The Centers for Medicare and Medicaid Services (CMS) announced on May 30th, 2024, that it will offer a second opportunity to apply to the Enhancing Oncology Model (EOM) in July 2024. CMS also announced important refinements to the model’s policies designed to incentivize more providers to participate.
EOM is a voluntary payment model intended to better support patients undergoing cancer treatment and reduce Medicare fee-for-service (FFS) spending.
It’s important to understand the potential benefits and financial implications of the model to determine whether participation would be beneficial for your organization and prepare for compliance and reporting requirements.
Payment Model Design
In this model, participating oncology practices assume the financial and quality performance responsibility for a six-month episode of care surrounding chemotherapy administration to Medicare patients with common cancer types.
The model will begin July 2025 and run for five years through June 2030.
EOM builds on the Oncology Care Model, which ran from July 2016 to June 2022.
Per the model’s Fact Sheet, EOM focuses on individuals receiving systemic cancer treatment for seven cancer types:
- Breast cancer
- Chronic leukemia
- Small intestine and colorectal cancer
- Lung cancer
- Lymphoma
- Multiple myeloma
- Prostate cancer
Participants in the model continue to receive FFS payments, and additionally receive the following two incentives designed to improve quality and reduce cost.
Monthly Enhanced Oncology Services (MEOS) Payment
EOM participants may bill MEOS for enhanced services provided to eligible EOM beneficiaries. This amount is in addition to FFS billing and is intended to cover the cost of care management and coordination.
Retrospective Performance-Based Payment (PBP) or Recoupment (PBR)
EOM participants can earn a retrospective payment based on the quality of care and savings. However, if the total cost of care exceeds the benchmark threshold for recoupment, then the participant will retroactively owe the difference.
Model Updates
There will be payment model design updates beginning in 2025 that benefit participants.
Increased Enhanced Payment Amount
For individuals who are not dually eligible for Medicare and Medicaid, CMS is increasing the base amount of the MEOS payment from $70 per individual per month to $110.
For individuals who are dually eligible, the total MEOS payment will increase from $100 per individual per month to $140.
Higher Threshold for Performance Based Recoupment
CMS will require participants to pay back costs that exceed the benchmark amount for episodes of care, as opposed to starting paybacks when costs exceed 98% of the benchmark. In other words, the current 2% discount on the benchmark will be eliminated.
Per the EOM Model FAQ, these updates will be applicable to participants in both cohorts. For Cohort 1, this will take place on all episodes initiating on or after January 1, 2025. For Cohort 2, this will take place for episodes on or after July 1, 2025.
Alignment with the First Cohort
The first EOM cohort began in July 2023 and will end in June 2030. This first cohort was originally intended to participate for five years but received a two-year extension.
Participants in both cohorts will end the program on the same date. There are no other differences between the cohorts, other than the duration of the performance period.
Eligibility
Both Physician Group Practices (PGP) and payers are eligible to apply to the EOM model. In addition to Medicare, there are three commercial payers currently participating in the model: BlueCross BlueShield (BCBS) of South Carolina, BCBS of Tennessee, and CVS Health/Aetna.
Physician Group Practices
Eligible PGPs participate at the tax identification number (TIN) level and must have at least one EOM practitioner and one oncology provider. An EOM practitioner is defined as a Medicare-enrolled physician or non-physician practitioner who furnishes evaluation and management services to beneficiaries receiving cancer treatments. An oncology provider is defined as a Medicare-enrolled physician with a specialty code of Hematology/Oncology or Medical Oncology.
PGPs are responsible for coordinating with the patient’s family and care team, and are incentivized to engage with their patients proactively, during and between appointments. To provide a seamless and coordinated care experience, PGPs are required to offer the following services:
- 24/7 access to a clinician with real-time access to the medical record
- Patient navigation
- Care planning
- Use of evidence-based clinical guidelines
- Collect electronic Patient Reported Outcomes (ePROs) data
- Screening for health-related social needs (HRSN)
- Use of data for continuous quality improvement
- Use of Certified Electronic Health Record Technology (CEHRT)
Other Payers
EOM Other Payers can include:
- Private payers
- Medicare Advantage plans
- State Medicaid agencies
- Medicaid managed care organizations.
They must execute a Memorandum of Understanding with CMS to participate in the model.
Next Steps and Timeline
The Request for Applications is now available and contains additional details for applicants. The application portal will open on July 1, 2024, and will receive submissions through September 16, 2024.
Tentatively, CMS has scheduled the following webinars leading up to the application deadline:
- Overview and Application Support, June 24, 2024
- Payment Methodology Updates, July 18, 2024
- EOM Second Application Period Office Hour, August 1, 2024
- Quality Health Equity, and Clinical Data Strategy, August 15, 2024
- EOM Second Application Period Office Hour, August 29, 2024
We’re Here to Help
For help understanding the impacts of the Enhancing Oncology Model, please contact your Moss Adams professional.