EOM Creates a Heavy Lift for Small Practices, Leading Oncologists Say

Leading oncologists said Monday that the proposed Enhancing Oncology Model (EOM), which would take effect next July, requires practices to take on more risk and data collection with less guaranteed revenue, making it too much to ask for many small practices—especially those without experience in value-base care.

Michael Diaz, MD, president and managing physician, Florida Cancer Specialists & Research Institute, moderated the panel, “Practice Perspectives on the EOM: Why or Why Not Participate?” featuring:

• Sibel Blau, MD, president and CEO for the Quality Cancer Care Alliance (QCCA), and medical director, Oncology Division, Northwest Medical Specialties, PLLC;
• Susan Escudier, MD, FACP, vice president, Value-Based Care & Quality Programs, Texas Oncology; and
• Barbara McAneny, MD, FASCO, MACP, CEO of New Mexico Cancer Center, Ltd and past president, American Medical Association.

The Center for Medicare and Medicaid Innovation (CMMI) unveiled the EOM in late June as the successor to the Oncology Car Model (OCM), which had drawn on the experience of McAneny’s COME HOME project in creating a model designed to improve outcomes and patient experience while reducing cancer care costs.

The EOM clearly draws on lessons from the OCM experience but with some key differences:

• All practices must take on risk right away, regardless of size or experience with value-based care.
• The EOM has 2 risk tiers: The lower-risk tier will not let a practice escape reporting under the Merit-based Incentive Payment System, or MIPS. Practices that followed the OCM did not have to report under MIPS.
• The EOM will impose additional data reporting requirements on social determinants of health (SDOH), while at the same time cutting monthly payments to deliver added services.
• The EOM will focus on 7 types of cancer, so fewer patients will be covered under the model—which means less revenue to run patient navigation and other services.

Blau said 11 of the 18 QCCA practices have applied for the EOM, and some elements show that CMMI listened to feedback from oncologists based on the OCM. Her initial reaction to the EOM was, “It’s good that it’s here,” but whether the numbers will work for the smallest practices is an open question.

With the OCM, she said, practices had time to learn the model before taking on risk. “I can’t imagine a non-OCM practice taking on this with no history and experience,” Blau said, especially with EOM changes that restrict the number of covered patients to 7 disease types. The smaller number of patients will make it very difficult to earn a pay-for-performance bonus, and the additional requirements for inclusion of electronic patient reported outcomes (ePROs) will be challenging for some.

“Our practice was pretty successful with the OCM,” Escudier said. “I think it instituted some favorable changes in practice in terms of some of the patient-centric features; the care plans, I liked a lot.”

As for the EOM, her first reaction was, “Gosh, they're asking us to do more for less.”

Escudier noted, as others have, that with the EOM covering only a portion of the Medicare population, practices will face a choice of what to do about offering added services, such as navigation or 24/7 access to medical records to all patients. The consensus is that practices will treat all patients the same way.

She also questioned whether oncology practices had the capacity to solve problems of poverty, transportation, and other social conditions alongside treating patients’ cancer.

Diaz and McAneny said they have observed many of the same issues. “In the EOM, the chance of rewards are not that big, but the chances of loss are big,” McAneny said, and this could crush smaller practices that have large numbers of patients in rural areas. The risk scenarios presented in the EOM could put some small practices out of business, she said, and what happens to the patients? If the doctors are absorbed by a hospital system, costs for Medicare will increase.

“We don't mind being held accountable,” Diaz said. “But we aren't necessarily graced with having these large potential positive upsides…. Because when we're talking about risk, it's not just for the cost of their cancer care.”

McAneny also took issue with the SDOH data collection, which she said would create cultural issues with the Native American populations she serves. About 48% of McAneny’s patients are Medicaid eligible and 12% receive coverage from the Indian Health Service.

“First, it’s very important in terms of looking at this from the viewpoint of the people we're trying to impact,” she said. Data collection “is a very dominant culture” to a group that doesn’t see this as a way to solve problems. “So, we’re starting with that bias.

“Secondly, when you collect data, you are implying to people that you're actually going to do something better. And, as [Escudier] just said, oncology practices are not going to fix poverty, or racism, which are the key issues of the social determinants of health. We don't have the bandwidth to do that.

“Third, I really have some concerns about collecting these data and sending it to the federal government.” The Navajo Nation population she has served for 15 years has deep mistrust of the federal government. Over a 400-year period, McAneny said, every time the government collects data, “they get moved to less desirable territories, the benefits get taken away, and treaties get broken.

“It's not easy for somebody who looks like me to establish some street cred with people who live in that population…Am I willing to put that acceptance that is hard fought on the line to collect data to give to the federal government, when nothing is going to come back to that population that will be of value to them? That is really something that I'm struggling with.”

Blau offered some warnings for ePROs, which she said can be important for managing symptoms but have to be deployed with extreme care. “If a practice is not savvy, patients will be complaining about everything,” and this could overwhelm a small practice.

Escudier said her practice had a developed a system for managing patient symptoms and needed to maintain control over it. McAneny agreed, saying giving patients unrestricted ability to call in symptoms could have unintended consequences. “Patient satisfaction can drop from this instead of increase,” which in turn could drive more clinicians out of practice.

“It’s not ideal to have a one-size-fits-all solution,” Diaz said.