may be anticipated. During the OCM program, these MEOS payments were what funded the additional practice transformation costs. With heightened requirements and analytics and a sharply reduced MEOS payment limited to beneficiaries with the 7 aforementioned cancers and no guarantee of payment if practices cannot prove their ongoing eligibility for the MEOS payment, the financials of the EOM program may become a limiting factor for participation.

Full Risk Models Are Another Hurdle

Practices will need to carefully run their projected numbers. Since every participating EOM practice will be required to enroll under 1 of 2 risk models, they will be required to return monies to CMS should they not hit their targets for any given 6-month episode over the 5-year program. The Request for Applications does attempt to clearly walk practices through the stop-gain and stop-loss provisions for the 2 risk models for an average $100,000 target. Most practices will have targets and expenditures in the range of multiple millions, so the impact will be of a significantly higher order of magnitude and will vary for each prospective EOM participant. Those who were in the OCM program have the benefit of knowing what targets and expenditures Medicare calculated for each 6-month episode of that program, but the EOM is for only 7 cancers, not the full patient mix of OCM.

Oncology practices cannot predict what CMS will calculate, so the decision to participate in the EOM will be based on very rough estimates. One prominent oncologist with several years of experience with CMS calculations and models has repeatedly noted that one bad 6-month episode under 2-sided risk could be a practice-ending event. Hopefully, the stop-loss provisions will mitigate that impact, and catastrophic insurance will help (if affordable insurance can be found).

What Can Practices Do?

Medicare has created an unavoidable tsunami for oncology practices. They are being swept rapidly down a path that is supposedly voluntary, but which will be very difficult to ignore. OCM practices found significant learning and value in the information, data, and feedback they received from CMS. The majority of these practices did not choose to enter the 2-sided risk models, but they will have no choice under the EOM. Most payers chose not to join the OCM model, but CMS is again touting that as a strong option for EOM. My guess is that many practices will feel they have no choice but to participate and will remain hopeful that they can take advantage of the EOM clause that allows them to terminate at will upon notifying CMS, which would hopefully reduce significant financial damage.

If practices do participate, this will be one more learning curve step along the path to a more complex practice management process that includes new patient engagement models outside of the office, more population management strategies, and better data analytics and financial management skills. They will receive a wealth of information from CMS for a large portion of their patients. Hopefully, EOM participants will not experience a practice-ending event in the process. It will be very interesting to see how many (if any) practices end up participating in the EOM, and which payers besides CMS will participate. Stay tuned for the next phase of this adventure.

Please feel free to reach out to me directly at This email address is being protected from spambots. You need JavaScript enabled to view it. if you have any questions or comments.

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