How Specialty Solutions Help Deliver on CMMI's New ‘Enhancing Oncology Model’
The CMS Innovation Center recently announced the July 2023 launch of the Enhancing Oncology Model (EOM), a value-based payment model for medical oncologists intended to lower the total cost of care for patients with cancer while improving the quality of the care received. This voluntary, 5-year program represents an evolution of the earlier Oncology Care Model, or OCM, which had 126 participating practices by the end, but which in the aggregate failed to save money for CMS and had minimal impact on selected quality measures.
Like the OCM, the EOM focuses on patients with cancer who are receiving active treatment with infusional or oral chemotherapy and determines the total cost of care for those patients over a 6-month “episode” from the time of treatment. Participating provider groups are held accountable for reducing that total cost of care while reaching benchmark performance targets in key quality measures. The EOM intentionally differs from the OCM in some important ways, drawing on lessons learned from the OCM and the Innovation Center’s renewed commitment to health equity.
As a value-based oncology care management company providing innovative solutions for patients, providers, and health plans, Thyme Care was founded to help bring about many of the same changes that the EOM is focused on. While imperfect in its approach, we are enthusiastic about several components of the EOM, as they perfectly align with our mission to radically improve the cancer journey across the care continuum. In particular, we’ve identified four key guiding principles in the EOM that we feel very much validate the work we already do at Thyme Care to enable affordable, high-quality cancer care for patients: 1) an emphasis on health equity 2) the continued importance of care navigation 3) investments in proactive symptom management through ePROs and 4) a focus on aligned incentives through value-based payment arrangements.
1. Promoting Equitable Health Care
The EOM design acknowledges that however important the individual patient-oncologist relationship may be, the cancer journey takes place in a complex and confusing system that is often not designed to meet the specific needs of patients, in particular their socio-demographic, economic, and health-literacy status.
One of the most prominent differences between the EOM and its predecessor, the OCM, has been its emphasis on supporting a data-driven approach to health disparities and health equity. In keeping with CMS’ new ACO Reach model, the EOM requires providers to collect socio-demographic and health-related social needs (HRSN) data not typically available to CMS. The socio-demographic data must be reported back to CMS to inform how the program (and the practice) is providing equitable care, and both types of data must be used by the practice to develop and submit a Health Equity Plan, detailing how they will use this data to develop strategies that address disparities in care delivery that might exist in their practice.
Our experience at Thyme Care has highlighted how much social factors play a role in influencing clinical outcomes, and we have designed our care management platform to capture these important characteristics of patients, using that data to inform our outreach. Through our engagement, we address the barriers to care that might result from a member’s specific circumstances, such as impediments to transportation, food, housing, and social and emotional support. As such, our analytic and patient-focused solutions fit squarely into the health equity requirements of the EOM.
2. Emphasis on Care Navigation
The EOM continues the requirement from OCM that practices provide navigation services to all patients that need them. CMS sees patient navigation as central to addressing gaps in care, improving outcomes, and lowering costs. In assessing the impact of the OCM, it is clear that the most successful practices invested in some level of care navigation to provide enhanced guidance and support to patients outside the clinic, which led to notable reductions in acute care visits and increased savings.
For many practices, however, providing this level of ongoing support in an effective and systematic way is operationally difficult and resource intensive, especially after the patient leaves the four walls of the practice. At Thyme Care, we’ve built a solution that leverages analytics and technology to deliver care navigation at scale. Enabled by a data-driven care management platform, our team of oncology nurses and resource specialists works directly with oncology practices to extend their reach, developing an in-depth understanding of the patient and their caregivers to help them navigate the cancer journey and facilitate their care, leading to a better experience for all. Thyme Care meets every patient where they are, providing education, guidance, and advocacy and linking them to their providers and to community resources, ultimately leading to improved outcomes and lower costs.
3. Proactive Symptom Management Through ePROs
The EOM will include an important patient-centered requirement that was not part of the OCM: assessing patient-reported outcomes data captured by an electronic means, or “electronic Patient Reported Outcomes” (ePROs). Collecting and systematically responding to ePROs has been shown to improve a variety of outcomes for patients with cancer, including overall satisfaction, reduced ED visits and hospitalizations, and even cancer survival. While not a requirement for practices until performance year 3 of the program, creating the technology, infrastructure, and processes to bring ePROs into day-to-day practice for provider groups that have not yet done so will likely be difficult.
Thyme Care is already bringing this solution to the patients we navigate. Using an evidence-based tool that proactively assesses symptoms common for those undergoing chemotherapy, Thyme Care is able to help patients manage their symptoms, and if needed, efficiently escalate concerns to their oncology provider so that the patient’s needs are quickly met. Thyme Care’s analytics utilize the ePRO data to refine risk algorithms used by our care team, in order to anticipate when a patient is likely in need of support.
4. Helping Through Aligned Financial Incentives
A core feature of the EOM is the financial model it uses to incentivize practices to make necessary investments in enhanced services, like the ones mentioned above. Here there are notable differences between the EOM and its predecessor. Unlike the OCM, the EOM requires practices to participate in a two-sided risk model. Practices can be paid a “performance-based payment” (PBP) if the total cost of care is below the target cost and quality targets are met but may have to pay a “performance-based recoupment” (PBR) payment back to CMS if the cost of care proves to be greater than the target. The EOM also provides a “monthly enhanced oncology service” (MEOS) payment to participating practices as up-front revenue to support them in providing the array of services required (this payment is less than what was provided during the OCM). In an effort to incent practices to care for patients with sociodemographic needs, an additional amount that is not counted in the total cost of care is paid to practices for those patients who are dually eligible for medicare and Medicaid.
Shifting to value-based care is impossible without the funding framework that makes it financially viable. The reductions in the MEOS payment from OCM to EOM, coupled with the year-long gap between the two programs, may bring about financial and operational challenges for practices looking to participate. However, despite its limitations, the financial framework that CMMI has created (first with OCM, and now with EOM) is laudable in its attempt to align the financial incentives of clinicians and payers. At Thyme Care, our deep relationships with providers and health plans, as well as our direct touch points with patients, put us in the unique position to facilitate value-based arrangements with payers beyond the EOM. We have built a model where health plans are willing to invest in navigation and an analytic platform that enables us to demonstrate a return on that investment. Our model supports risk-based arrangements, allowing us to drive value to our provider partners while helping them deliver higher-value care to their patients.
Ultimately, we at Thyme Care share in the goals outlined in the EOM to improve care coordination, quality, and outcomes for cancer patients. We applaud its emphasis on health equity, care navigation, and proactive symptom management as key components of its model, components that also closely align with the solutions we have built at Thyme Care. We look forward to helping our aligned oncology practices and others succeed in value-based agreements such as the EOM, furthering the mission of making high-quality, affordable cancer care accessible to all.