value-based care in ONCOLOGY

marta g. zanchi

Published in

nina capital

9 min readJul 29, 2022

lessons learned and towards an enhanced oncology model

JULY 2022

by Federico Aureli & Himanshu Sharma

The concept of value-based care — a movement away from a fee-for-service healthcare model (based on volume of care services) towards one based on more effective patient care (based on outcomes per cost of care services) — has been around for decades.

The shift has been neither easy nor fast. One could point to many reasons for this painfully slow motion: CMS launched multiple competing payment models, leading to confusion and fragmentation; key stakeholders resisted adoption, seeing their interests ignored; others, especially disadvantaged patients, became even more marginalized, and inequality of access to care has risen. One could say the last decades have been of experimentation: without enough conviction to move towards scrapping the existing fee-for-service models, initiatives for the most part disconnected have been launched as if in a sandbox environment, trying not to spoil the playground for the rest.

However, we believe that this time it will be different. In an August 2021 article in Health Affairs, CMS laid out its vision for Value-Based Care over the next 10 years. There are five key points that are worth taking into consideration.

CMS will focus on piloting fewer models and slowly expanding participation.
Payment models will align incentives for provider participation and give providers the right tools to change health care delivery.
Improving healthcare access and quality of care by emphasizing health equity in every payment model.
There will be added emphasis on Medicaid as well as partnerships with payers, states, and communities.
Transitioning out of the Fee For Service model is an important goal.

It is a time of possibilities for entrepreneurs with the vision and the patience to build solutions to the inevitable gaps that this new shift creates.

Here, we summarize what we’ve learned on one such transition from the Oncology Care Model (OCM) to the new Enhanced Oncology Model (EOM) and share our thoughts on where innovation can help better serve oncology patients and improve outcomes.

innovation can help better serve oncology patients and improve outcomes

value-based care: a recap

If you are familiar with the concept of value-based care, you can skip this section.

Value-based care (VBC) is a method of providing healthcare in which providers are compensated according to the value of the service they provide. It tries to include patient outcomes into the payment/reimbursement to the providers as a reward. This stands in contrast to the current fee-for-service model, the predominant payment system, in which providers are paid based on the volume of services they give.

The VBC model tries to align incentives of the different stakeholders, so that:

patients receive continual monitoring and personalized treatment with the goal to improve outcomes and care quality.
payers benefit from lower hospitalizations and readmissions, which in turn lower expenses.
providers reap the opportunity to practice patient care focusing on quality rather than volume, on prevention rather than acute treatment, which in turn increases clinicians’ satisfaction and reduces burnout (a condition very common in the modern clinician).

value-based care in oncology in the united states

Building from the fragmentation and inefficiency of cancer care delivery, the Centers for Medicare and Medicaid in the States have run a program for implementing VBC in oncology management called OCM.

This program, launched in 2016 has recently ended (June 2022) and will be replaced next year by a new framework, the EOM.

OCM: what is it?

Under the Oncology Care Model (OCM), physician practices voluntarily entered into payment arrangements that included financial and performance accountability for episodes of care surrounding chemotherapy administration to cancer patients beneficiaries of Medicare FFS. (source).

These reward payments were delivered on top of the standard fee for service payments, in order to compensate for the additional resources needed to sustain the new model. They consisted of two separate entities:

A Monthly Enhanced Oncology Service (MEOS) of $ 160 per beneficiary per month was given to the clinics (regardless of the outcomes) for the implementation of enhanced services such as patient navigation tools.
Potential Performance-based payment (PBP) is based on the total cost of care (including drugs) and quality performance during a 6-month episode starting with the beginning of chemotherapy.

Overall, 126 practices and 5 commercial health insurance payers were involved, with the recruitment of more than 100,000 patients. Among the requirements for the clinics were: the provision of enhanced services such as patient navigation tools and 24/7 patient access; and, the use of electronic health records and data to drive continuous quality improvement.

outcomes of OCM: what have we learned?

A recent report in the Journal of Clinical Oncology on the outcomes of OCM found that this framework led to the reduced use of some high-cost supportive care medications, suggesting more value-conscious care.

However, based on the CMS itself, despite results on total Medicare spending being promising, the savings are not sufficient to cover the expected payments of practices (MEOS and PBP) on top of their standard fees.

A survey was conducted by the Community Oncology Alliance distributed among participating clinics in order to assess their views on the impact of OCM

On a scale of 0 (no impact) to 100 (tremendous impact), the ratings were:

62 for “patient experience,”
56 for both “operational efficiencies” and “consistency on cancer treatments,”
49 for “reduced total cost of care”

“Despite not having reached the saving goals, it is safe to say that OCM has been a catalyst for innovation in oncology care management. The sole concept of a patient requiring urgent access to care in between scheduled visits would have been disregarded 5–7 years ago. Now clinics and patients are used to it and believe in their efficacy, and have expressed desire for a follow-on model.”
~ Lavi Kwiatkowsy, CEO of Canopy, on the impact of OCM

EOM: what is it?

Like the old model (OCM), the Enhanced Oncology Model (EOM) will be a voluntary payment and delivery program, scheduled to begin July 2023 and conclude June 2028 in Medicare FFS beneficiaries undergoing chemotherapy treatment. The goals of the new model remain the same as the old one: enhancing the quality of care of oncological patients while reducing the costs of the medicare fee for service (FFS), the program that pays healthcare providers for their services.

As in the OCM, two additional financial incentives are added on top of the Fee For Service FFS payment for EOM participants in order to increase quality and cut costs:

An additional payment of $70 per beneficiary each month for MEOS, which will assist in care transformation.
A PBP is based on quality indicators over six-month periods that start with chemotherapy and the overall cost of treatment (including medications).

Among the required activities for EOM participants are 24/7 access to care, patient navigation, care planning, use of evidence-based guidelines, use of electronic Patient Reported Outcomes (ePROs), screening for health-related social needs, use of data for quality improvement, and use of certified electronic health record technology.

OCM vs EOM

*Taken from CMS* *presentation* *on EOM*

Three key main differences arise from the old model:

the beneficiaries in EOM will only include patients undergoing chemotherapy for seven cancer types, while in OCM it included all cancers. Moreover, exclusive hormonal therapy is also excluded, together lowering the number of eligible patients;
the MEOS payments are cut by more than 50%;
EOM includes two new practice redesign activities: the gradual implementation of electronic patient-reported outcomes (ePROs); screening beneficiary social needs using health-focused screening tools.

Implementation of patient-reported outcomes in the payment recoupments is a great step toward value-based care. They consist of questionnaires asking patients to self-rate their symptoms and distress.

Their use and effectiveness in oncology have been validated by the studies of Ethan Bash, with demonstrated improvement in treatment compliance and overall survival.

“Engaging patients with PROs is crucial. Any tool that increases active participation and lets patients feel part of an actual community improves retention. You will not lose a patient if he/she feels connected”
~ Todd Meyerrose, CEO of Navio, working with PROs in oncology.

opinions and feedback

Oncology experts approve of the initiative and have expressed support for the efforts to reduce health disparities, but have highlighted some concerns.

Cutting in half the MEOS payments increases the level of risk for providers, giving the increased amount of information and resources required to run the model
Leaving a 1-year gap between the two models leaves clinics without a framework after they have invested in implementing CMS programs.

Plus, CMS maintained the framework on a voluntary basis, still moving away from the date in which VBC will be actually implemented on a large scale.

gaps in the market and call for action

Pressure to transition towards value-based care is bound to persist. Starting to construct new models today could give healthcare providers an early advantage that will help them compete more successfully in the future. Those who aren’t prepared may be left behind as the market changes even further in favor of value.

As we shift towards VBC 2.0, we believe that companies that focus on improving patient outcomes will add substantial value to the space. With the constant pressures to adapt a VBC model, aligning the incentives of patients, providers, payers, and government will be a turning point for the future of care management.

We especially think that with the start of EOM, companies implementing these features can pave the way for innovation:

Integration of passive monitoring data points with wearables, such as gait or heart rate, on top of ePROs. This allows for 360-focused continuous monitoring, taking into consideration both sides of the spectrum of outcomes and data points.
Full Stack end-to-end platform. The need for a platform to manage billing of FFS, MEOS and PBP when applicable to EOM. It should also integrate with the EMR system to make it easy to adopt.
Explainable AI. Physicians want a solution that is explainable and not a black box. Care teams would prefer a solution that explains the rationale for prioritization and care steps.
Social determinants of health (SDOH) data. Priority should be given to SDOH data for which organizations have an immediate, practical response.

On #4, SDOH data, two aspects will be key: actionable data and communication with CMS.

Actionable data: When a social need arises and the provider informs the patient there is nothing that can be done to address it, it can be frustrating for both parties — and it can harm patient confidence. One example of this could be adding reimbursable services such as transportation or nutrition, ultimately reducing costs and improving health equity and care. Such a platform should allow the care team to know which patients need what services and hopefully PROs will integrate with other service providers to allow a swift implementation.

Communication with CMS: Platforms that are able to gather and communicate sociodemographic data directly with CMS will alleviate physicians from administrative tasks.

Here are some examples of companies that are already helping oncology patients:

Outcomes 4me

This company has developed an app specifically for breast cancer patients that lets them find out what treatment options are best for them. It provides tools for ePROs with its symptom tracking and management system. Moreover, clinical trials are listed on the app so that patients can be aware of the possibilities in their area/state.

Navio

Navio is creating personalized support tools at no cost to patients, such as treatment calendars, and medication reminders, together with PROs. They also make it easy to participate in research studies from the convenience of home.

“Having a platform that is really easy to understand and for both patients themselves and clinicians is key. That is what we are doing with Navio, keeping track of consistent measures so patients and providers can reflect on their health status.”
~ Todd Meyerrose, CEO of Navio

Canopy

Canopy has developed an ePRO-Based Patient Monitoring solution that keeps every patient connected to their care team between treatments so that issues can be identified and resolved without delay.

“Studies show that when patients are continuously monitored, the ability to persist on treatment improves along with overall survival. We have validated these results and presented publications showing increased treatment persistence and reductions in acute hospital visits for patients receiving access to Canopy. We believe in a future where clinics are using technology to deliver the highest level of care to all patients, while capturing the appropriate reimbursement for each patient — either through the EOM, or using FFS models.”
~ Lavi Kwiatkowsy, founder and CEO of Canopy

We at Nina Capital have already invested in patient engagement and ePROMs such as Lena Health and Promptly Health.

If you are a founder working on building something in the oncology space, please reach out to us at Nina Capital and we would love to work with you :)

Federico & Himanshu