One of the pathways created, Alternative Payment Models (APMs) was crafted with the goal of comprehensive, high quality care with lower costs. One type of APM is a bundled payment program. The CMS Innovation Center (CMMI) launched a bundled payments for care improvement initiative that has linked payments for multiple services that patients have received during a single episode of care. However, the implementation of bundled payment programs into high cost, complex disease states, such as cancer, has been a challenge.
Prior Attempts at Value in Cancer
The initial model, the Oncology Care Model (OCM) was a six-year program that concentrated on Medicare fee-for-service beneficiaries who were undergoing chemotherapy for cancer. The aims of the program were to improve quality, lower Medicare payments, thus resulting in less taxpayer money spending for these patients. Over 4,500 oncologists across 200 practices, spanning 33 states participated in OCM. Further, 1 in 4 patients enrolled in traditional Medicare who received chemotherapy were provided care through the model. However, payments actually increased by over 20%, mostly driven by rising drug related payments. OCM improved practice-reported quality measures and led to reduced payments for high-risk cancers, but due to the volume performance-based payments given, the model resulted in net losses for Medicare. There have also been concerns regarding the lack of a health equity focus that actually widened pre-existing disparities in minority populations of patients with cancer.A Renewed Focus in Cancer Bundles: the Enhancing Oncology Model
Launching in July 2023, the Enhancing Oncology Model (EOM) is CMMI’s new program for bundled payments in cancer care. The program is a voluntary, five-year model that builds upon lessons learned from OCM, with a specific focus on equity, quality, and evidence-based care. EOM participants include from payers and physician group practices, that will be paid fee-for-service with two additional financial incentives. The first payment, “Monthly Enhancement Oncology Services” or MEOS, will be a $70 per-beneficiary-per-month payment, and the second is a potential “Performance-Based Payment” that will be based upon the total cost of care and quality measures assessed over 6-month periods. It is important to remember that performance based payments actually led to the financial failure of OCM.Participants will be required to participate in certain redesign activities that are the foundation of this model. These include the following: 24/7 patient access to an appropriate clinician, patient navigation services, a care plan, guideline-based treatment algorithms, assessments of health-related social needs using a screening tool, implementation of electronic patient reported outcomes, continuous data-driven quality improvement, and utilization of electronic health record technology. Data reporting will allow for measurement of quality in the domains of patient experience, avoidance of acute care utilization, management of symptom toxicity, management of psychosocial health, and management of end-of-life care.
Beneficiaries who are undergoing chemotherapy for breast cancer, chronic leukemia, small or large intestinal cancers, lung cancer, lymphoma, multiple myeloma, and prostate cancer are eligible for EOM participation.
How Does This Affect Urology?
Given that prostate cancer patients are eligible beneficiaries under the EOM, and in many settings, urologists are administrating systemic chemotherapy such as docetaxel for advanced prostate cancer, there will be potential lessons for urology practices based on the potential success of this new model. If successful, this model can serve as the basis of payment reform in prostate cancer, as well as systemic therapy that is being increasingly utilized across other urologic malignancies. Further, there has also been interest in bundling care of localized prostate cancer, such as patients who are on active surveillance for low-risk disease, to incentivize high value, high-quality, low-cost care.Written by: Ruchika Talwar, MD, Urologic Oncology Fellow, Department of Urology, Vanderbilt University Medical Center, Nashville, TN