Evaluating the Addition of Clinical and Staging Data to Improve the Pricing Methodology of the Oncology Care Model

PURPOSE

The Oncology Care Model (OCM) is the largest value-based care model focusing on oncology, but the current pricing methodology excludes relevant data on the cancer stage and current clinical status, limiting the precision of the risk adjustment.

METHODS

This analysis evaluated 15,580 episodes of breast cancer, lung cancer, and multiple myeloma, starting between July 1, 2016, and January 1, 2020, with data from a cohort of OCM practices affiliated with academic medical centers. The authors merged clinical data with claims for OCM episodes defined by the Center for Medicare and Medicaid Innovation to identify potential quality improvement opportunities. The regression model evaluated the association of the cancer stage at initial diagnosis and current clinical status with variance to the OCM target price.

RESULTS

Cancer stage at the time of initial diagnosis was significant for breast and lung cancers, with stage IV episodes having the highest losses of -$6,700 (USD) for breast cancer (P < .001) and -$18,470 (USD) for lung cancer (P < .001). Current clinical status had a significant impact for all three cancers in the analysis, with losses correlated with clinical complexity. Breast cancer and multiple myeloma episodes categorized as recurrent or progressive disease had significantly higher losses than stable episodes, at -$6,755 (USD) for breast (P < .001) and -$19,448 (USD) for multiple myeloma (P < .001). Lung cancer episodes categorized as initial diagnosis had significantly fewer losses than stable episodes, at -$3,751 (USD) (P = .001).

CONCLUSION

As the Center for Medicare and Medicaid Innovation designs and launches new oncology-related models, the agency should adopt methodologies that more accurately set target prices, by incorporating relevant clinical data within cancer types to minimize penalizing practices that provide guideline-concordant cancer care.

Policies and Practices to Address Cancer's Long-term Adverse Consequences

As cancer detection and treatment improve, the number of long-term survivors will continue to grow, as will the need to improve their survivorship experience and health outcomes. We need to better understand cancer and its treatment's short- and long-term adverse consequences, and to prevent, detect, and treat these consequences effectively. Delivering care through a collaborative care model, standardizing information offered to and collected from patients, standardizing approaches to documenting, treating, and reducing adverse effects, and creating a data infrastructure to make population-based information widely available are all actions that can improve survivors' outcomes. National policies that address gaps in insurance coverage, the cost and value of treatment and survivorship care, and worker benefits such as paid sick leave can also concurrently reduce cancer burden. The National Cancer Policy Forum and the Forum on Aging, Disability, and Independence at the National Academies of Sciences, Engineering, and Medicine sponsored a virtual workshop on Addressing the Adverse Consequences of Cancer Treatment, November 9-10, 2020, to examine long-term adverse consequences of cancer treatment and to identify practices and policies to reduce treatment's negative impact on survivors. This commentary discusses high-priority issues raised during the workshop and offers a path forward.

Integrated practice units present an opportunity over siloed survivorship care settings

Given the rapidly rising cancer burden in the USA, the need to innovate survivorship care for oncology patients is rising rapidly. The current body of empirical evidence in survivorship care has focused on care provided by general practitioners (GP) and specialists/surgeons (SS). In particular, current evaluations address cost of care, cancer recurrence, quality of life, and overall survival of patients, with results indicating no statistically significant differences in GP- and SS-led care models and little emphasis on the broader characteristics of care settings. We fill this gap in survivorship care by introducing a perspective on the potential for holistic care delivery with a multidisciplinary team approach at integrated practice units (IPUs). Additionally, we propose a comprehensive examination of survivorship care across GP-, SS-, and IPU-led settings to provide researchers and practitioners with solid ground to determine the optimal survivorship care model, considering four key characteristics: (1) operating mode and skills, (2) cost and accountability of care, (3) health outcome measurement, and (4) workflow and scheduling.

Trends in Cancer Treatment Service Availability Across Critical Access Hospitals and Prospective Payment System Hospitals

BACKGROUND

Rural residents experience worse cancer prognosis and access to cancer care providers than their urban counterparts. Critical access hospitals (CAHs) represent over half of all rural community hospitals. However, research on cancer services provided within CAHs is limited.

OBJECTIVE

The objective of this study was to investigate trends in cancer services availability in urban and rural Prospective Payment System (PPS) hospitals and CAHs.

DESIGN

Retrospective, time-series analysis using data from 2008 to 2017 American Hospital Association Annual Surveys. Multivariable logistic regressions were used to examine differential trends in cancer services between urban PPS, rural PPS, and CAHs, overall and among small (<25 beds) hospitals.

SUBJECTS

All US acute care and cancer hospitals (4752 in 2008 to 4722 in 2017).

MEASURES

Primary outcomes include whether a hospital provided comprehensive oncology services, chemotherapy, and radiation therapy each year.

RESULTS

In 2008, CAHs were less likely to provide all cancer services, especially chemotherapy (30.4%) and radiation therapy (2.9%), compared with urban (64.4% and 43.8%, respectively) and rural PPS hospitals (42.0% and 23.3%, respectively). During 2008-2017, compared with similarly sized PPS hospitals, CAHs were more likely to provide oncology services and chemotherapy, but with decreasing trends. Radiation therapy availability between small PPS hospitals and CAHs did not differ.

CONCLUSIONS

Compared with all PPS hospitals, CAHs offered fewer cancer treatment services and experienced a decline in service capability over time. These differences in chemotherapy services were mainly driven by hospital size, as small urban and rural PPS hospitals had lower rates of chemotherapy than CAHs. Still, the lower rates of radiotherapy in CAHs highlight disproportionate challenges facing CAHs for some specialty services.

Breast Cancer Stage Is Associated With Exceeding Target Price in the Oncology Care Model

PURPOSE

To explore mean difference between Oncology Care Model (OCM) total costs and target price among breast cancer episodes by stage under the Centers for Medicare and Medicaid Services OCM payment methodology.

METHODS

Breast cancer episodes from OCM performance period 1-4 reconciliation reports (July 1, 2016-July 1, 2018) were linked with health record data from a large, academic medical center. Demographics, total cost of care (TCOC), and target price were measured by stage. Adjusted differences between TCOC and target price were compared across cancer stage using multivariable linear regression.

RESULTS

A total of 539 episodes were evaluated from 252 unique patients with breast cancer, of which 235 (44%) were stage I, 124 (23%) stage II, 33 (6%) stage III, and 147 (27%) stage IV. About 37% of episodes exceeded target price. Mean differences from target price were -$1,782, $2,246, -$6,032, and $11,379 all in US dollars (USD) for stages I through IV, respectively. Stage IV episodes had highest mean TCOC ($44,210 USD) and mean target price ($32,831 USD) but also had higher rates of chemotherapy, inpatient admission, and novel therapy use. After adjusting for covariates, stage IV and ≥ 65-year-old patients had the highest mean difference from target price ($17,175 USD; 95% CI, $12,452 to $21,898 USD).

CONCLUSION

Breast cancer episodes in older women with distant metastases most frequently exceeded target price, suggesting that target price did not adequately account for complexity of metastatic cancers. A metastatic adjustment introduced in PP7 represents a promising advancement in the target price methodology and an impact evaluation will be needed.

Potential Winners and Losers: Understanding How the Oncology Care Model May Differentially Affect Hospitals

PURPOSE

With the introduction of the Oncology Care Model and plans for the transition to Oncology Care First, alternative payment models (APMs) are an increasingly important piece of the oncology care landscape. Evidence is mixed on the Oncology Care Model's impact on utilization and costs, but as policymakers consider expansion of similar models, it is critical to understand the characteristics of hospitals that may be differentially affected.

METHODS

We used 2007-2016 SEER-Medicare data to identify patients with breast and prostate cancer receiving chemotherapy, endocrine therapy (breast), or androgen deprivation therapy (prostate). For each hospital, we calculated 6-month expected mortality, emergency department (ED) visits, inpatient admissions, and costs, all commonly collected APM outcomes. After calculating observed-to-expected rates for each outcome by hospital, we estimated the association between observed-to-expected rates and characteristics of each hospital to understand hospital characteristics that might be associated with higher- or lower-than-expected rates of each outcome.

RESULTS

Hospitals with > 15% rural patients had significantly higher-than-expected mortality (0.31 points higher, P < .001) and ED visit rates (0.10 points higher, P = .029) as well as significantly lower costs (0.06 points lower, P = .004). Hospitals unaffiliated with a medical school also experienced significantly higher-than-expected mortality and ED visits. Hospitals eligible for disproportionate share hospital payment experienced significantly higher ED visits but lower costs. For-profit hospitals experienced higher-than-expected mortality.

CONCLUSION

Rural hospitals and those unaffiliated with a medical school may require special consideration as APMs expand in oncology care. Designated cancer centers and larger hospitals may be advantaged.

Expenditures among young adults with acute lymphoblastic leukemia by site of care

BACKGROUND

Individuals diagnosed with acute lymphoblastic leukemia (ALL) between the ages of 22 and 39 years experience worse outcomes than those diagnosed when they are 21 years old or younger. Treatment at National Cancer Institute-designated Comprehensive Cancer Centers (CCC) mitigates these disparities but may be associated with higher expenditures.

METHODS

Using deidentified administrative claims data (OptumLabs Data Warehouse), the cancer-related expenditures were examined among patients with ALL diagnosed between 2001 and 2014. Multivariable generalized linear model with log-link modeled average monthly health-plan-paid (HPP) expenditures and amount owed by the patient (out-of-pocket [OOP]). Cost ratios were used to calculate excess expenditures (CCC vs non-CCC). Incidence rate ratios (IRRs) compared CCC and non-CCC monthly visit rates. Models adjusted for sociodemographics, comorbidities, adverse events, and months enrolled.

RESULTS

Clinical and sociodemographic characteristics were comparable between CCC (n = 160) and non-CCC (n = 139) patients. Higher monthly outpatient expenditures in CCC patients ($15,792 vs $6404; P < .001) were driven by outpatient hospital HPP expenditures. Monthly visit rates and per visit expenditures for nonchemotherapy visits (IRR = 1.6; P = .001; CCC = $8247, non-CCC = $1191) drove higher outpatient hospital expenditures among CCCs. Monthly OOP expenditures were higher at CCCs for outpatient care (P = .02). Inpatient HPP expenditures were significantly higher at CCCs ($25,918 vs $13,881; ꞵ = 0.9; P < .001) before accounting for adverse events but were no longer significant after adjusting for adverse events (ꞵ = 0.4; P = .1). Hospitalizations and length of stay were comparable.

CONCLUSIONS

Young adults with ALL at CCCs have higher expenditures, likely reflecting differences in facility structure, billing practices, and comprehensive patient care. It would be reasonable to consider CCCs comparable to the oncology care model and incentivize the framework to achieve superior outcomes and long-term cost savings.

LAY SUMMARY

Health care expenditures in young adults (aged 22-39 years) with acute lymphoblastic leukemia (ALL) are higher among patients at National Cancer Institute-designated Comprehensive Cancer Centers (CCC) than those at non-CCCs. The CCC/non-CCC differences are significant among outpatient expenditures, which are driven by higher rates of outpatient hospital visits and outpatient hospital expenditures per visit at CCCs. Higher expenditures and visit rates of outpatient hospital visits among CCCs may also reflect how facility structure and billing patterns influence spending or comprehensive care. Young adults at CCCs face higher inpatient HPP expenditures; these are driven by serious adverse events.

Utilization of Clinical Pathways Can Reduce Drug Spend Within the Oncology Care Model

PURPOSE:

Reducing drug spend is one of the greatest challenges for practices participating in the Oncology Care Model (OCM). Evidence-based clinical pathways have the potential to decrease drug spend while maintaining clinical outcomes consistent with published evidence. The goal of this study was to determine whether voluntary use of clinical pathways by a practice can maximize OCM episodic cost savings.

METHODS AND MATERIALS:

A community oncology practice used evidence-based clinical pathways for OCM-attributed patients. All treatment plans were submitted to the pathway vendor in real time for clinical pathway adherence measurement. Analysis was conducted before implementation and on an ongoing daily and weekly basis to identify cases in which higher cost drugs or regimens were ordered. A clinical data governance committee met biweekly to review clinical pathway performance metrics and drug utilization.

RESULTS:

From quarter 1 of 2017 to quarter 1 of 2019, the median drug spend increased less rapidly for Cancer Care Specialists of Illinois (CCSI; 18.6%) compared with OCM (34.4%). Furthermore, the percent difference in drug spend for CCSI relative to OCM decreased from 13.5% to 0.1% (P < .001). Each quarter, there was approximately a 1.7% decrease (95% CI, 1.0% to 2.4%) in drug spend for CCSI relative to OCM. Additional analyses found that, over a 15-month period (October 2017 through December 2019), CCSI achieved an increase in pathway adherence from 69% to 81%.

CONCLUSION:

Reduction in drug spend is possible within a value-based care model, using evidence-based clinical pathways.