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HomeHealth InsuranceFee Methodology – Healthcare Economist

Fee Methodology – Healthcare Economist

Again in July, I supplied an overview of the Enhancing Oncology Mannequin (EOM). Right now I construct upon that put up focusing largely on CMS’s EOM’s Fee Methodology. I exploit a Q&A format as effectively.

What’s the aim of EOM?

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

Which most cancers sorts are eligible for EOM included?

There are seven most cancers sorts 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.

Word 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) aren’t 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 embrace not solely conventional chemotherapies (e.g., azacitidine, carboplatin, decitabine), however contains immuno-oncology remedies (e.g., nivolumab, pembrolizumab) and focused therapies (e.g., bevacizumab, osimertinib, sorafenib? A full listing is on the market 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. Word, nonetheless, that “There isn’t any requirement {that a} chemotherapy-free interval exist earlier than the start of any episode.” The tackle the shortage of a ‘clear interval’ earlier than the set off occasion, CMS depends on danger adjustment.

How are episodes assigned to doctor observe teams?

That is primarily based on the oncology doctor group observe that both (i) supplied the primary analysis and administration (E&M) service throughout the 6 month efficiency interval so long as they supplied no less than 25% of E&M companies within the episode, or (ii) the PGP with the plurality of E&M companies if the preliminary PGP didn’t attain the 25% threshold.

What sorts 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 could be regarded as a capitation fee. Base MEOS funds are $70 monthly however improve to $100 monthly for dual-eligible beneficiaries. Primarily based on therapy price and high quality, PGPs have two-sided danger: high-quality/low price 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 upon the danger mannequin chosen. By default, EOM contributors and swimming pools are in RA1 until they request to be in RA2. The fee specs for RA1 and RA2 are under. RA1 requires PGPs to fulfill a bigger goal low cost (4%) however has a 2% most draw back danger; RA2 requires a smaller low cost (3%) however PGPs are accountable for extra constructive and unfavorable danger (most 6% draw back danger). By default, EOM contributors and swimming pools are in RA1 until 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 price. Particularly, EOM episodes solely embrace the Low-Revenue Price Sharing Subsidy (LICS) quantity and 80 p.c of the Gross Drug Price above the Catastrophic (GDCA) threshold. All different Half D expenditures aren’t 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 number of very excessive or very low price episodes will result in a poor efficiency rating, CMS winsorizes episode expenditures on the fifth and ninety fifth percentiles.

Moreover, CMS danger adjusts episode prices primarily based on components comparable to demographics (i.e., age, intercourse), earnings (i.e., twin eligibility, Half D LIS eligibility), comorbidities (autoimmune problems, COPD, dementia, endocrine problems, heard illness hematologic illness, hypertension), rely of different HCCs, receipt of particular companies (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. Threat adjustment is predicated 50% on nationwide cancer-specific price predictions and a mixture of regional and PGP particular price estimates with bigger PGPs having extra weight on their historic information and smaller PGPs having extra weight on regional price predictions.

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

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 (at the moment 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 cope with new remedies?

EOM might probably de-incentivize using clinically helpful however excessive price remedies. To not unduly disincentivize innovation, EOM features a new remedy adjustment the place oncology medicine are thought-about “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 contains 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 under primarily based 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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