Healthcare Costs for Medicare Patients With Hepatocellular Carcinoma in the United States

BACKGROUND & AIMS

Hepatocellular carcinoma (HCC) has an increasing mortality in the United States and is a leading cause of morbidity and mortality in patients with cirrhosis. We aimed to estimate the financial burden related to HCC in a large nationally representative United States cohort.

METHODS

We used the Surveillance, Epidemiology, and End Results program (SEER)-Medicare database to identify 4525 adult patients who were diagnosed with HCC between 2011 and 2015. We generated a 1:1 propensity score-matched cohort of patients with cirrhosis but no HCC as a comparator group to define incremental HCC-specific costs beyond costs related to underlying cirrhosis. Our main outcomes were patient liabilities and Medicare payments in the first year after HCC diagnosis.

RESULTS

Compared with patients with cirrhosis, those with HCC had higher incremental patient liabilities (median +$7166; interquartile range, $2401-$16,099) and Medicare payments (+$50,110; interquartile range, $142,42-$136,239; P < .001 for both) in the first year after diagnosis. Patients with HCC had significantly higher inpatient, outpatient, and physician service costs compared with the matched cohort with cirrhosis (P < .001 for all). Patients with early-stage HCC had lower incremental patient liabilities (median, $4195 vs $8238; P < .001) and Medicare payments (median, $28,207 vs $59,509; P < .001) than those with larger tumor burden. In multivariable median regression analysis, incremental patient liabilities and Medicare payments were significantly associated with the National Cancer Institute comorbidity index, nonalcoholic fatty liver disease etiology, presence of ascites, and presence of hepatic encephalopathy.

CONCLUSIONS

Patients with HCC suffer from cancer-related financial burden, highlighting a need for policy interventions and financial support systems.

Association Between Postdischarge Medical Oncology Follow-Up Appointments and Downstream Health Care Use: A Single-Institution Experience

PURPOSE:

There is limited understanding of the role of postdischarge medical oncology follow-up during care transition periods. Our study describes the care transition patterns and the association between postdischarge medical oncology appointments and downstream health care use at a tertiary academic center.

METHODS:

We conducted a retrospective cohort study of 25,135 medical oncology admissions between 2018 and 2020 at Yale New Haven Hospital. We examined the association between postdischarge medical oncology appointment timing with 30-day all-cause readmissions and emergency department (ED) visits using multivariable logistic regression models and propensity score–matched analyses.

RESULTS:

Compared with admissions without appointment within 30 days, admissions with postdischarge medical oncology appointment within 30 days were associated with lower rates of all-cause 30-day readmission (odds ratio [OR] = 0.56, 95% CI, 0.52 to 0.59; P < .001) and ED visit (OR = 0.56, 95% CI, 0.52 to 0.59; P < .001). Admissions with appointment ≤ 14 days were associated with lower rates of 30-day readmission (OR = 0.28, 95% CI, 0.25 to 0.32; P < .001) and ED visit (OR = 0.56, 95% CI, 0.52 to 0.63; P < .001) compared with those with appointment within 15-30 days. Similar patterns in health care use were seen with propensity score matching. Subgroup analyses of cancer types with the most admissions observed similar trends between 30-day readmission and ED visits with appointment timing.

CONCLUSION:

Timely postdischarge medical oncology appointments were associated with significantly lower likelihood of 30-day readmission and ED visits, suggesting a potential role for postdischarge follow-up as an intervention to decrease health care use.

Effect of a Community Health Worker Intervention on Acute Care Use, Advance Care Planning, and Patient-Reported Outcomes Among Adults With Advanced Stages of Cancer: A Randomized Clinical Trial

Importance

Deficiencies in advance care planning and symptom management are associated with avoidable acute care use among patients with cancer. Community health worker (CHW)-led approaches may be an approach to reduce acute care use but remain untested in community settings.

Objective

To determine whether a CHW-led advance care planning and symptom screening intervention can reduce acute care use more than usual care in a community setting.

Design, Setting, and Participants

This randomized clinical trial was conducted among patients with newly diagnosed advanced-stage or recurrent solid and hematologic cancers from August 8, 2017, through November 30, 2021. Data analysis was performed November 30, 2021, through January 1, 2022, by intention to treat.

Interventions

Participants were randomized 1:1 to usual care (control group) or usual care with the 6-month CHW-led intervention (intervention group).

Main Outcomes and Measures

The primary outcome was acute care use. Secondary outcomes included advance care planning documentation, supportive care use, patient-reported outcomes, survival, and end-of-life care use.

Results

Among 128 participants, median (range) age was 67 (19-89) years; 61 (47.7%) were female; and 2 (1.6%) were American Indian or Alaska Native, 11 (8.6%) were Asian, 5 (3.9%) were Black, 23 (18.0%) were Hispanic or Latino, 2 (1.6%) were of mixed race, 2 (1.6%) were Native Hawaiian or other Pacific Islander, 86 (67.2%) were White, and 20 (15.6%) did not report race. Intervention participants had 62% lower risk of acute care use than the control (hazard ratio, 0.38; 95% CI, 0.19-0.76) within 6 months. At 12 months, intervention participants had 17% lower odds of acute care use (odds ratio [OR], 0.83; 95% CI, 0.69-0.98), 8 times the odds of advance care planning documentation (OR, 7.18; 95% CI, 2.85-18.13), 4 times the odds of palliative care (OR, 4.46; 95% CI, 1.88-10.55), nearly double the odds of hospice (OR, 1.83; 95% CI, 1.16-2.88), and nearly double the odds of improved mental and emotional health from enrollment to 6 and 12 months postenrollment (OR, 1.82; 95% CI, 1.03-3.28; and OR, 2.20; 95% CI, 1.04-4.65, respectively) than the control. There were no differences in the death (control, 26 [40.6%] vs intervention, 32 [50.0%]). Fewer intervention participants had acute care use (0 vs 6 [23.1%]) in the month before death than the control.

Conclusions and Relevance

In this randomized clinical trial, integration of a CHW-led intervention into cancer care reduced acute care use and is one approach to improve cancer care delivery for patients with advanced stages of disease in community settings.

Trial Registration

ClinicalTrials.gov Identifier: NCT03154190.

Accountable care in oncology: Where do we go from here?

The study by Erfani et al. confirms that ACOs did not achieve the promise of cancer care cost reduction, but leaves open important questions about the impacts of accountable care on the quality, coordination, and equity of cancer care delivery. While the inability of ACOs to deliver cost reductions for patients with cancer may feel like a step backwards for accountable care in oncology, the work of Erfani et al. actually represents an important step forward in the field, settling the important cost question in order to open a broader conversation on the goals of ACOs and value-based care delivery models in oncology, the means to evaluate them in a comprehensive, patient-centered manner, and the urgency of incorporating the needs and voices of diverse populations in the important work of cancer care delivery reform.

The study by Erfani et al. confirms that ACOs did not achieve the promise of cancer care cost reduction, but leaves open important questions about the impacts of accountable care on the quality, coordination, and equity of cancer care delivery.

The Oncology Care Model and Adherence to Oral Cancer Drugs: A Difference-in-Differences Analysis

BACKGROUND

Adherence to oral cancer drugs is suboptimal. The Oncology Care Model (OCM) offers oncology practices financial incentives to improve the value of cancer care. We assessed the impact of OCM on adherence to oral cancer therapy for chronic myelogenous leukemia (CML), prostate cancer, and breast cancer.

METHODS

Using 2014-2019 Medicare data, we studied chemotherapy episodes for Medicare fee-for-service beneficiaries prescribed tyrosine kinase inhibitors (TKIs) for CML, antiandrogens (ie, enzalutamide, abiraterone) for prostate cancer, or hormonal therapies for breast cancer in OCM-participating and propensity-matched comparison practices. We measured adherence as the proportion of days covered and used difference-in-difference (DID) models to detect changes in adherence over time, adjusting for patient, practice, and market-level characteristics.

RESULTS

There was no overall impact of OCM on improved adherence to TKIs for CML (DID = -0.3%, 90% confidence interval [CI] = -1.2% to 0.6%), antiandrogens for prostate cancer (DID = 0.4%, 90% CI = -0.3% to 1.2%), or hormonal therapy for breast cancer (DID = 0.0%, 90% CI = -0.2% to 0.2%). Among episodes for Black beneficiaries in OCM practices, for whom adherence was lower than for White beneficiaries at baseline, we observed small improvements in adherence to high cost TKIs (DID = 3.0%, 90% CI = 0.2% to 5.8%) and antiandrogens (DID = 2.2%, 90% CI = 0.2% to 4.3%).

CONCLUSIONS

OCM did not impact adherence to oral cancer therapies for Medicare beneficiaries with CML, prostate cancer, or breast cancer overall but modestly improved adherence to high-cost TKIs and antiandrogens for Black beneficiaries, who had somewhat lower adherence than White beneficiaries at baseline. Patient navigation and financial counseling are potential mechanisms for improvement among Black beneficiaries.

Implementation of the Institute of Medicine Treatment Plan in Oncology Practice

Participation in the Centers for Medicare & Medicaid Services (CMS) value-based payment reform, the Oncology Care Model (OCM), requires that every beneficiary has a documented 13-point Institute of Medicine treatment plan (TP) when commencing antineoplastic therapy. The intent is to enhance shared decision-making between the patient and care team by providing transparent treatment recommendations and engaging patients and caregivers in meaningful discussion. There is limited discussion in the literature about how to adapt the CMS recommendations to diverse practice settings while maintaining fidelity to the intent of the TP. Here, the authors compare how 3 clinically and geographically unique OCM participating institutions implemented the TP in their respective institutions within the domains of the Consolidated Framework for Implementation Research. Similar themes in implementation are identified, including engaging stakeholders, leveraging information technology, and considering scalability. Adaptations that are unique to the culture and setting of each site are also described.

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.

Supportive health education reduces health care utilization and costs in Latinas with breast cancer and their caregivers

PURPOSE

To compare costs and relative cost savings from reductions in unscheduled health services use for two 8-week psychosocial interventions (telephone interpersonal counseling [TIPC], supportive health education [SHE]) delivered by telephone to Latinas with breast cancer and their informal caregivers. Cost information is required before adopting supportive care interventions as part of routine care. There is limited information on costs of producing supportive care interventions or their impact on service use.

METHODS

Latinas and their caregivers were randomized to either TIPC or SHE. At baseline and month 4, hospitalizations and urgent care and emergency department (ED) visits in the previous month were recorded. These were compared by trial arm for 181 survivors and 169 caregivers using logistic regression, adjusting for age and health services use at baseline.

RESULTS

Total cost per 100 survivors was $28,695 for SHE and $27,399 for TIPC. Urgent care and ED visits were reduced for survivors in SHE versus TIPC (odds ratio (OR) = 0.31, 95% confidence interval (CI) [0.12, 0.88], p = .03). For hospitalizations, OR for SHE versus TIPC was 0.59, 95% CI [0.26, 1.37], p = .07. There were no differences between trial arms for caregiver health services use. Cost savings for SHE versus TIPC from reductions in health services use per 100 survivors ranged from $800 for urgent care to $17,000 for ED visits and $13,000 for hospitalizations.

CONCLUSIONS

Based on this evidence, SHE can be a cost-saving supportive care solution that benefits not only survivors and caregivers, but also oncology practices reimbursed through episodes of care.

Evaluating the Impact of Oncology Care Model Reporting Requirements on Biomarker Testing and Treatment

PURPOSE

The Oncology Care Model (OCM) is Medicare's first alternative payment model program for patients with cancer. As of October 2017, participating practices were required to report biomarker testing of patients with advanced non-small-cell lung cancer (aNSCLC). Our objective was to evaluate the effect of this OCM reporting requirement on quality of care.

METHODS

We selected patients with aNSCLC receiving care in practices in a nationwide de-identified electronic health record-derived database. We used an adjusted difference-in-differences (DID) logistic regression model to compare changes in biomarker testing rates (EGFR, ROS1, and ALK) and receipt of biomarker-guided therapy between patients in OCM versus non-OCM practices, before and after OCM implementation.

RESULTS

The analysis included 14,048 patients from 45 OCM practices (n = 8,151) and 105 non-OCM practices (n = 5,897). The overall unadjusted rates for biomarker testing and receipt of biomarker-guided therapy increased over the study period (2011-2018) in both OCM (55.5% v 71.6%; 89.8% v 94.6%, respectively) and non-OCM (55.2% v 69.7%; 90.1% v 95.2%, respectively) practices. In the adjusted DID model, the rates of biomarker testing (odds ratio [OR], 1.09 [95% CI, 0.88 to 1.34]; P = .45) and receipt of biomarker-guided therapy (OR, 0.87 [95% CI, 0.52 to 1.45]; P = .58) were similar between OCM and non-OCM practices.

CONCLUSION

OCM biomarker documentation and reporting requirements did not appear to increase the proportions of patients with aNSCLC who underwent testing or who received biomarker-guided therapy in OCM versus non-OCM practices.

The Changing Health Insurance Coverage Landscape in the United States

Changes in the health insurance coverage landscape in the United States during the past decade have important implications for receipt and affordability of cancer care. In this paper, we summarize evidence for the association between health insurance coverage and cancer prevention and treatment. We then discuss ongoing changes in health care coverage, including implementation of provisions of the Affordable Care Act, increasing prevalence of high-deductible health insurance plans, and factors that affect health care delivery, with a focus on vertical integration of hospitals and providers. We summarize the evidence for the effects of the changes in health coverage on care and discuss areas for future research with the goal of informing efforts to improve cancer care delivery and outcomes in the United States.

The Affordable Care Act and access to care across the cancer control continuum: A review at 10 years

Lack of health insurance coverage is strongly associated with poor cancer outcomes in the United States. The uninsured are less likely to have access to timely and effective cancer prevention, screening, diagnosis, treatment, survivorship, and end-of-life care than their counterparts with health insurance coverage. On March 23, 2010, the Patient Protection and Affordable Care Act (ACA) was signed into law, representing the largest change to health care delivery in the United States since the introduction of the Medicare and Medicaid programs in 1965. The primary goals of the ACA are to improve health insurance coverage, the quality of care, and patient outcomes, and to maintain or lower costs by catalyzing changes in the health care delivery system. In this review, we describe the main components of the ACA, including health insurance expansions, coverage reforms, and delivery system reforms, provisions within these components, and their relevance to cancer screening and early detection, care, and outcomes. We then highlight selected, well-designed studies examining the effects of the ACA provisions on coverage, access to cancer care, and disparities throughout the cancer control continuum. Finally, we identify research gaps to inform evaluation of current and emerging health policies related to cancer outcomes.