Surprised by EOM Results, Veterans in Value-Based Care Ponder Next Strategic Moves

July 26, 2024

Oncology Value-Based Care Model Faces Scrutiny Amidst Shifting Results

Washington State – A growing wave of concern is sweeping through community oncology practices as initial performance results from the Enhancing Oncology Model (EOM) indicate a potential setback for value-based care. For years, leaders like Sibel Blau, MD, president and executive chair of Northwest Medical Specialties, have championed these models, but recent outcomes are prompting a reevaluation of their effectiveness.

The Shift from OCM to EOM: A More Challenging Landscape

The oncology Care Model (OCM), which ran from 2016 to 2022, aimed to improve cancer care quality and reduce costs. Its successor, the EOM, introduced stricter parameters and immediate financial risk for participating practices. While the OCM saw a reported $315 million investment from Medicare – according to a study published in JAMA Oncology – the EOM was designed as a more cost-conscious initiative.

Early performance period 1 (PP1) results (July 1, 2023 – December 31, 2023) showed promise for many practices, with some receiving performance-based bonuses. However, the recent release of performance period 2 (PP2) results (January 1, 2024 – June 30, 2024) revealed a stark contrast. Many of the same practices that received bonuses in PP1 found themselves without funding, or with considerably reduced payments. This unexpected shift has ignited frustration among practice leaders, with many struggling to understand the discrepancy.

“It’s a big change,” stated Dr. Blau during a panel discussion at the Community Oncology Alliance (COA) Payer Exchange Summit.”This is the first time in the entire history that we’ve been doing this…and now, where does it put me? I want to do this, I want to learn, I want to adapt, but we’ve already done other great things, and I’m doubting this whole decision.”

Factors Contributing to the Shift

Several factors are being investigated as potential contributors to the evolving outcomes. Kate Baker, MD, MMHC, medical director of Value-Based Care at Tennessee Oncology, highlighted the difficulty in pinpointing a clear cause.”We’re really just trying to dig into our data now and see if we can see big differences,” she said.

Experts suggest potential influences include:

• Drug Pricing Fluctuations: Changes in the cost and availability of cancer treatments can significantly impact performance metrics.
• Treatment Protocol Updates: The adoption of new treatment regimens, such as 4-drug combinations for multiple myeloma following the PERSEUS trial results presented at the American Society of Hematology in December 2023, can affect cost calculations. The FDA approved the regimen in July 2024.
• Biosimilar Market Dynamics: While biosimilars initially offered cost savings, the market is now experiencing increased competition from more expensive biosimilars and 505(b)(2) drugs.
• Evaluation Methodology: The EOM evaluates practices based on performance relative to peers treating the same cancer type, rather than across all cancers. This can disproportionately affect smaller practices with unique or complex cases.

The challenge is further compounded by a important data lag, delaying feedback for practices and hindering their ability to make timely adjustments.

metric	OCM	EOM
Financial Risk	Delayed	immediate
Cancer Types Covered	Most	7 common Types
Performance Evaluation	Broader Scope	Cancer-Type Specific
Data Feedback	significant Lag	Significant Lag

Industry Response and Future Outlook

Panelists at the COA Summit, including Puneeth Indurial, MD, MS, from the American Oncology Network, and Richard Ingram, MD, of Shenandoah Oncology, expressed concerns about the sustainability of the EOM. Many practices invested heavily in value-based care infrastructure,anticipating a long-term shift in Medicare reimbursement.

“We’ll definitely undertake a deeper look at whether participation makes sense on an ongoing basis,” said Indurial. “Because at the end of the day, we have to keep the doors open. Or else,patients don’t get care.”

the EOM currently includes 38 practices,down from 44 at its launch and the 122 that participated in the OCM. practices must decide by November 30 whether to continue participation. The uncertainty surrounding the EOM’s viability raises questions about the future of value-based care in oncology.

Understanding Value-Based Care in Oncology

Value-based care focuses on delivering high-quality care while reducing costs. In oncology, this involves measuring outcomes, coordinating care, and addressing social determinants of health.It’s a movement driven by the need for a more enduring and patient-centered healthcare system. While models like the EOM have faced challenges, the underlying principles of value-based care remain crucial for improving cancer care delivery.

Pro Tip: Staying informed about changes in CMS policies and industry best practices is essential for navigating the evolving landscape of value-based care.

Frequently Asked questions

What is value-based care in oncology?

Value-based care in oncology focuses on improving patient outcomes while lowering costs through coordinated and high-quality care.

What was the Oncology Care Model (OCM)?

The OCM was a Medicare initiative designed to test a value-based payment model for oncology practices, running from 2016 to 2022.

What is the Enhancing Oncology Model (EOM)?

The EOM is the successor to the OCM, aiming for a more cost-conscious approach to value-based care in oncology.

Why are practices re-evaluating participation in the EOM?

recent performance results have been unfavorable for many practices, raising concerns about the model’s financial viability and administrative burden.

What factors are impacting EOM performance?

Factors include drug pricing changes,updates to treatment protocols,biosimilar market dynamics,and the evaluation methodology.

What are your thoughts on the future of value-based care in oncology? Do you believe the EOM can be salvaged, or will a new approach be necessary?

Share your insights and join the conversation below!

How can organizations improve risk adjustment strategies to more accurately reflect patient complexity and maximize reimbursement in value-based care arrangements?

Decoding the Disconnect: Why EOM Results Are Falling Short

Many organizations deeply entrenched in value-based care (VBC) are reporting unexpected results at the end of month (EOM) reporting. Despite years of investment in infrastructure, data analytics, and care model redesign, achieving projected savings and quality improvements is proving more challenging than anticipated. This isn’t a failure of the VBC concept itself, but a signal that current strategies require recalibration.The core issue often lies in accurately translating contractual agreements into operational realities.

Several factors contribute to this disconnect. Thes include:

* Risk Adjustment Complexity: Accurate risk adjustment is paramount. Underestimating patient complexity leads to insufficient reimbursement and unrealized savings. The shift towards more sophisticated risk scoring methodologies (like HCC) demands continuous refinement of coding practices and data capture.

* Data Integrity Challenges: “Garbage in,garbage out” remains a critical concern. Incomplete or inaccurate data feeds into population health management tools, skewing risk stratification and hindering effective intervention. The VALUE function in tools like Excel (used for data validation – see resources like https://jingyan.baidu.com/article/f0e83a2582f9ca22e5910129.html for understanding data type conversion) can be a starting point, but robust data governance is essential.

* Attribution Issues: Correctly attributing patients to the right care teams and accurately tracking their care journey across different settings is surprisingly difficult. Fragmentation of care and lack of interoperability between electronic health records (ehrs) exacerbate this problem.

* Behavioral Change resistance: Implementing VBC requires meaningful behavioral changes from both providers and patients. Overcoming resistance to new workflows, shared decision-making, and proactive engagement is a continuous process.

Strategic Adjustments: A Roadmap for Course Correction

Veterans in VBC are now focusing on these key strategic adjustments:

1. Enhanced data Analytics & Predictive Modeling

Moving beyond descriptive analytics to predictive modeling is crucial. This involves leveraging machine learning to identify patients at high risk of adverse events, predict future healthcare costs, and personalize care plans.

* Invest in advanced analytics platforms: These platforms should integrate data from multiple sources (EHRs,claims data,social determinants of health) and provide actionable insights.

* Focus on real-time data: Shifting from retrospective reporting to real-time data monitoring allows for timely interventions and prevents costly complications.

* Develop robust dashboards: Visualizing key performance indicators (KPIs) related to cost, quality, and utilization helps stakeholders track progress and identify areas for improvement.

2. Strengthening Care Coordination & Integration

Fragmented care is a major driver of needless costs and poor outcomes. Improving care coordination requires:

* Expanding care teams: Incorporating care coordinators, social workers, and pharmacists into primary care teams can address patients’ holistic needs.

* Implementing care pathways: Standardized care pathways for chronic conditions ensure consistent, evidence-based care.

* Leveraging telehealth: Telehealth expands access to care, improves patient engagement, and reduces the need for expensive emergency room visits.

3. Refining Risk Adjustment Strategies

Optimizing risk adjustment is an ongoing process.

* Invest in coding education: Ensure coding staff are proficient in accurately capturing patient diagnoses and comorbidities.

* Implement prospective risk adjustment: Identify high-risk patients at the beginning of the year and proactively manage their care.

* Regularly audit coding practices: Identify and correct coding errors to maximize reimbursement.

4. Prioritizing Patient Engagement

Engaged patients are more likely to adhere to treatment plans, participate in preventive care, and manage their chronic conditions effectively.

* Shared Decision-Making: Empower patients to actively participate in their care decisions.

* Personalized Interaction: Tailor communication to patients’ individual needs and preferences.

* Digital Health Tools: Utilize patient portals, mobile apps, and remote monitoring devices to enhance engagement.

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