The new Enhancing Oncology Model (EOM) is set to begin on July 1, 2023, and continue for five years. As the replacement for the Oncology Care Model (OCM), the EOM is meant to improve the quality of care and health equity in oncology practices. Participants must add participant redesign activities, such as screening for social determinants of health and using electronic health records.
While the model has good intentions and some key benefits that address social determinants of health, there are also some concerns over the risk participants will be taking and the potential for lost revenue.
We interviewed Dr. Kashyap Patel, CEO, Carolina Blood and Cancer Care Associates, to get his insights on the EOM.
(Edited lightly for clarity and conciseness.)
How do you think the Enhancing Oncology Model will help improve the quality of patient care?
There’s a report that showed the cancer care disparity will impact up to one-third of the patients in America. And a lot of these patients are impacted because of the adverse social determinants of health, which include access to care, access to testing, access to transportation, food insecurity, etc.
And one of the priorities that the Enhancing Oncology Model has kept is to compile and collect the data on the social determinants of health, the Z codes and the socioeconomic broad categories, which can help identify what kind of difficulty the patient is having. Is it a literacy issue? Is it a transportation issue? Is it a food issue? Is it a social issue? Is it a housing issue?
So this will help us really link the access to care with the outcome. CMMI has taken initiative.
Do you have any advice for practices looking to implement a social determinants of health screening process into their workflow so that they can meet these EOM goals?
We started collecting data probably about two years back in the spring of 2021 on some of these social determinants of health. And it's actually, very, very impactful. The way we do it is we designed our own form, and we collect all the data from patients’, you know, demographics, their ethnicity, their income level, their literacy level, their food insecurity, etc.
One of the ways a practice could look into doing it: either design the form specifically to meet the CMMI requirement or, in my opinion, it may be helpful to have a much broader form because, in addition to the social determinants of health and Z codes, there's also a need to identify the lack of cancer screenings as one of the contributors to the healthcare inequity.
They can just design an extra template and embed that form into the PatientPoint exam room screen so that while a patient is waiting to be seen by a doctor, they can actually collect this data that somebody will send to the doctor’s e-mail account, and then the doctor can add it into the patient’s chart.
But it’s important to do more than collect data, right? It's then connecting the patient with the care that they need at the moment. What is the next step after you get this data? You know they lack food. How do you get them help right then and there?
This is where I have to disagree with CMMI. It's one thing to find that a patient doesn't have food, but then who's responsible to support them for that particular need? It's important to collect data, but it's important to address the deficits and close the loop. One of the papers published in the Journal of Cancer showed that patients with three or four adverse social determinants of health have statistically significant inferior outcomes. So if we find that the quality of care that's being delivered is inferior because of the bad outcomes, why should CMMI not address this?
I can't sleep peacefully at night if I found that today in my office out of 120 patients who checked through five different doctors, 17 patients have food insecurity. What we are doing is we've identified about 15-plus not-for-profits in our community to fulfil SDOH-related needs within our capacity and our partners'. We are closing the loop, but we are also collecting the data on closing the loop.
So it's very, very important that CMMI does not just collect the data, that they compensate doctors to address health-related social needs. They should use this as the quality parameter, that if I identify patients sleeping on the street or in a car because they don't have a home, then I have a moral imperative, as well as I would say quality imperative, to find a shelter for this patient.
Every county in America has resources from communities to address such issues. The issue is that because we are compartmentalized, fragmented and reductionist, we don't assimilate these resources.
Do you have any other processes or any advice for any oncology practices worried about meeting EOM requirements?
I definitely want practices to look into two things. One is that as a part of the Omnibus Act that was passed, the pandemic-associated Medicaid expansion is now back to the state. Probably a third of the Medicaid beneficiaries who are on Medicaid right now will lose their Medicaid qualification. So this will impact dual eligibility.
So for example, if my practice has 50 patients who are dual-eligible, Medicare and Medicaid, twenty of them will end up losing that dual-eligible status. That means they're at 20% out-of-pocket cost. Plus, my new payment will go down because the way CMMI will look into it is that they tied an extra $30 per beneficiary per month, as a part of the pilot, to give extra resources to the practice, but a third of that will be lost.
So I definitely would ask practices to look into their patient demographics. The responsibility of reporting the SDOH is quite a huge one because you probably collect data on about 50 parameters, then you filter it down to like seven groups of the Z codes. It's quite labor-intensive and getting paid $70 per beneficiary per month. I think $70 is not enough of an amount to cover the additional manpower cost.
We looked into another way of, for example, doing more for chronic care management. These are the telehealth interventions that probably will not be billed if you are part of the CMMI EOM. But if you do this by itself, then you may be able to serve patients better, but you do not expose yourself to downside risk from day one, which is one of the mandates, and also get less payment for extra delivery of the data back to the CMMI.
So with all these different factors, do you think overall EOM is an improvement on OCM?
EOM has been an improvement, except that CMMI should have looked into compensating physicians/providers for closing the loop. It's almost like we look at the fire by identifying health-related social needs or SDOH, identify where the fire is burning but whether you care to shut it down or not is up to you. You see what I'm saying?
So for example, if I track information that my patient is living in a car, it's not my responsibility technically to find them a shelter, but my moral imperative says that I need to do that. So we'll be spending resources, and if I spend resources, I may expose my practice to financial inadequacies because I'm burning up cash while trying to douse the fire that actually should have been supported by appropriate compensation for extra time and resources. So that's the worst part.
Second thing is that they actually took the large number of patients who are early-stage breast cancer on oral treatment out of the equation, which is quite a large number of patients. So on the whole, the reporting requirements have worsened because we have to do more and more reporting, but the number of eligible patients has gone down.
And the third thing is that there's something called an Advanced Alternative Payment Model bonus. This is tied to the number of Medicare beneficiaries who are on an alternate payment model. And because CMMI has eliminated a significant number of patients who are eligible for EOM, I doubt any of the practices would be eligible for the Advanced Alternative Payment Model bonus, so that means that I'm exposing my practice to downside risk from day one. I'm getting paid probably about 60% less for doing 40% more work.
And the fourth thing is that I may not be able to get a payment bonus. That really complicates things because part of my patients will fall into this category. So it's a lot more complicated, and that's the reason why we are not going to decide until we get a clarification from CMMI.
And the last thing I want to mention, which not many people are thinking, is that CMMI has not looked into adjusting the model for COVID-related comorbidities. We know that the number of patients with a COVID history will have cardiac arrhythmias. Data has shown that the cost of care for the post-acute sequelae of COVID has gone up from, you know, anywhere from $270 to $900. So if my price adjustment is not taking into account COVID-related specific complications, I may be exposing myself to more downside risks.