The Enhancing Oncology Model Promotes Novel Therapies, May Reduce Cost of Care

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Expert provides numerous resources to learn more about the Centers for Medicare & Medicaid Services Enhancing Oncology Model.

Erica Feinberg, PharmD, BCPS, senior clinical data analyst, The US Oncology Network, Nashville, Tennessee, joined Pharmacy Times at the 2023 ASCO Annual Meeting to discuss the Centers for Medicare & Medicaid Innovation (CMMI’s) update of the Oncology Care Model (OCM), titled the Enhancing Oncology Model (EOM). Feinberg illustrates an array of examples about the model in context, the value of the EOM on affordable access to novel oncology therapies, and adjustments for risk and novel therapy use.

PT Staff: What are the fundamental differences (updates) between OCM and EOM?

Erica Feinberg, PharmD BCPS: So the key differences are there's a great decrease [that is narrowed] from all the cancer types to just 7 key type cancer types. There's a change in the risk requirement; now there's a downside risk required. There's also a change in how they calculate the adjustments, which is what my study is on (novel therapy adjustments), and there's changes in social need tools, including health related social needs screening changes.

PT Staff: What is the novel therapy adjustment (NTA)?

Erica Feinberg, PharmD BCPS: So the NTA is a way to make sure that new novel therapies are being used within the EOM model to get the patients the best care, but [it does] not affect practices that use more novel therapies above baseline so that the EOM doesn't inhibit the use of novel therapies— that’s an adjustment made.

PT Staff: How does novel therapy adjustment work in the EOM setting? Can you provide an example?

Erica Feinberg, PharmD BCPS: So one of the changes from OCM to EOM was that it's now calculated at the cancer type level to the population level. So for example, we'll take lutetium-177 (Pluvicto; Novartis) for prostate cancer. So how it works is an EOM participant’s actual expenditures for prostate cancer episodes is calculated, so they get that amount.

So let's say it's $2,000,300. They take the participants expenditures from novel therapy attributed to prostate cancer for the episode. So let's say they spent $149,500 on the lutetium 177. So they take the person's proportion of the expenditures on the novel therapy—they take that amount spent— divided by the amount of all the expenditures [which] gives them a percentage. In this case would be 6.5%. And then they take the non-EOM oncology practice groups and look at their proportion of actual episode expenditures in novel therapy—so then they find the difference. As long as you have a difference in the amount of the novel therapies you're using, you'll get an adjustment (there's no negative effect). So if you don't use more, you will not have a negative adjustment at all. It's just positive if you are using more.

So they take the differences between what the non-EOM practices and EOM practices are and they get a percentage out of that. In this case, if they said it was 4% from the non-EOM, now we have 2.5% (EOM value [6.5%]-non-EOM value [4%] = 2.5%). And so they take that 2.5%-- the proportion of the participants prostate cancer expenditure— and multiply it by the total episode. So that's the $2,300,000, which gives them a dollar amount. So in this case, it would be $7,500. And then they [multiply] it by 8—they change that number by 80% of the EOM participants— So they take that and times that by .8% and that gives them some of the EOM’s participants baseline prices for attributed prostate cancer. So basically, now their amount is $2,000,5000.

There's a really great breakdown of this with this specific drug. But if you go to the EOM website and you look at the payment model, there's a page and there's a really nice chart. And I must look at it every time, but it breaks all that down really easily. So if you want to look at it more, it's really nice.

Credit: Centers for Medicare & Medicaid Services. Enhancing Oncology Model Model (EOM)- Payment Methodology. Pg. 65-67. https://innovation.cms.gov

Credit: Centers for Medicare & Medicaid Services. Enhancing Oncology Model Model (EOM)- Payment Methodology. Pg. 65-67. https://innovation.cms.gov

PT Staff: How does EOM align with President Biden’s Cancer Moonshot pillars?

Erica Feinberg, PharmD BCPS: Centers for Medicare & Medicaid Services (CMS) really highlights that it's improving care for both the patients—care for the whole patient—and advancing health care overall. So Biden's Moonshot wants to decrease cancer by 50% over the next 20 years. And so this model is helping both improve access to patient care through social determinants of health (SDOH) needs and improving cost overall. So it's really aligned with his program.

PT Staff: What impresses you most about EOM, based on findings from your simulation exercise?

Erica Feinberg, PharmD BCPS: I think one of the most interesting things we found was that 75.5% of novel therapy expenditures in OCM came from the 7 cancers that are just now part of the EOM. So those are really more of the high-cost cancers. And so the EOM will account for the drugs being used in them and those novel therapies. We also found that in OCM, only 38.1% of eligible performance periods received that NTA. But when we ran our simulation, we saw that it had been calculated at a cancer level like EOM that 49.5% of eligible cancers would have received that adjustment. So it's really showing that CMS has changed their model for EOM to promote novel therapies and be able to have them in the cost of care.

PT Staff: Can you explain how risk adjustment methodology works within EOM?

Erica Feinberg, PharmD BCPS: Basically what happens is they look at a baseline of all of the Medicare claims, and groups that aren't participating in EOM, and the ones that are. They’ll say, “You have to save this much money. And if you save this much money, we'll give you money back. If you don't save this much money, this percent of baseline,* you have to pay Medicare back.”

There are some graphs I can also point out, there's a really nice thing that I was looking at right before here to about how they calculate that baseline is a very complicated calculations based on where the region is. The NTA is [also] in there but it's really overall it's like, “How much did you see if compared to baseline? Other groups?”

PT Staff: Are there limits to the scope of EOM?

Erica Feinberg, PharmD BCPS: There's only about half as many patients now in EOM compared to OCM. So there's some of those things that are involved with it. Other aspects to consider is that CMS conclude that OCM didn't save money as a whole. So hopefully with this new model, that scope will change. But overall, I think EOM and CMS [are] moving in the right direction with the EOM model.

* So do it based on percentage. There are 2 different risk categories you can join when you sign up, and if you're in the less risk category (if you still don't save enough money based on the baseline) you have to pay Medicare back.

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