Impact of state Medicaid expansion on practice performance in the Enhancing Oncology Model.

196 Background: The Enhancing Oncology Model (EOM) drives health equity via increased monthly payments for dual-eligible beneficiaries, and an enhanced financial benchmark. The benchmark price includes a nearly equivalent adjustment for patients who are not dual-eligible but have Part D Low-Income Subsidy (LIS); this covers non-expansion states. However, the LIS covariate is not applied to lung and prostate cancer episodes. We explore how this methodological gap impacts practices situated in high-poverty states. Methods: We modeled a practice with 1,000 oncology episodes, a cancer type distribution of 20% lung cancer and 11% prostate cancer (observed during the EOM’s first performance period), and used CMS data on average monthly Medicaid and Medicare eligibility to calculate the share of full-dual and LIS eligible beneficiaries. We approximated the impact on episode benchmarks by multiplying these figures by the published Part D coefficients for dual-eligible and LIS status. Results: Within the 10 states with the highest estimated LIS episodes, we find that the impact of the benchmark adjustment ranges from 0.25% to 0.5% of the total episode cost - an underestimate of the true effect, given that only baseline costs are considered. Notably, most of the top ten states have a higher proportion of residents below 150% of the federal poverty level compared to the national average. Half of these states have not adopted Medicaid expansion. Conclusions: Promoting health equity is a core objective of the EOM program. However, the financial performance methodology may unintentionally penalize practices in low-income states, many of which have not expanded Medicaid - an unfortunate dual penalty. State Estimated % full dual episodes Estimated % LIS Change in the episode baseline % of all episode costs Percent below <150% of Poverty Percent below <150% of Poverty versus the national average Medicaid Expansion Status Connecticut 5.89% 11.25% $267,751 0.44% 15.80% -4.40% Adopted Alabama 6.72% 9.93% $239,128 0.39% 25.20% 5.00% Not adopted Mississippi 9.67% 9.68% $233,303 0.38% 30.20% 10.00% Not adopted Maine 13.07% 8.95% $216,330 0.36% 18.20% -2.00% Adopted Georgia 6.06% 8.45% $199,357 0.33% 22.10% 1.90% Not adopted Florida 9.91% 7.53% $176,559 0.29% 21.30% 1.10% Not adopted West Virginia 8.56% 6.46% $153,761 0.25% 26.30% 6.10% Adopted Tennessee 9.31% 6.16% $147,936 0.24% 22.70% 2.50% Not adopted Louisiana 7.57% 6.08% $147,936 0.24% 28.60% 8.40% Adopted New Mexico 5.94% 5.89% $147,936 0.24% 28.50% 8.30% Adopted