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HomeHealthcareCost Methodology – Healthcare Economist

Cost Methodology – Healthcare Economist


Again in July, I offered an overview of the Enhancing Oncology Mannequin (EOM). As we speak I construct upon that put up focusing largely on CMS’s EOM’s Cost Methodology. I take advantage of a Q&A format as properly.

What’s the purpose of EOM?

In keeping with CMS “EOM is a CMMI different fee mannequin designed to advance well being fairness, promote higher care coordination, enhance entry to care, scale back prices, and enhance outcomes for Medicare fee-for-service (FFS) beneficiaries with most cancers who obtain chemotherapy.”

Which most cancers varieties are eligible for EOM included?

There are seven most cancers varieties eligible for EOM: (i) breast, (ii) persistent leukemia, (iii) lung, (iv) lymphoma, (v) a number of myeloma, (vi) prostate most cancers, and (vii) small gut / colorectal most cancers.

Notice that low-risk breast most cancers (i.e., long-term oral endocrine chemotherapy) and low-intensity prostate most cancers (indicated by androgen deprivation and/or anti-androgen remedy with out chemotherapy) will not be included in EOM.

Does EOM solely think about chemotherapies?

No! Though all of the CMS language makes use of the time period “chemotherapy” often, EOM Initiating Therapies embody not solely conventional chemotherapies (e.g., azacitidine, carboplatin, decitabine), however consists of immuno-oncology remedies (e.g., nivolumab, pembrolizumab) and focused therapies (e.g., bevacizumab, osimertinib, sorafenib? A full checklist is offered on the EOM web site right here.

Cell and gene therapies–which CMS calls n Adoptive Cell Switch (ACT) remedy–are excluded from the EOM program. As an illustration, CAR T-cell therapies are excluded from the EOM program.

How lengthy are EOM episodes?

6 months.

Episodes begin at a “set off occasion” which is the initiation of a Half B or Half D anti-cancer remedy. Beneficiaries who proceed to obtain chemotherapy after finishing a six month episode provoke a brand new episode. Notice, nevertheless, that “There isn’t any requirement {that a} chemotherapy-free interval exist earlier than the start of any episode.” The tackle the dearth of a ‘clear interval’ earlier than the set off occasion, CMS depends on threat adjustment.

How are episodes assigned to doctor follow teams?

That is based mostly on the oncology doctor group follow that both (i) offered the primary analysis and administration (E&M) service throughout the 6 month efficiency interval so long as they offered a minimum of 25% of E&M providers within the episode, or (ii) the PGP with the plurality of E&M providers if the preliminary PGP didn’t attain the 25% threshold.

What forms of funds can physicians group practices (PGPs) obtain?

Practices obtain the usual Medicare FFS billing. As well as, EOM has the choice to incorporate a Month-to-month Enhanced Oncology Companies (MEOS) fee, which might be considered a capitation fee. Base MEOS funds are $70 per 30 days however enhance to $100 per 30 days for dual-eligible beneficiaries. Primarily based on therapy value and high quality, PGPs have two-sided threat: high-quality/low value PGPs can earn a retrospective performance-based fee (PBP), however low-quality/high-cost PGPs can owe a retrospective performance-based recoupment (PBR).

PBP and PBRs rely on the chance mannequin chosen. By default, EOM members and swimming pools are in RA1 except they request to be in RA2. The fee specs for RA1 and RA2 are beneath. RA1 requires PGPs to fulfill a bigger goal low cost (4%) however has a 2% most draw back threat; RA2 requires a smaller low cost (3%) however PGPs are responsible for extra optimistic and unfavorable threat (most 6% draw back threat). By default, EOM members and swimming pools are in RA1 except they request to be in RA2.

What sort of expenditures are included in an episode?

All Medicare Half A and Half B FFS expenditures (funds) and sure Half D expenditures are counted as a part of the episode value. Particularly, EOM episodes solely embody the Low-Revenue Value Sharing Subsidy (LICS) quantity and 80 p.c of the Gross Drug Value above the Catastrophic (GDCA) threshold. All different Half D expenditures will not be included in an EOM episode as a result of they’re paid on a capitated foundation by Half D plans.

How does EOM account for outlier episodes and variations in affected person traits?

To cut back the chance that a couple of very excessive or very low value episodes will result in a poor efficiency rating, CMS winsorizes episode expenditures on the fifth and ninety fifth percentiles.

Moreover, CMS threat adjusts episode prices based mostly on elements corresponding to demographics (i.e., age, intercourse), earnings (i.e., twin eligibility, Half D LIS eligibility), comorbidities (autoimmune issues, COPD, dementia, endocrine issues, heard illness hematologic illness, hypertension), rely of different HCCs, receipt of particular providers (i.e., cancer-directed surgical procedures, bone marrow transplant, radiation), institutional standing, participation in a scientific trial, prior chemotherapy use, and episode size (e.g., if died or disenrolled)
weight problems. Danger adjustment relies 50% on nationwide cancer-specific value predictions and a mixture of regional and PGP particular value estimates with bigger PGPs having extra weight on their historic information and smaller PGPs having extra weight on regional value predictions.

Extra particulars on how CMS calculates the goal quantities for EOM participant PGPs is beneath.

Does EOM account for tumor stage or tumor mutations?

Sure, however crudely. There’s a scientific adjuster if the affected person ever had metastatic illness (presently solely used for breast, lung and small gut/colorectal cancers), and a single biomarker is adjusted for (HER2+ sufferers with breast most cancers).

How does EOM take care of new remedies?

EOM might probably de-incentivize the usage of clinically helpful however excessive value remedies. To not unduly disincentivize innovation, EOM features a new remedy adjustment the place oncology medication are thought of “new” for two years from FDA approval for that particular indication.

Does EOM account for high quality of care?

Considerably. EOM does this via Combination High quality Rating (AQS). Briefly, PGPs are solely eligible to obtain bonuses in the event that they meet a minimal threshold on the AQS.

High quality of care consists of sure actions (24/7 entry to care, affected person navigation, documented care plan, following scientific tips, conducting health-related social wants screening, and use of licensed digital well being data expertise (CEHRT). The precise high quality measures are listed beneath based mostly on CMS’s High quality Technique Webinar from August 25, 2022.

For extra particulars on EOM because it evolves, see the CMS’s EOM web site.




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