Addressing Disparities Through the Enhancing Oncology Model and the Opportunity With Medically Integrated Dispensing

Lisa Harrison, RPh
President,Specialty Distribution
AmerisourceBergen

The health equity conversation has come to the fore in a significant way since the emergence of the COVID-19 virus, with subsequent focus on the treatment of patients as individuals rather than hosts of a disease. As the oncology sector continually considers how disparities play into the overall success of patient care, attention to payer responsibility is essential.

On June 27, 2022, the Centers for Medicare & Medicaid Services (CMS) announced the Enhancing Oncology Model (EOM), a 5-year voluntary multi-payer model with dual objectives of improved care quality and cost reduction for cancer care delivered by participants.¹

An eagerly anticipated development, the EOM follows up on its successor, the Oncology Care Model (OCM), which was launched in July 2016 and incentivized clinicians to focus care on treatment quality and cost control. Analysis of the program revealed that OCM resulted in a gross reduction in Medicare payments, but an ultimate total loss after accounting for Monthly Enhanced Oncology Services (MEOS) payments and Performance-Based Payments (PBPs). Despite this, the resulting care delivery improvements were a significant benefit to all participating patients with cancer, regardless of health care coverage.^2,3

In line with trends of the broader payer ecosystem, one distinguishing factor of the new EOM is the push towards greater consideration of social determinants of health care disparities.¹

“Over the years, cancer care has been primarily focused on the treatment plan for the disease. Addressing disparities to improve patient care and outcomes is going to require us to flip that script,” said Lisa Harrison, RPh, president of Specialty Distribution at AmerisourceBergen (AB) in an interview. At AB, Harrison leads sales and operations for Besse Medical and Oncology Supply within the company’s Specialty Physician Services (SPS) division. In this role, Harrison also oversees the group’s pharmacy services. “More than ever before, the patient is really going to need to be at the center of the equation and care teams will need to meet them where they are.”

In the interview, Harrison dove into the new EOM, marketplace trends that foreshadow payer consideration of health disparities, how social determinants of health are being accounted for in payer models, and how medically integrated dispensing may be a central part of this conversation.

Dissecting EOM Vs OCM

Notably, a few key differences exist between the EOM and OCM models, such as the approach to downside risk, reduced payments for enhanced oncology services, inclusion of fewer cancer types, and a new focus on health equity.

“EOM is narrowed down to essentially 7 cancer types: breast cancer, chronic leukemia, small intestine or colorectal cancer, lung cancer, lymphoma, multiple myeloma, and prostate cancer,” Harrison said. “This model will build on the structure and learnings of the original OCM, but with an increased focus on managing provider risk, promoting patient-centric care, and addressing health disparities and social determinants of health.”

Like OCM, EOM hinges on 6-month treatment episodes where participants are responsible for the total cost of care during that period which is triggered by initiation of anticancer therapy. Some elements of this model will remain the same as in the OCM, such as drug payments being considered toward the total cost of care responsibility and requirement for participant redesign activity implementation.⁴

Harrison pointed out that MEOS payments, which were a per-beneficiary payment of $160 per month, were reduced to $70. Another financial consideration for practices considering EOM participation is the new 2-sided risk model. With OCM, participation mostly resulted in only upside risk with performance-based payments awarded if there were savings compared with historical benchmarks. With EOM, 1 of 2 risk arrangements must be selected, both of which have downside risk.

Of particular interest to Harrison is the model’s focus on health equity, which will institute the collection and submission of sociodemographic data and the development of health equity plans to show how practices are addressing disparities and ultimately promoting equity within the patient population.

“The new practice redesign activities include a gradual implementation of electronic patient-reported outcomes and the screening of beneficiary social needs using screening tools. It will also require reporting of data about disparities in access to cancer care. The reported outcomes will essentially inform targeted strategies for those vulnerable and underserved patient populations, so this is a whole new world for defining and capturing data.”

Health Equity at the Center of Marketplace Trends

Looking at health disparities more broadly, Harrison said social determinants of health have emerged as an essential element of value-based care.

“I believe that the pandemic has pushed this topic front and center for the health care industry. We’ve seen the Biden administration be vocal about reinforcing existing policies and increasing funding to deal with social determinants of health, especially in cancer care,” Harrison stressed.

Some of those initiatives included reigniting the Cancer Moonshot Initiative, which was launched by President Joe Biden during his time as Vice President during President Barack Obama’s administration.⁵ Additionally, the Department of Health and Human Services (HHS) also recently announced a historic investment of over $49 million to increase health care coverage for children, parents, and families.⁶

The EOM is another key piece of this puzzle. The model allows for higher MEOS payments for dual-eligible beneficiaries, defined as those who are eligible for both Medicare as well as Medicaid based on income status.

“This will help force the conversation and the focus across the industry away from the historical [concerns] of just saving money,” said Harrison, continuing that the subsequent goal will be to focus on care for the “whole patient to work towards achieving better outcomes.”

Data-Informed Payment Models

Harrison said payers need to have their eyes set on multiple factors when designing payment methods that account for social determinants of health, but it all boils down to understanding and interpreting data around disparities.

“At the core, data helps drive understanding. The real challenge is that before you can capture the data, you must identify and define the different types of disparities. And we must remember that it may look different from patient to patient, from community to community,” Harrison said.

Casting a broad net will be key to arriving at a “definition” of disparities in cancer care. Once those basic factors are outlined in the space, standardization around reporting and how best to address those disparities will be of the utmost importance. Although clinicians are experts at collecting data regarding their patients’ medical needs, there may be a learning curve while the community is properly educated about what other information needs to be collected to accurately assess individual risks of health disparities.

“Mandates for the collection and reporting of those key data elements are necessary to better understand subpopulations [at risk] and potential health outcomes,” Harrison continued. “More than anything, payers must consider the education that will be necessary for this area. If providers aren’t aware, educated, and frankly, fairly reimbursed for the time and attention that’s needed here, we won’t make the progress that we’re hoping to make.”

Current State of Equitable Care Screenings

Understanding the reasons why social determinants of health are uniquely relevant to patients with cancer underlies the conversation about equitable care and screening overall. According to Harrison, research has shown that patients who reside in areas with lower socioeconomic status have lower rates of cancer screening and are more often diagnosed with cancer at later stages of disease, a fact that is confounded by the generalized high cost of cancer care across settings.^7,8 Individuals impacted the most are patients with lower educational attainment, lower income, and no or insufficient health care coverage.

Therefore, value-based care models have put outcomes and quality front and center for providers, with social determinants of health creeping into equation more and more. Despite the overall push in the health care sector to provide preventative care for free due to the well-researched and undisputed health savings that result, these services may still be inaccessible to a portion of the population. Additionally, costly diagnostic follow-up tests and procedures present a heavy financial burden for some.

Harrison offered the example of a study published in JAMA Network Open in 2021 that examined out-of-pocket costs of diagnostic breast cancer screening services for patients with insurance who received care from 2010 to 2017. Results showed that out of 6,216,270 screening mammography procedures, 993,005 (16%) were followed by additional imaging examinations. Out-of-pocket costs varied by type of imaging and increased over time as did cost sharing.⁷

Another study from 2016 indicated that the cost of care for patients with breast cancer was higher with more advanced stages of disease, regardless of how far into treatment patients were. For instances, women with stage I/II disease incurred average allowed costs of $61,621, $82,121, $91,109, and $97,066 at 6-, 12-, 18-, and 24-month timepoints postdiagnosis, respectively. Corresponding average allowed costs in those with stage IV disease were $89,463, $134,682, $162,086, and $182,655.8

“We’ve seen payers attempt to model their payment plans to optimize affordability and access to care, but oversight and adequate coverage of diagnostic services too can ultimately lead to lower costs and, more importantly, better outcomes for patients in the long run,” Harrison said.

Another factor to consider is the continued personalization of cancer care that requires advanced testing and diagnostics to deliver the most appropriate therapy for each patient. Without addressing these challenges, gaps in the way patients are treated will likely continue to grow and health disparities will further impact patients’ abilities to benefit from modern advances in care.

“It starts with screening of course, and the insurance industry has addressed this in some ways by including cancer screenings as an essential health benefit that must be covered. But there are still challenges for patients,” Harrison said. “When we look at the development of new therapeutics, the required testing and diagnostics [have the potential to result in] a heavy financial burden for a patient.”

Medically Integrated Dispensing

Digging into her personal passion, Harrison began the discussion on medically integrated dispensing by talking about her start with AmerisourceBergen where she served in a role that helped community-based practices set up in-office dispensing capabilities.

“Our industry association NCODA defines medically integrated dispensing as a dispensing pharmacy within an oncology center of excellence that promotes a patient-centered, multidisciplinary team approach,” Harrison said. “That means that it’s a pharmacy or dispensary that’s integrated into the oncology practice, allowing patients to receive their prescriptions onsite inside that medical clinic.”

To piggyback off this definition, Harrison emphasized the mass movement toward oral oncolytics and how this has changed the way cancer is managed. Innovation in the space outpaces other health care sectors and continues with its upward trajectory. In fact, 50% of all the newly approved cancer treatments in 2021 were oral medications, according to FDA resources.⁹

Value-based care models focus on simplifying and personalizing care by removing obstacles and delivering coordinated team-based and patient-centered care methods that are physically embedded in the clinic. Medically integrated dispensing represents a key component of this equation since specialty pharmacy services can also be kept in-house. Barriers to these types of systems exist, such as when payers have prior arrangements with outside specialty pharmacies, which may lead to patients acquiring medications elsewhere.

“When you think about this in the context of the disparity conversations, medically integrated dispensing teams can act as another layer of defense in making sure patients are not falling through the cracks,” Harrison said. “They can discuss financial and social determinants of health issues that may be impeding medication access or adherence and connect patients with financial assistance and other supportive services when they need it.

Harrison emphasized how this may cut down on frustration and burden on the patient since education around therapies, therapy consultation, adherence, financial toxicity issues, and personal outreach and care all happen within a closed-loop care team.

“AmerisourceBergen has done a lot of work to ensure payers understand the value of medically integrated dispensing. Although we’re at the forefront of that work, we have many more opportunities,” Harrison said. “I believe that medically integrated dispensing practices play a central role in value-based care and addressing disparities.”

Future Directions

Taking all elements together, Harrison said payers and providers working together will be necessary to tackle the barriers to health equity in a meaningful way. In addition, focusing on a patient-centered care model vs just looking at the treatment plan in a vacuum, as is being pushed by models like EOM, will help drive innovation in this area.

Barriers to care have a wide breadth and affect patients in different ways. Understanding this may help multidisciplinary providers as they look to treat the whole patient and bring necessary services, which may be as simple as transportation to the clinic, to those in need.

“It requires clinicians to focus on and have conversations with patients that go beyond their medical condition and treatment plan. Ultimately, we need provider education and to make sure that reimbursement frameworks support the additional resources that are needed to focus on the whole patient, not just the disease.”

References

1. Enhancing Oncology Model. CMS. June 27, 2022. Accessed September 9, 2022. https://bit.ly/3B7DOvh
2. Oncology Care Model (OCM), Evaluation of Performance Periods 1 to 6. CMS. Accessed September 9, 2022. https://bit.ly/3D9EiUx
3. Mirchandani H, Champagne N, Pelizzari P. Enhancing Oncology Model (EOM): OCM “2.0”. Milliman White Paper. July 2022. Accessed September 9, 2022. https://bit.ly/3x8sQED
4. How does the EOM compare to the OCM? ACCC. July 20, 2022. Accessed September 9, 2022. https://bit.ly/3RAcixA
5. Fact sheet: President Biden reignites Cancer Moonshot to end cancer as we know it. The White House. February 2, 2022. Accessed September 9, 2022. https://bit.ly/3TZpNsb
6. HHS announces historic investment of over $49 Million to increase health care coverage for children, parents, and families. Department of Health and Human Services. July 19, 2022. Accessed September 9, 2022. https://bit.ly/3LhI0h3
7. Lowry KP, Bell S, Fendrick AM, Carlos RC. Out-of-pocket costs of diagnostic breast imaging services after screening mammography among commercially insured women from 2010 to 2017. JAMA Netw Open. 2021;4(8):e2121347. doi:10.1001/jamanetworkopen.2021.21347
8. Blumen H, Fitch K, Polkus V. Comparison of treatment costs for breast cancer, by tumor stage and type of service. Am Health Drug Benefits. 2016;9(1):23-32.
9. Novel Drug Approvals for 2021. FDA. May 31, 2022. Accessed October 3, 2022. https://bit.ly/3V8y51M