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EOM and QPP Participation Options: A Decision-Making Primer

In our prior blog post, we discussed some of important differences between OCM and EOM and the impact that these changes will have on practices that are considering participation in the new Centers for Medicare and Medicaid (CMS) value-based care model.  Given the major differences between the OCM and EOM, how do practices decide whether to submit their EOM application and whether they should ultimately participate? In this blog post, we aim to highlight three key strategic considerations that practices should weigh in these decisions.

1. Consider what is known and not known about each of these alternatives

It’s worth noting that, similar to OCM, CMS considers EOM to be an Alternative Payment Model (APM). Therefore, it’s important to understand how EOM fits within the broader context of the Medicare Quality Payment Program (QPP). Any clinician or oncology “physician group practice” (PGP) that treats patients covered by Medicare Part A and Medicare Part B (i.e. “traditional Medicare”, and not Medicare Advantage), must participate in Medicare’s QPP in some form. The five main forms in which oncology PGPs can participate in QPP include the following:

  • Full participation in the Merit-based Incentive Payment System (MIPS) through the Advancing Cancer Care (ACC) MIPS Value Pathway (ACC-MVP).
    • MVPs are basically a packaged subset of Quality Measures, Interoperability Requirements, Improvement Activities, and Cost Measures intended for a given specialty, currently proposed as optional for oncology PGPs that don’t participate in EOM.
  • Full participation in MIPS outside of the ACC-MVP
    • Same as option (2) above except practices can elect any of the eligible MIPS Quality Measures, Interoperability Requirements, Improvement Activities, and Cost Measures
  • MIPS-APM with reporting (i.e. hybrid option involving participation in both EOM and MIPS)
    • Oncology PGP participates fully in EOM and is subject to EOM episode pricing and performance-based payment/ performance-based recoupment requirements and earns additional incentives by reporting Advancing Care Initiatives and Interoperability requirements. The value of these incentives must be cost-neutral for the QPP as a whole and therefore are likely to represent roughly  0.1%-0.3% of a practice’s total traditional Medicare A/B revenue.
  • MIPS-APM without reporting (i.e. EOM participation only)
    • Same as option 4 except practice opts-out of all MIPS reporting and therefore is not eligible for any MIPS reporting incentives.
  • Advanced APM
    • Only applicable to the more advanced risk arrangement of EOM (RA-2).

At this point, there are three things that we know with utmost certainty about the future of Medicare’s QPP:

  1. Oncology PGPs that don’t participate in EOM will have to participate fully in MIPS under Medicare’s QPP.
  2. Several important parameters of QPP that can have significant implications for practices will surely change each year through CMS’s annual MIPS rule-making process for the Medicare Physician Fee Schedule.
  3. The MIPS program is currently slated to include downside risk in 2023, and CMS will continue to make downside risk a key component of the MIPS participation throughout future years of the program.

As an example of why this is important for oncology PGP’s to keep in mind, for the 2023 performance year practices are expected to have a maximum risk exposure in MIPS roughly equivalent to 6.9 percent of part A/B professional services payments.  However, for 2024 and beyond, CMS could increase the downside financial risk in MIPS, or change the weighting of the various MIPS scoring components so as to increase the impact of per-capita cost measures.  MIPS could also begin requiring much of the socio-demographic data collection, HRSN data collection, or ePRO data collection that will be included in OCM.

In short, it’s quite difficult to predict how MIPS requirements and oncology PGP’s financial risk associated with MIPS will evolve over time and the impact this will have on the financial risk and administrative burden that oncology PGP participants in MIPS will face in the future.

This why it’s important for practices to submit their non-binding EOM application so that they can preserve the option to further consider whether they would be more successful in EOM vs. MIPS based on additional details that we learn about each program. As this relates to EOM, it’s worth noting that oncology PGP-specific baseline claims data will be available to practices who submit their application.  At that point, OneOncology will support practices in making final determinations regarding pooling decisions, stop-loss insurance products, and provide claims-data analysis services to help practices further understand their financial risk in EOM.

2. Consider the value of access to data

EOM participation will likely yield the opportunity for participants to submit a Data Request Attestation form to CMS, and by doing so allow oncology PGPs to gain access to the most granular and robust claims data sets that have ever been provided to any oncology PGP in any value-based payment model including those of commercial or Medicare Advantage (MA) payers. Therefore, the claims data sets available to EOM participants will be more valuable for continuous performance improvement efforts than any opportunity that oncology practices will have with any payer.

Many participants in OCM, including practices that did not earn a performance-based payment, have publicly acknowledged that the claims data files available to OCM Participants was a major driver of continuous quality improvement (CQI) throughout OCM, and access to this data gave practices clear insights into how to succeed in two-sided risk payment models. The EOM RFI seems to indicate that CMS will likely afford practices access to data that is at least as useful for these purposes as was the case for OCM.

Therefore, practices should compare the access to claims data that would be available through EOM versus what they would expect to receive through the MIPS program, and the value that access to data will have for their practice.

By integrating data from EMR, pharmacy, billing data, and EOM, OneOncology practices can benefit from economies of scale that can have a multiplying effect on the available insights into quality and performance improvement.

3. Consider potential partnerships with commercial and MA payers

Engaging commercial and MA payers in payment arrangements that are similar to EOM could yield opportunities to scale the investments in Practice Redesign Activities that are required under EOM. Within a few years of the launch of OCM, several national private payers implemented value-based oncology payment models with some degree of similarity to OCM, and several national private payers have engaged OneOncology in designing the next generation of commercial payer APMs . For example, Cancer and Hematology Centers of Western Michigan (CHCWM) has for several years been engaged in an innovative value-based payment partnership with Priority Health, a Michigan-based non-profit health plan. Furthermore, OneOncology has worked with practices and payers to co-develop and implement value-based payment programs that improved upon many aspects of OCM, notably the Astera Cancer Care and Horizon Blue Cross Blue Shield episodes program and the Tennessee Oncology and Blue Cross Blue Shield of Tennessee Oncology Medical Home.

Leveraging Medicare payment model data and experience to design and implement partnerships with private payers serves as an important example of the economies of intelligence that participation in CMMI payment models like OCM and EOM can be applied more broadly across OneOncology partner practices.

In summary, oncology PGPs should consider the following key factors in submitting their EOM application and determining whether they should ultimately participate in EOM:

  1. Both EOM and MIPs will include downside risk. The increasing financial risk associated with MIPS will be informed throughout future Medicare Physician Fee Schedule rule-making.
  2. EOM will be a preferred option relative to MIPS with regard to access to robust claims data sets that can inform risk-mitigation opportunities throughout the program.
  3. EOM data will be more valuable in building practice capabilities to engage in value-based payment contracts with commercial and MA payers.
  4. EOM participation is non-binding for oncology PGPs who submit an application by the Sep. 30th deadline, which preserves a practice’s option to participate in the program starting July 1, 2023 and will allow practices to access baseline data sets that will better inform ways to mitigate future EOM-related financial risk.