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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). In the present day I construct upon that put up focusing largely on CMS’s EOM’s Fee Methodology. I exploit a Q&A format as nicely.

What’s the purpose 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 varieties are eligible for EOM included?

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

Be aware 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” regularly, EOM Initiating Therapies embrace 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 record is obtainable 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. For example, 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 medicine. Beneficiaries who proceed to obtain chemotherapy after finishing a six month episode provoke a brand new episode. Be aware, nonetheless, that “There isn’t any requirement {that a} chemotherapy-free interval exist earlier than the start of any episode.” The handle the dearth of a ‘clear interval’ earlier than the set off occasion, CMS depends on danger adjustment.

How are episodes assigned to doctor apply teams?

That is primarily based on the oncology doctor group apply that both (i) supplied the primary analysis and administration (E&M) service throughout the 6 month efficiency interval so long as they supplied at the very least 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 varieties 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 regarded as a capitation fee. Base MEOS funds are $70 monthly however improve to $100 monthly for dual-eligible beneficiaries. Based mostly on therapy value and high quality, PGPs have two-sided danger: 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 upon 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 satisfy a bigger goal low cost (4%) however has a 2% most draw back danger; RA2 requires a smaller low cost (3%) however PGPs are chargeable for extra optimistic and unfavorable danger (most 6% draw back danger). By default, EOM members and swimming pools are in RA1 except they request to be in RA2.

What kind 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 embrace the Low-Earnings Price Sharing Subsidy (LICS) quantity and 80 % 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 probability that a number 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 danger adjusts episode prices primarily based on elements corresponding to demographics (i.e., age, intercourse), revenue (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 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 (at present 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 useful however excessive value remedies. To not unduly disincentivize innovation, EOM features a new remedy adjustment the place oncology medicine 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). In brief, 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 information expertise (CEHRT). The precise high quality measures are listed beneath 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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