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Dickson NR, Beauchamp KD, Perry TS, Roush A, Goldschmidt D, Edwards ML, Blakely LJ. Impact of clinical pathways on treatment patterns and outcomes for patients with non-small-cell lung cancer: real-world evidence from a community oncology practice. J Comp Eff Res 2022; 11:609-619. [PMID: 35546311 DOI: 10.2217/cer-2021-0290] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Introduction: The evolving treatment landscape for non-small-cell lung cancer (NSCLC) and complexities of regulations and reimbursement present challenges to community oncologists. Clinical pathways are tools to optimize care, but information on their value in the real world is limited. This retrospective study assessed treatment patterns and clinical outcomes in patients with Stage I-III NSCLC pre- and post-pathways implementation at Tennessee Oncology, a large, community-based oncology practice in the USA. Methods & Materials: Chart data were abstracted for adults diagnosed with Stage I-III NSCLC who received systemic treatment. Patients were divided into pre-pathways (treatment initiation 2014-2015) and post-pathways (treatment initiation 2016-2018) cohorts. Patient characteristics, treatment patterns and outcomes were summarized descriptively. Kaplan-Meier curves were used to assess time-dependent outcomes, and log-rank test was used to compare the cohorts. Results: 291 patients were included (Stage I-II: 38 pre-pathways, 55 post-pathways; Stage III: 105 pre-pathways, 93 post-pathways). Duration on first-line (1L) therapy was similar for Stage I-II patients pre- and post-pathways (median 1.9 months vs 2.1 months; p = 0.75), but increased for Stage III patients post-pathways (2.1 months vs 1.4 months pre-pathways; p < 0.01). Achievement of a complete or partial response with 1L therapy was similar post-pathways among Stage I-Stage -IIII patients (60.0% vs 55.2% pre-pathways), but increased for Stage III patients (56.0% vs 35.2% pre-pathways). Conclusion: Given that improvements in rates of treatment response post-pathways occurred only for patients diagnosed with Stage III NSCLC, among whom immunotherapy uptake increased post-pathways, such improvements may be attributable to evolving practices in cancer care, including advances in treatment and care delivery, rather than clinical pathways implementation. Further research is warranted to assess the impact of clinical pathways in the current treatment era, given that immunotherapy has now become the standard of care in NSCLC.
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West HJ, Tan YA, Barzi A, Wong D, Parsley R, Sachs T. Novel Program Offering Remote, Asynchronous Subspecialist Input in Thoracic Oncology: Early Experience and Insights Gained During the COVID-19 Pandemic. JCO Oncol Pract 2021; 18:e537-e550. [PMID: 34860558 PMCID: PMC9014456 DOI: 10.1200/op.21.00339] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE AccessHope is a program developed initially by City of Hope to provide remote subspecialist input on cancer care for patients as a supplemental benefit for specific payers or employers. The leading platform for this work has been an asynchronous model of review of medical records followed by a detailed assessment of past and current management along with discussion of potential future options in a report sent to the local oncologist. This summary describes an early period of development and growth of this service, focusing on cases of lung cancer, particularly during the COVID-19 pandemic. METHODS Cases were primarily identified by a trigger list of cancer diagnoses that included non-small-cell lung cancer and small-cell lung cancer. After medical records were obtained, a summary narrative was provided to a thoracic oncology specialist who wrote a case review sent to the local physician, followed by a direct discussion with the recipient. We focused on feasibility as measured by case volumes, the rates of concordance between the subspecialist reviewer with the local team, and cost savings from recommended changes, using descriptive statistics. RESULTS From April 2019 to November 2020, 110 cases were reviewed: 55% male, median age 62.5 years (range, 33-92 years); 82% non-small-cell lung cancer (12% stage I or II, 16% stage III, and 57% stage IV), and 17% small-cell lung cancer (4% limited and 14% extensive). Median turnaround time for report send-out was 5.0 days. The review agreed with local management in 79 (72%) cases and disagreed in 31 (28%) cases; notably, specific additional recommendations were associated with evidence-based anticipated improvements in efficacy in 76 cases (69%) and improvement in potential for cure in 14 cases (13%). Recommendations leading to cost savings were identified in 14 cases (13%), translating to a projected cost savings of $19,062 (USD) per patient for the entire cohort of patient cases reviewed. CONCLUSION We demonstrate the feasibility of completing a rapid turnaround of cases of lung cancer either patient-initiated for review or prospectively triggered by diagnosis and stage. This program of asynchronous second opinions identified evidence-based management changes affecting current treatment in 28% and potential improvements to improve care in 92% of patients, along with cost savings realized by eliminating low-value interventions.
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Affiliation(s)
- Howard Jack West
- Department of Medical Oncology, City of Hope Comprehensive Cancer Center, Duarte, CA.,AccessHope, Los Angeles, CA
| | | | - Afsaneh Barzi
- Department of Medical Oncology, City of Hope Comprehensive Cancer Center, Duarte, CA.,AccessHope, Los Angeles, CA
| | - Debra Wong
- Department of Medical Oncology, City of Hope Comprehensive Cancer Center, Duarte, CA.,AccessHope, Los Angeles, CA
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Abstract
Value-based care within insurance design utilizes evidence-based medicine as a means of defining high-value versus low-value diagnostics and treatments. The goals of value-based care are to shift spending and coverage toward high-value care and reduce the use of low-value practices. Within oncology, several value-based methods have been proposed and implemented. We review value-based care being used within oncology, including defining the value of oncology drugs through frameworks, clinical care pathways, alternative payment models including the Oncology Care Model, value-based insurance design, and reducing low-value care including the Choosing Wisely initiatives.
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Ostropolets A, Zhang L, Hripcsak G. A scoping review of clinical decision support tools that generate new knowledge to support decision making in real time. J Am Med Inform Assoc 2020; 27:1968-1976. [PMID: 33120430 PMCID: PMC7824048 DOI: 10.1093/jamia/ocaa200] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2020] [Revised: 07/24/2020] [Accepted: 08/04/2020] [Indexed: 12/19/2022] Open
Abstract
OBJECTIVE A growing body of observational data enabled its secondary use to facilitate clinical care for complex cases not covered by the existing evidence. We conducted a scoping review to characterize clinical decision support systems (CDSSs) that generate new knowledge to provide guidance for such cases in real time. MATERIALS AND METHODS PubMed, Embase, ProQuest, and IEEE Xplore were searched up to May 2020. The abstracts were screened by 2 reviewers. Full texts of the relevant articles were reviewed by the first author and approved by the second reviewer, accompanied by the screening of articles' references. The details of design, implementation and evaluation of included CDSSs were extracted. RESULTS Our search returned 3427 articles, 53 of which describing 25 CDSSs were selected. We identified 8 expert-based and 17 data-driven tools. Sixteen (64%) tools were developed in the United States, with the others mostly in Europe. Most of the tools (n = 16, 64%) were implemented in 1 site, with only 5 being actively used in clinical practice. Patient or quality outcomes were assessed for 3 (18%) CDSSs, 4 (16%) underwent user acceptance or usage testing and 7 (28%) functional testing. CONCLUSIONS We found a number of CDSSs that generate new knowledge, although only 1 addressed confounding and bias. Overall, the tools lacked demonstration of their utility. Improvement in clinical and quality outcomes were shown only for a few CDSSs, while the benefits of the others remain unclear. This review suggests a need for a further testing of such CDSSs and, if appropriate, their dissemination.
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Affiliation(s)
- Anna Ostropolets
- Department of Biomedical Informatics, Columbia University Irving Medical Center, New York, New York, USA
| | - Linying Zhang
- Department of Biomedical Informatics, Columbia University Irving Medical Center, New York, New York, USA
| | - George Hripcsak
- Department of Biomedical Informatics, Columbia University Irving Medical Center, New York, New York, USA
- NewYork-Presbyterian Hospital, New York, New York, USA
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5
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Hull O, Niranjan SJ, Wallace AS, Williams BR, Turkman YE, Ingram SA, Williams CP, Smith T, Knight SJ, Bhatia S, Rocque GB. Should we be talking about guidelines with patients? A qualitative analysis in metastatic breast cancer. Breast Cancer Res Treat 2020; 184:115-121. [PMID: 32737711 DOI: 10.1007/s10549-020-05832-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2020] [Accepted: 07/22/2020] [Indexed: 11/28/2022]
Abstract
BACKGROUND Little data exist on perceptions of guideline-based care in oncology. This qualitative analysis describes patients' and oncologists' views on the value of guideline-based care as well as discussing guidelines when making metastatic breast cancer (MBC) treatment decisions. PATIENTS AND METHODS In-person interviews completed with MBC patients and community oncologists and focus groups with academic oncologists were audio-recorded and transcribed. Two coders utilized a content analysis approach to analyze transcripts independently using NVivo. Major themes and exemplary quotes were extracted. RESULTS Participants included 20 MBC patients, 6 community oncologists, and 5 academic oncologists. Most patients were unfamiliar with the term "guidelines." All patients desired to know if they were receiving guideline-discordant treatment but were often willing to accept this treatment. Five themes emerged explaining this including trusting the oncologist, relying on the oncologist's experiences, being informed of rationale for deviation, personalized treatment, and openness to novel therapies. Physician discussions regarding the importance of guidelines revealed three themes: consistency with scientific evidence, insurance coverage, and limiting unusual practices. Oncologists identified three major limitations in using guidelines: lack of consensus, inability to "think outside the box" to personalize treatment, and lack of guideline timeliness. Although some oncologists discussed guidelines, it was often not considered a priority. CONCLUSIONS Patients expressed a desire to know whether they were receiving guideline-based care but were amenable to guideline-discordant treatment if the rationale was made clear. Providers' preference to limit discussions of guidelines is discordant with patients' desire for this information and may limit shared decision-making.
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Affiliation(s)
- Olivia Hull
- Division of Hematology and Oncology, Department of Medicine, The University of Alabama at Birmingham, WTI 240, 1720 2nd Avenue South, Birmingham, AL, 35294, USA
| | - Soumya J Niranjan
- School of Health Professions, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Audrey S Wallace
- Department of Radiation Oncology, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Beverly R Williams
- Division of Gerontology, Geriatrics and Palliative Care, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Yasemin E Turkman
- School of Nursing, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Stacey A Ingram
- Division of Hematology and Oncology, Department of Medicine, The University of Alabama at Birmingham, WTI 240, 1720 2nd Avenue South, Birmingham, AL, 35294, USA
| | - Courtney P Williams
- Division of Hematology and Oncology, Department of Medicine, The University of Alabama at Birmingham, WTI 240, 1720 2nd Avenue South, Birmingham, AL, 35294, USA
| | - Tom Smith
- Division of Palliative Care, The Johns Hopkins Hospital, Baltimore, MD, USA
| | - Sara J Knight
- Department of Internal Medicine, Division of Epidemiology, University of Utah, Salt Lake City, UT, USA.,Informatics, Decision-Enhancement, and Analytical Sciences (IDEAS) Center, Department of Veteran Affairs, Salt Lake City Health Care System, Salt Lake City, UT, USA
| | - Smita Bhatia
- Institute for Cancer Outcomes and Survivorship, University of Alabama at Birmingham, Birmingham, AL, USA.,Comprehensive Cancer Center, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Gabrielle B Rocque
- Division of Hematology and Oncology, Department of Medicine, The University of Alabama at Birmingham, WTI 240, 1720 2nd Avenue South, Birmingham, AL, 35294, USA. .,Division of Gerontology, Geriatrics and Palliative Care, University of Alabama at Birmingham, Birmingham, AL, USA. .,Comprehensive Cancer Center, University of Alabama at Birmingham, Birmingham, AL, USA.
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6
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Lee XJ, Blythe R, Choudhury AAK, Simmons T, Graves N, Kularatna S. Review of methods and study designs of evaluations related to clinical pathways. AUST HEALTH REV 2020; 43:448-456. [PMID: 30089529 DOI: 10.1071/ah17276] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2017] [Accepted: 05/19/2018] [Indexed: 11/23/2022]
Abstract
Objective The HealthPathways program is an online information portal that helps clinicians provide consistent and integrated patient care within a local health system through localised pathways for diagnosis, treatment and management of various health conditions. These pathways are consistent with the definition of clinical pathways. Evaluations of HealthPathways programs have thus far focused primarily on website utilisation and clinical users' experience and satisfaction, with limited evidence on changes to patient outcomes. This lack motivated a literature review of the effects of clinical pathways on patient and economic outcomes to inform a subsequent HealthPathways evaluation. Methods A systematic review was performed to summarise the analytical methods, study designs and results of studies evaluating clinical pathways with an economic outcome component published between 1 January 2000 and 31 August 2017 in four academic literature databases. Results Fifty-five relevant articles were identified for inclusion in this review. The practical pre-post study design with retrospective baseline data extraction and prospective intervention data collection was most commonly used in the evaluations identified. Straightforward statistical methods for comparing outcomes, such as the t-test or χ2 test, were frequently used. Only four of the 55 articles performed a cost-effectiveness analysis. Clinical pathways were generally associated with improved patient outcomes and positive economic outcomes in hospital settings. Conclusions Clinical pathways evaluations commonly use pragmatic study designs, straightforward statistical tests and cost-consequence analyses. More HealthPathways program evaluations focused on patient and economic outcomes, clinical pathway evaluations in a primary care setting and cost-effectiveness analyses of clinical pathways are needed. What is known about the topic? HealthPathways is a web-based program that originated from Canterbury, New Zealand, and has seen uptake elsewhere in New Zealand, Australia and the UK. The HealthPathways program aims to assist the provision of consistent and integrated health services through dedicated, localised pathways for various health conditions specific to the health region. Evaluations of HealthPathways program focused on patient and economic outcomes have been limited. What does this paper add? This review synthesises the academic literature of clinical pathways evaluations in order to inform a subsequent HealthPathways evaluation. The focus of the synthesis was on the analytical methods and study designs used in the previous evaluations. The previous clinical pathway evaluations have been pragmatic in nature with relatively straightforward study designs and analysis. What are the implications for practitioners? There is a need for more economic and patient outcome evaluations for HealthPathways programs. More sophisticated statistical analyses and economic evaluations could add value to these evaluations, where appropriate and taking into consideration the data limitations.
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Affiliation(s)
- Xing Ju Lee
- Institute of Health and Biomedical Innovations, School of Public Health and Social Work, Queensland University of Technology, Brisbane, 60 Musk Avenue, Kelvin Grove, Qld 4059, Australia.
| | - Robin Blythe
- Institute of Health and Biomedical Innovations, School of Public Health and Social Work, Queensland University of Technology, Brisbane, 60 Musk Avenue, Kelvin Grove, Qld 4059, Australia.
| | - Adnan Ali Khan Choudhury
- Northern Queensland Primary Health Network, James Cook University, Building 500, 1 James Cook Drive, Douglas, Qld 4811, Australia. Email
| | - Toni Simmons
- Mackay Hospital and Health Service, Mackay, 475 Bridge Road, Mackay, Qld 4740, Australia. Email
| | - Nicholas Graves
- Institute of Health and Biomedical Innovations, School of Public Health and Social Work, Queensland University of Technology, Brisbane, 60 Musk Avenue, Kelvin Grove, Qld 4059, Australia.
| | - Sanjeewa Kularatna
- Institute of Health and Biomedical Innovations, School of Public Health and Social Work, Queensland University of Technology, Brisbane, 60 Musk Avenue, Kelvin Grove, Qld 4059, Australia.
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Rajurkar S, Mambetsariev I, Pharaon R, Leach B, Tan T, Kulkarni P, Salgia R. Non-Small Cell Lung Cancer from Genomics to Therapeutics: A Framework for Community Practice Integration to Arrive at Personalized Therapy Strategies. J Clin Med 2020; 9:E1870. [PMID: 32549358 PMCID: PMC7356243 DOI: 10.3390/jcm9061870] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2020] [Revised: 06/12/2020] [Accepted: 06/12/2020] [Indexed: 12/25/2022] Open
Abstract
Non-small cell lung cancer (NSCLC) is a heterogeneous disease, and therapeutic management has advanced with the identification of various key oncogenic mutations that promote lung cancer tumorigenesis. Subsequent studies have developed targeted therapies against these oncogenes in the hope of personalizing therapy based on the molecular genomics of the tumor. This review presents approved treatments against actionable mutations in NSCLC as well as promising targets and therapies. We also discuss the current status of molecular testing practices in community oncology sites that would help to direct oncologists in lung cancer decision-making. We propose a collaborative framework between community practice and academic sites that can help improve the utilization of personalized strategies in the community, through incorporation of increased testing rates, virtual molecular tumor boards, vendor-based oncology clinical pathways, and an academic-type singular electronic health record system.
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Affiliation(s)
| | | | | | | | | | | | - Ravi Salgia
- Department of Medical Oncology and Therapeutics Research, City of Hope, Duarte, CA 91010, USA; (S.R.); (I.M.); (R.P.); (B.L.); (T.T.); (P.K.)
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8
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Li M, Lakdawalla DN, Goldman DP. Association Between Spending and Outcomes for Patients With Cancer. J Clin Oncol 2020; 38:323-331. [PMID: 31804868 PMCID: PMC6994252 DOI: 10.1200/jco.19.01451] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/02/2019] [Indexed: 12/19/2022] Open
Affiliation(s)
- Meng Li
- Leonard D. Schaeffer Center for Health Policy and Economics, University of Southern California, Los Angeles, CA
- Sol Price School of Public Policy, University of Southern California, Los Angeles, CA
| | - Darius N. Lakdawalla
- Leonard D. Schaeffer Center for Health Policy and Economics, University of Southern California, Los Angeles, CA
- Sol Price School of Public Policy, University of Southern California, Los Angeles, CA
- School of Pharmacy, University of Southern California, Los Angeles, CA
| | - Dana P. Goldman
- Leonard D. Schaeffer Center for Health Policy and Economics, University of Southern California, Los Angeles, CA
- Sol Price School of Public Policy, University of Southern California, Los Angeles, CA
- School of Pharmacy, University of Southern California, Los Angeles, CA
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9
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te Marvelde L, McNair P, Whitfield K, Autier P, Boyle P, Sullivan R, Thomas RJ. Alignment with Indices of A Care Pathway Is Associated with Improved Survival: An Observational Population-based Study in Colon Cancer Patients. EClinicalMedicine 2019; 15:42-50. [PMID: 31709413 PMCID: PMC6833448 DOI: 10.1016/j.eclinm.2019.08.009] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2019] [Revised: 06/20/2019] [Accepted: 08/14/2019] [Indexed: 11/04/2022] Open
Abstract
BACKGROUND Causes of variations in outcomes from cancer care in developed countries are often unclear. Australia has developed health system pathways describing consensus standards of optimal cancer care across the phases of prevention through to follow-up or end-of-life. These Optimal Care Pathways (OCP) were introduced from 2013 to 14. We investigated whether care consistent with the OCP improved outcomes for colon cancer patients. METHODS Colon patients diagnosed from 2008 to 2014 were identified from the Australian State of Victoria Cancer Registry (VCR) and cases linked with State and Federal health datasets. Surrogate variables describe OCP alignment in our cohort, across three phases of the pathway; prevention, diagnosis and initial treatment and end-of-life. We assessed the impact of alignment on (1) stage of disease at diagnosis and (2) overall survival. FINDINGS Alignment with the prevention phase of the OCP occurred for 88% of 13,539 individuals and was associated with lower disease stage at diagnosis (OR = 0.33, 95% confidence interval 0.24 to 0.42), improved crude three-year survival (69.2% versus 62.2%; p < 0.001) and reduced likelihood of emergency surgery (17.7% versus 25.6%, p < 0.001). For patients treated first with surgery (n = 10,807), care aligned with the diagnostic and treatment phase indicators (44% of patients) was associated with a survival benefit (risk-adjusted HRnon-aligned vs aligned = 1.23, 95% confidence interval 1.13 to 1.35), better perioperative outcomes and higher alignment with follow-up and end-of-life care. The survival benefit persists adjusting for potential confounding factors, including age, sex, disease stage and comorbidity.Interpretation.This population-based study shows that care aligned to a pathway based on best principles of cancer care is associated with improved outcomes for patients with colon cancer. FUNDING None.
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Affiliation(s)
- Luc te Marvelde
- Cancer Epidemiology Division, Cancer Council Victoria, Australia
- Cancer Strategy & Development, Department of Health and Human Services, Victoria, Australia
| | - Peter McNair
- Victorian Agency for Health Information, Victoria, Australia
| | - Kathryn Whitfield
- Cancer Strategy & Development, Department of Health and Human Services, Victoria, Australia
| | - Philippe Autier
- International Prevention Research Institute (iPRI), Lyon, France
- University of Strathclyde Institute of Global Public Health at IPRI, Lyon, France
| | - Peter Boyle
- International Prevention Research Institute (iPRI), Lyon, France
- University of Strathclyde Institute of Global Public Health at IPRI, Lyon, France
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10
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Nejati M, Razavi M, Harirchi I, Zendehdel K, Nejati P. The impact of provider payment reforms and associated care delivery models on cost and quality in cancer care: A systematic literature review. PLoS One 2019; 14:e0214382. [PMID: 30951536 PMCID: PMC6450626 DOI: 10.1371/journal.pone.0214382] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2018] [Accepted: 03/12/2019] [Indexed: 11/17/2022] Open
Abstract
OBJECTIVES To investigate the impact of provider payment reforms and associated care delivery models on cost and quality in cancer care. METHODS Data sources/study setting: Review of English-language literature published in PubMed, Embase and Cochrane library (2007-2019). Study design: We performed a systematic literature review (SLR) to identify the impact of cancer care reforms. Primary endpoints were resource use, cost, quality of care, and clinical outcomes. Data collection/extraction methods: For each study, we extracted and categorized comparative data on the impact of policy reforms. Given the heterogeneity in patients, interventions and outcome measures, we did a qualitative synthesis rather than a meta-analysis. RESULTS Of the 26 included studies, seven evaluations were in fact qualified as quasi experimental designs in retrospect. Alternative payment models were significantly associated with reduction in resource use and cost in cancer care. Across the seventeen studies reporting data on the implicit payment reforms through care coordination, the adoption of clinical pathways was found effective in reduction of unnecessary use of low value services and associated costs. The estimates of all measures in ACO models varied considerably across participating providers, and our review found a rather mixed impact on cancer care outcomes. CONCLUSION The findings suggest promising improvement in resource utilization and cost control after transition to prospective payment models, but, further primary research is needed to apply robust measures of performance and quality to better ensure that providers are delivering high-value care to their patients, while reducing the cost of care.
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Affiliation(s)
- Mina Nejati
- The Cancer Institute at Imam Khomeini Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Moaven Razavi
- The Schneider Institutes for Health Policy at the Heller School of Brandeis University, Waltham, MA, United States of America
| | - Iraj Harirchi
- The Cancer Institute at Imam Khomeini Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Kazem Zendehdel
- The Cancer Institute at Imam Khomeini Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Parisa Nejati
- Rasoule-Akram Hospital, Iran University of Medical Sciences, Tehran, Iran
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11
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Rocque GB, Williams CP, Kenzik KM, Jackson BE, Azuero A, Halilova KI, Ingram SA, Pisu M, Forero A, Bhatia S. Concordance with NCCN treatment guidelines: Relations with health care utilization, cost, and mortality in breast cancer patients with secondary metastasis. Cancer 2018; 124:4231-4240. [DOI: 10.1002/cncr.31694] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2018] [Revised: 06/11/2018] [Accepted: 06/25/2018] [Indexed: 12/25/2022]
Affiliation(s)
- Gabrielle B. Rocque
- Comprehensive Cancer Center; University of Alabama at Birmingham; Birmingham Alabama
- Division of Hematology and Oncology; University of Alabama at Birmingham; Birmingham Alabama
| | - Courtney P. Williams
- Division of Hematology and Oncology; University of Alabama at Birmingham; Birmingham Alabama
| | - Kelly M. Kenzik
- Comprehensive Cancer Center; University of Alabama at Birmingham; Birmingham Alabama
- Division of Hematology and Oncology; University of Alabama at Birmingham; Birmingham Alabama
- Institute for Cancer Outcomes and Survivorship; University of Alabama at Birmingham; Birmingham Alabama
| | | | - Andres Azuero
- School of Nursing; University of Alabama at Birmingham; Birmingham Alabama
| | - Karina I. Halilova
- Division of Hematology and Oncology; University of Alabama at Birmingham; Birmingham Alabama
| | - Stacey A. Ingram
- Division of Hematology and Oncology; University of Alabama at Birmingham; Birmingham Alabama
| | - Maria Pisu
- Comprehensive Cancer Center; University of Alabama at Birmingham; Birmingham Alabama
- Division of Preventive Medicine; University of Alabama at Birmingham; Birmingham Alabama
| | - Andres Forero
- Comprehensive Cancer Center; University of Alabama at Birmingham; Birmingham Alabama
- Division of Hematology and Oncology; University of Alabama at Birmingham; Birmingham Alabama
| | - Smita Bhatia
- Comprehensive Cancer Center; University of Alabama at Birmingham; Birmingham Alabama
- Institute for Cancer Outcomes and Survivorship; University of Alabama at Birmingham; Birmingham Alabama
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12
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Williams CP, Kenzik KM, Azuero A, Williams GR, Pisu M, Halilova KI, Ingram SA, Yagnik SK, Forero A, Bhatia S, Rocque GB. Impact of Guideline-Discordant Treatment on Cost and Health Care Utilization in Older Adults with Early-Stage Breast Cancer. Oncologist 2018; 24:31-37. [PMID: 30120157 DOI: 10.1634/theoncologist.2018-0076] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2018] [Accepted: 06/27/2018] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND National Comprehensive Cancer Network (NCCN) guideline-based treatment is a marker of high-quality care. The impact of guideline discordance on cost and health care utilization is unclear. MATERIALS AND METHODS This retrospective cohort study of Medicare claims data from 2012 to 2015 included women age ≥65 with stage I-III breast cancer receiving care within the University of Alabama at Birmingham Cancer Community Network. Concordance with NCCN guidelines was assessed for treatment regimens. Costs to Medicare and health care utilization were identified from start of cancer treatment until death or available follow-up. Adjusted monthly cost and utilization rates were estimated using linear mixed effect and generalized linear models. RESULTS Of 1,177 patients, 16% received guideline-discordant treatment, which was associated with nonwhite race, estrogen receptor/progesterone receptor negative, human epidermal growth receptor 2 (HER2) positive, and later-stage cancer. Discordant therapy was primarily related to reduced-intensity treatments (single-agent chemotherapy, HER2-targeted therapy without chemotherapy, bevacizumab without chemotherapy, platinum combinations without anthracyclines). In adjusted models, average monthly costs for guideline-discordant patients were $936 higher compared with concordant (95% confidence limits $611, $1,260). For guideline-discordant patients, adjusted rates of emergency department visits and hospitalizations per thousand observations were 25% higher (49.9 vs. 39.9) and 19% higher (24.0 vs. 20.1) per month than concordant patients, respectively. CONCLUSION One in six patients with early-stage breast cancer received guideline-discordant care, predominantly related to undertreatment, which was associated with higher costs and rates of health care utilization. Additional randomized trials are needed to test lower-toxicity regimens and guide clinicians in treatment for older breast cancer patients. IMPLICATIONS FOR PRACTICE Previous studies lack details about types of deviations from chemotherapy guidelines that occur in older early-stage breast cancer patients. Understanding the patterns of guideline discordance and its impact on patient outcomes will be particularly important for these patients. This study found 16% received guideline-discordant care, predominantly related to reduced intensity treatment and associated with higher costs and rates of health care utilization. Increasing older adult participation in clinical trials should be a priority in order to fill the knowledge gap about how to treat older, less fit patients with breast cancer.
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Affiliation(s)
- Courtney P Williams
- Divisions of Hematology & Oncology, The University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Kelly M Kenzik
- Divisions of Hematology & Oncology, The University of Alabama at Birmingham, Birmingham, Alabama, USA
- Institute for Cancer Outcomes and Survivorship, The University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Andres Azuero
- School of Nursing, The University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Grant R Williams
- Divisions of Hematology & Oncology, The University of Alabama at Birmingham, Birmingham, Alabama, USA
- Institute for Cancer Outcomes and Survivorship, The University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Maria Pisu
- Division of Preventive Medicine, The University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Karina I Halilova
- Divisions of Hematology & Oncology, The University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Stacey A Ingram
- Divisions of Hematology & Oncology, The University of Alabama at Birmingham, Birmingham, Alabama, USA
| | | | - Andres Forero
- Divisions of Hematology & Oncology, The University of Alabama at Birmingham, Birmingham, Alabama, USA
- The University of Alabama at Birmingham Comprehensive Cancer Center, Birmingham, Alabama, USA
| | - Smita Bhatia
- Institute for Cancer Outcomes and Survivorship, The University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Gabrielle B Rocque
- Divisions of Hematology & Oncology, The University of Alabama at Birmingham, Birmingham, Alabama, USA
- The University of Alabama at Birmingham Comprehensive Cancer Center, Birmingham, Alabama, USA
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Chawla A, Peeples M, Li N, Anhorn R, Ryan J, Signorovitch J. Real-world utilization of molecular diagnostic testing and matched drug therapies in the treatment of metastatic cancers. J Med Econ 2018; 21:543-552. [PMID: 29295635 DOI: 10.1080/13696998.2017.1423488] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
AIMS To assess the frequency of biopsies and molecular diagnostic testing (human DNA/RNA analysis), anti-cancer drug use (genomically-matched targeted therapy [GMTT], unmatched targeted therapy [UTT], endocrine therapy [ET], and chemotherapy [CT]), and medical service costs among adults with metastatic cancer. METHODS Adults diagnosed with metastatic breast, non-small cell lung (NSCLC), colorectal, head and neck, ovarian, and uterine cancer (2010Q1-2015Q1) were identified in the OptumHealth Care Solutions claims database and followed from first metastatic diagnosis for ≥1 month and until the end of data availability. Utilization was assessed for each cancer cohort (all and patients aged ≥65 years); per-patient-per-month (PPPM) medical service costs were assessed for all patients. Testing frequency estimates were applied to Surveillance, Epidemiology, and End Results Program data to estimate the number of untested patients (2010-2014). RESULTS Patients with metastatic cancer (n = 8,193; breast [n = 3,414], NSCLC [n = 2,231], colorectal [n = 1,611], head and neck [n = 511], ovarian [n = 275], and uterine [n = 151]) were 63 years old (mean), with 11.1-22.2 months of observation. Biopsy and molecular diagnostic testing frequencies ranged from 7% (uterine) to 73% (ovarian), and from 34% (head and neck) to 52% (breast), respectively. Few were treated with GMTT (breast, 11%; NSCLC, 9%; colorectal, 6%). Treatment with UTT ranged from 0.7% (uterine) to 21% (colorectal). Biopsy, diagnostic testing, and anti-cancer drug therapy were less frequent for those ≥65 years. Medical service costs (PPPM, mean) ranged from $6,618 (head and neck) to $9,940 (ovarian). The estimated number of untested new patients with metastatic cancer was 636,369 (all) and 341,397 (≥65). LIMITATIONS In addition to the limitations of claims analyses, diagnostic testing frequency may be under-estimated if patients underwent testing prior to study inclusion. CONCLUSIONS The low frequency of molecular diagnostic testing suggests there are opportunities to better inform management of patients with advanced cancer, particularly decisions to treat with GMTT.
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Affiliation(s)
| | | | - Nanxin Li
- b Analysis Group, Inc. , Boston , MA , USA
| | | | - Jason Ryan
- c Foundation Medicine, Inc. , Cambridge , MA , USA
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14
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Ward JC, Levit LA, Page RD, Hennessy JE, Cox JV, Kamin DY, Bruinooge SS, Shih YCT, Polite BN. Impact on Oncology Practices of Including Drug Costs in Bundled Payments. J Oncol Pract 2018; 14:e259-e268. [DOI: 10.1200/jop.17.00036] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Introduction: This analysis evaluates the impact of bundling drug costs into a hypothetic bundled payment. Methods: An economic model was created for patient vignettes from: advanced-stage III colon cancer and metastatic non–small-cell lung cancer. First quarter 2016 Medicare reimbursement rates were used to calculate the average fee-for-service (FFS) reimbursement for these vignettes. The probabilistic risk faced by practices was captured by the type of patients seen in practices and randomly assigned in a Monte Carlo simulation on the basis of the given distribution of patient types within each cancer. Simulations were replicated 1,000 times. The impact of bundled payments that include drug costs for various practice sizes and cancer types was quantified as the probability of incurring a loss at four magnitudes: any loss, > 10%, > 20%, or > 30%. A loss was defined as receiving revenue from the bundle that was less than what the practice would have received under FFS; the probability of loss was calculated on the basis of the number of times a practice reported a loss among the 1,000 simulations. Results: Practices that treat a substantial proportion of patients with complex disease compared with the average patient in the bundle would have revenue well below that expected from FFS. Practices that treat a disproportionate share of patients with less complex disease, as compared with the average patient in the bundle, would have revenue well above the revenue under FFS. Overall, bundled payments put practices at greater risk than FFS because their patient case mix could greatly skew financial performance. Conclusion: Including drug costs in a bundle is subject to the uncontrollable probabilistic risk of patient case mixes.
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Affiliation(s)
- Jeffery C. Ward
- Swedish Cancer Institute, Edmonds, WA; American Society of Clinical Oncology, Alexandria, VA; Center for Cancer and Blood Disorders, Weatherford, TX; WellRithms, Portland, OR; Parkland Health System; University of Texas Southwestern, Dallas; University of Texas MD Anderson Cancer Center, Houston, TX; and University of Chicago, Chicago, IL
| | - Laura A. Levit
- Swedish Cancer Institute, Edmonds, WA; American Society of Clinical Oncology, Alexandria, VA; Center for Cancer and Blood Disorders, Weatherford, TX; WellRithms, Portland, OR; Parkland Health System; University of Texas Southwestern, Dallas; University of Texas MD Anderson Cancer Center, Houston, TX; and University of Chicago, Chicago, IL
| | - Ray D. Page
- Swedish Cancer Institute, Edmonds, WA; American Society of Clinical Oncology, Alexandria, VA; Center for Cancer and Blood Disorders, Weatherford, TX; WellRithms, Portland, OR; Parkland Health System; University of Texas Southwestern, Dallas; University of Texas MD Anderson Cancer Center, Houston, TX; and University of Chicago, Chicago, IL
| | - John E. Hennessy
- Swedish Cancer Institute, Edmonds, WA; American Society of Clinical Oncology, Alexandria, VA; Center for Cancer and Blood Disorders, Weatherford, TX; WellRithms, Portland, OR; Parkland Health System; University of Texas Southwestern, Dallas; University of Texas MD Anderson Cancer Center, Houston, TX; and University of Chicago, Chicago, IL
| | - John V. Cox
- Swedish Cancer Institute, Edmonds, WA; American Society of Clinical Oncology, Alexandria, VA; Center for Cancer and Blood Disorders, Weatherford, TX; WellRithms, Portland, OR; Parkland Health System; University of Texas Southwestern, Dallas; University of Texas MD Anderson Cancer Center, Houston, TX; and University of Chicago, Chicago, IL
| | - Deborah Y. Kamin
- Swedish Cancer Institute, Edmonds, WA; American Society of Clinical Oncology, Alexandria, VA; Center for Cancer and Blood Disorders, Weatherford, TX; WellRithms, Portland, OR; Parkland Health System; University of Texas Southwestern, Dallas; University of Texas MD Anderson Cancer Center, Houston, TX; and University of Chicago, Chicago, IL
| | - Suanna S. Bruinooge
- Swedish Cancer Institute, Edmonds, WA; American Society of Clinical Oncology, Alexandria, VA; Center for Cancer and Blood Disorders, Weatherford, TX; WellRithms, Portland, OR; Parkland Health System; University of Texas Southwestern, Dallas; University of Texas MD Anderson Cancer Center, Houston, TX; and University of Chicago, Chicago, IL
| | - Ya-Chen Tina Shih
- Swedish Cancer Institute, Edmonds, WA; American Society of Clinical Oncology, Alexandria, VA; Center for Cancer and Blood Disorders, Weatherford, TX; WellRithms, Portland, OR; Parkland Health System; University of Texas Southwestern, Dallas; University of Texas MD Anderson Cancer Center, Houston, TX; and University of Chicago, Chicago, IL
| | - Blase N. Polite
- Swedish Cancer Institute, Edmonds, WA; American Society of Clinical Oncology, Alexandria, VA; Center for Cancer and Blood Disorders, Weatherford, TX; WellRithms, Portland, OR; Parkland Health System; University of Texas Southwestern, Dallas; University of Texas MD Anderson Cancer Center, Houston, TX; and University of Chicago, Chicago, IL
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15
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Handley NR, Schuchter LM, Bekelman JE. Best Practices for Reducing Unplanned Acute Care for Patients With Cancer. J Oncol Pract 2018; 14:306-313. [PMID: 29664697 DOI: 10.1200/jop.17.00081] [Citation(s) in RCA: 96] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Variation and cost in oncology care represent a large and growing burden for the US health care system, and acute hospital care is one of the single largest drivers. Reduction of unplanned acute care is a major priority for clinical transformation in oncology; proposed changes to Medicare reimbursement for patients with cancer who suffer unplanned admissions while receiving chemotherapy heighten the need. We conducted a review of best practices to reduce unplanned acute care for patients with cancer. We searched PubMed for articles published between 2000 and 2017 and reviewed guidelines published by professional organizations. We identified five strategies to reduce unplanned acute care for patients with cancer: (1) identify patients at high risk for unplanned acute care; (2) enhance access and care coordination; (3) standardize clinical pathways for symptom management; (4) develop new loci for urgent cancer care; and (5) use early palliative care. We assessed each strategy on the basis of specific outcomes: reduction in emergency department visits, reduction in hospitalizations, and reduction in rehospitalizations within 30 days. For each, we define gaps in knowledge and identify areas for future effort. These five strategies can be implemented separately or, with possibly more success, as an integrated program to reduce unplanned acute care for patients with cancer. Because of the large investment required and the limited data on effectiveness, there should be further research and evaluation to identify the optimal strategies to reduce emergency department visits, hospitalizations, and rehospitalizations. Proposed reimbursement changes amplify the need for cancer programs to focus on this issue.
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Abstract
The Affordable Care Act (ACA) has reformed US health care delivery through insurance coverage expansion, experiments in payment design, and funding for patient-centered clinical and health care delivery research. The impact on cancer care specifically has been far reaching, with new ACA-related programs that encourage coordinated, patient-centered, cost-effective care. Insurance expansions through private exchanges and Medicaid, along with preexisting condition clauses, have helped more than 20 million Americans gain health care coverage. Accountable care organizations, oncology patient-centered medical homes, and the Oncology Care Model-all implemented through the Center for Medicare & Medicaid Innovation-have initiated an accelerating shift toward value-based cancer care. Concurrently, evidence for better cancer outcomes and improved quality of cancer care is starting to accrue in the wake of ACA implementation.
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Affiliation(s)
- Gabriel A Brooks
- From the *Dartmouth-Hitchcock Medical Center, Lebanon, NH; †The Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, NH; ‡Texas Oncology, Dallas, TX; and §The US Oncology Network, The Woodlands, TX
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Daly B, Zon RT, Page RD, Edge SB, Lyman GH, Green SR, Wollins DS, Bosserman LD. Oncology Clinical Pathways: Charting the Landscape of Pathway Providers. J Oncol Pract 2018; 14:e194-e200. [PMID: 29412768 DOI: 10.1200/jop.17.00033] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023] Open
Affiliation(s)
- Bobby Daly
- Memorial Sloan Kettering Cancer Center, New York; Roswell Park Cancer Institute, Buffalo, NY; Michiana Hematology-Oncology, Mishawaka, IN; Center for Cancer and Blood Disorders, Fort Worth, TX; Fred Hutchinson Cancer Research Center and University of Washington, Seattle, WA; American Society of Clinical Oncology, Alexandria, VA; and City of Hope, Rancho Cucamonga, CA
| | - Robin T Zon
- Memorial Sloan Kettering Cancer Center, New York; Roswell Park Cancer Institute, Buffalo, NY; Michiana Hematology-Oncology, Mishawaka, IN; Center for Cancer and Blood Disorders, Fort Worth, TX; Fred Hutchinson Cancer Research Center and University of Washington, Seattle, WA; American Society of Clinical Oncology, Alexandria, VA; and City of Hope, Rancho Cucamonga, CA
| | - Ray D Page
- Memorial Sloan Kettering Cancer Center, New York; Roswell Park Cancer Institute, Buffalo, NY; Michiana Hematology-Oncology, Mishawaka, IN; Center for Cancer and Blood Disorders, Fort Worth, TX; Fred Hutchinson Cancer Research Center and University of Washington, Seattle, WA; American Society of Clinical Oncology, Alexandria, VA; and City of Hope, Rancho Cucamonga, CA
| | - Stephen B Edge
- Memorial Sloan Kettering Cancer Center, New York; Roswell Park Cancer Institute, Buffalo, NY; Michiana Hematology-Oncology, Mishawaka, IN; Center for Cancer and Blood Disorders, Fort Worth, TX; Fred Hutchinson Cancer Research Center and University of Washington, Seattle, WA; American Society of Clinical Oncology, Alexandria, VA; and City of Hope, Rancho Cucamonga, CA
| | - Gary H Lyman
- Memorial Sloan Kettering Cancer Center, New York; Roswell Park Cancer Institute, Buffalo, NY; Michiana Hematology-Oncology, Mishawaka, IN; Center for Cancer and Blood Disorders, Fort Worth, TX; Fred Hutchinson Cancer Research Center and University of Washington, Seattle, WA; American Society of Clinical Oncology, Alexandria, VA; and City of Hope, Rancho Cucamonga, CA
| | - Sybil R Green
- Memorial Sloan Kettering Cancer Center, New York; Roswell Park Cancer Institute, Buffalo, NY; Michiana Hematology-Oncology, Mishawaka, IN; Center for Cancer and Blood Disorders, Fort Worth, TX; Fred Hutchinson Cancer Research Center and University of Washington, Seattle, WA; American Society of Clinical Oncology, Alexandria, VA; and City of Hope, Rancho Cucamonga, CA
| | - Dana S Wollins
- Memorial Sloan Kettering Cancer Center, New York; Roswell Park Cancer Institute, Buffalo, NY; Michiana Hematology-Oncology, Mishawaka, IN; Center for Cancer and Blood Disorders, Fort Worth, TX; Fred Hutchinson Cancer Research Center and University of Washington, Seattle, WA; American Society of Clinical Oncology, Alexandria, VA; and City of Hope, Rancho Cucamonga, CA
| | - Linda D Bosserman
- Memorial Sloan Kettering Cancer Center, New York; Roswell Park Cancer Institute, Buffalo, NY; Michiana Hematology-Oncology, Mishawaka, IN; Center for Cancer and Blood Disorders, Fort Worth, TX; Fred Hutchinson Cancer Research Center and University of Washington, Seattle, WA; American Society of Clinical Oncology, Alexandria, VA; and City of Hope, Rancho Cucamonga, CA
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18
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Improving cancer patient emergency room utilization: A New Jersey state assessment. Cancer Epidemiol 2017; 51:15-22. [DOI: 10.1016/j.canep.2017.09.006] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2017] [Revised: 09/20/2017] [Accepted: 09/27/2017] [Indexed: 01/07/2023]
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Rocque GB, Williams CP, Kenzik KM, Jackson BE, Halilova KI, Sullivan MM, Rocconi RP, Azuero A, Kvale EA, Huh WK, Partridge EE, Pisu M. Where Are the Opportunities for Reducing Health Care Spending Within Alternative Payment Models? J Oncol Pract 2017; 14:e375-e383. [PMID: 28981388 DOI: 10.1200/jop.2017.024935] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE The Oncology Care Model (OCM) is a highly controversial specialty care model developed by the Centers for Medicare & Medicaid aimed to provide higher-quality care at lower cost. Because oncologists will be increasingly held accountable for spending as well as quality within new value-based health care models like the OCM, they need to understand the drivers of total spending for their patients. METHODS This retrospective cohort study included patients ≥ 65 years of age with primary fee-for-service Medicare insurance who received antineoplastic therapy at 12 cancer centers in the Southeast from 2012 to 2014. Medicare administrative claims data were used to identify health care spending during the prechemotherapy period (from cancer diagnosis to antineoplastic therapy initiation) and during the OCM episodes of care triggered by antineoplastic treatment. Total health care spending per episode includes all types of services received by a patient, including nononcology services. Spending was further characterized by type of service. RESULTS Average total health care spending in the three OCM episodes of care was $33,838 (n = 3,427), $23,811 (n = 1,207), and $19,241 (n = 678). Antineoplastic drugs accounted for 27%, 32%, and 36% of total health care spending in the first, second, and third episodes. Ten drugs, used by 31% of patients, contributed 61% to drug spending ($18.8 million) in the first episode. Inpatient spending also substantially contributed to total costs, representing 17% to 20% ($30.5 million) of total health care spending. CONCLUSION Health care spending was heavily driven by both antineoplastic drugs and hospital use. Oncologists' ability to affect these types of spending will determine their success under alternative payment models.
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Affiliation(s)
- Gabrielle B Rocque
- University of Alabama at Birmingham, Birmingham; University of South Alabama Mitchell Cancer Institute; University of South Alabama, Mobile, AL; and Center for Outcomes Research, JPS Health Network, Fort Worth, TX
| | - Courtney P Williams
- University of Alabama at Birmingham, Birmingham; University of South Alabama Mitchell Cancer Institute; University of South Alabama, Mobile, AL; and Center for Outcomes Research, JPS Health Network, Fort Worth, TX
| | - Kelly M Kenzik
- University of Alabama at Birmingham, Birmingham; University of South Alabama Mitchell Cancer Institute; University of South Alabama, Mobile, AL; and Center for Outcomes Research, JPS Health Network, Fort Worth, TX
| | - Bradford E Jackson
- University of Alabama at Birmingham, Birmingham; University of South Alabama Mitchell Cancer Institute; University of South Alabama, Mobile, AL; and Center for Outcomes Research, JPS Health Network, Fort Worth, TX
| | - Karina I Halilova
- University of Alabama at Birmingham, Birmingham; University of South Alabama Mitchell Cancer Institute; University of South Alabama, Mobile, AL; and Center for Outcomes Research, JPS Health Network, Fort Worth, TX
| | - Margaret M Sullivan
- University of Alabama at Birmingham, Birmingham; University of South Alabama Mitchell Cancer Institute; University of South Alabama, Mobile, AL; and Center for Outcomes Research, JPS Health Network, Fort Worth, TX
| | - Rod P Rocconi
- University of Alabama at Birmingham, Birmingham; University of South Alabama Mitchell Cancer Institute; University of South Alabama, Mobile, AL; and Center for Outcomes Research, JPS Health Network, Fort Worth, TX
| | - Andres Azuero
- University of Alabama at Birmingham, Birmingham; University of South Alabama Mitchell Cancer Institute; University of South Alabama, Mobile, AL; and Center for Outcomes Research, JPS Health Network, Fort Worth, TX
| | - Elizabeth A Kvale
- University of Alabama at Birmingham, Birmingham; University of South Alabama Mitchell Cancer Institute; University of South Alabama, Mobile, AL; and Center for Outcomes Research, JPS Health Network, Fort Worth, TX
| | - Warner K Huh
- University of Alabama at Birmingham, Birmingham; University of South Alabama Mitchell Cancer Institute; University of South Alabama, Mobile, AL; and Center for Outcomes Research, JPS Health Network, Fort Worth, TX
| | - Edward E Partridge
- University of Alabama at Birmingham, Birmingham; University of South Alabama Mitchell Cancer Institute; University of South Alabama, Mobile, AL; and Center for Outcomes Research, JPS Health Network, Fort Worth, TX
| | - Maria Pisu
- University of Alabama at Birmingham, Birmingham; University of South Alabama Mitchell Cancer Institute; University of South Alabama, Mobile, AL; and Center for Outcomes Research, JPS Health Network, Fort Worth, TX
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20
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Results of a nationwide questionnaire-based survey on nutrition management following gastric cancer resection in Japan. Surg Today 2017; 47:1460-1468. [PMID: 28600636 DOI: 10.1007/s00595-017-1552-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2016] [Accepted: 04/09/2017] [Indexed: 12/22/2022]
Abstract
PURPOSE A study was conducted to clarify the actual status of nutrition management after gastric cancer surgery in Japan and obtain basic data for optimizing perioperative nutrition management. METHODS A questionnaire was sent to 354 hospitals with at least 50 cases of gastric cancer surgery per year. Questions included the perioperative nutrition management and length of hospital stay for patients who underwent gastric cancer surgery within three months of the survey. RESULTS Responses were obtained from 242 hospitals (68%; 20,858 patients). Nutrition management was consistent between laparotomy and laparoscopic surgery for 84% of respondents. The number of postoperative days was the most commonly chosen index for starting oral feeding. The most commonly chosen index for hospital dischargeability was diet composition/amount consumed in 182 hospitals (44%), followed by laboratory data stabilization in 106 hospitals (26%), and the number of postoperative days in 87 hospitals (21%). A positive correlation was found between the mean length of postoperative hospital stay and starting oral feeding (r = 0.23 for distal gastrectomy; r = 0.34 for total gastrectomy). The length of hospital stay tended to be shorter with an earlier start of oral feeding (p < 0.01). CONCLUSION Early postoperative oral feeding may be a factor in reducing the length of hospital stay after gastric cancer surgery.
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21
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Polite B, Ward JC, Cox JV, Morton RF, Hennessy J, Page R, Conti RM. A Pathway Through the Bundle Jungle. J Oncol Pract 2016; 12:504-9. [DOI: 10.1200/jop.2015.008789] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Affiliation(s)
- Blase Polite
- The University of Chicago, Chicago, IL; Puget Sound Cancer Centers, Edmonds, WA; University of Texas Southwestern Medical Center, Dallas; The Center for Cancer and Blood Disorders, Fort Worth, TX; Medical Oncology and Hematology Associates, Clive, IA; and Sarah Cannon, Nashville, TN
| | - Jeffery C. Ward
- The University of Chicago, Chicago, IL; Puget Sound Cancer Centers, Edmonds, WA; University of Texas Southwestern Medical Center, Dallas; The Center for Cancer and Blood Disorders, Fort Worth, TX; Medical Oncology and Hematology Associates, Clive, IA; and Sarah Cannon, Nashville, TN
| | - John V. Cox
- The University of Chicago, Chicago, IL; Puget Sound Cancer Centers, Edmonds, WA; University of Texas Southwestern Medical Center, Dallas; The Center for Cancer and Blood Disorders, Fort Worth, TX; Medical Oncology and Hematology Associates, Clive, IA; and Sarah Cannon, Nashville, TN
| | - Roscoe F. Morton
- The University of Chicago, Chicago, IL; Puget Sound Cancer Centers, Edmonds, WA; University of Texas Southwestern Medical Center, Dallas; The Center for Cancer and Blood Disorders, Fort Worth, TX; Medical Oncology and Hematology Associates, Clive, IA; and Sarah Cannon, Nashville, TN
| | - John Hennessy
- The University of Chicago, Chicago, IL; Puget Sound Cancer Centers, Edmonds, WA; University of Texas Southwestern Medical Center, Dallas; The Center for Cancer and Blood Disorders, Fort Worth, TX; Medical Oncology and Hematology Associates, Clive, IA; and Sarah Cannon, Nashville, TN
| | - Ray Page
- The University of Chicago, Chicago, IL; Puget Sound Cancer Centers, Edmonds, WA; University of Texas Southwestern Medical Center, Dallas; The Center for Cancer and Blood Disorders, Fort Worth, TX; Medical Oncology and Hematology Associates, Clive, IA; and Sarah Cannon, Nashville, TN
| | - Rena M. Conti
- The University of Chicago, Chicago, IL; Puget Sound Cancer Centers, Edmonds, WA; University of Texas Southwestern Medical Center, Dallas; The Center for Cancer and Blood Disorders, Fort Worth, TX; Medical Oncology and Hematology Associates, Clive, IA; and Sarah Cannon, Nashville, TN
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Abstract
Rapidly increasing national health care expenditures are a major area of concern as threats to the integrity of the health care system. Significant increases in the cost of care for patients with cancer are driven by numerous factors, most importantly the cost of hospital care and escalating pharmaceutical costs. The current fee-for-service system (FFS) has been identified as a potential driver of the increasing cost of care, and multiple stakeholders are interested in replacing FFS with a system that improves the quality of care while at the same time reducing cost. Several models have been piloted, including a Center for Medicare & Medicaid Innovation (CMMI)-sponsored medical home model (COME HOME) for patients with solid tumors that was able to generate savings by integrating a phone triage system, pathways, and seamless patient care 7 days a week to reduce overall cost of care, mostly by decreasing patient admissions to hospitals and referrals to emergency departments. CMMI is now launching a new pilot model, the Oncology Care Model (OCM), which differs from COME HOME in several important ways. It does not abolish FFS but provides an additional payment in 6-month increments for each patient on active cancer treatment. It also allows practices to participate in savings if they can decrease the overall cost of care, to include all chemotherapy and supportive care drugs, and fulfill certain quality metrics. A critical discussion of the proposed model, which is scheduled to start in 2016, will be provided at the 2016 American Society of Clinical Oncology (ASCO) Annual Meeting with practicing oncologists and a Centers for Medicare & Medicaid Services (CMS) representative.
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Affiliation(s)
- Christian A Thomas
- From the New England Cancer Specialists, Scarborough, ME; Swedish Cancer Institute, Edmonds, WA
| | - Jeffrey C Ward
- From the New England Cancer Specialists, Scarborough, ME; Swedish Cancer Institute, Edmonds, WA
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Shih YCT, Smieliauskas F, Geynisman DM, Kelly RJ, Smith TJ. Trends in the Cost and Use of Targeted Cancer Therapies for the Privately Insured Nonelderly: 2001 to 2011. J Clin Oncol 2015; 33:2190-6. [PMID: 25987701 PMCID: PMC4477789 DOI: 10.1200/jco.2014.58.2320] [Citation(s) in RCA: 114] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE This study sought to define and identify drivers of trends in cost and use of targeted therapeutics among privately insured nonelderly patients with cancer receiving chemotherapy between 2001 and 2011. METHODS We classified oncology drugs as targeted oral anticancer medications, targeted intravenous anticancer medications, and all others. Using the LifeLink Health Plan Claims Database, we studied and disaggregated trends in use and in insurance and out-of-pocket payments per patient per month and during the first year of chemotherapy. RESULTS We found a large increase in the use of targeted intravenous anticancer medications and a gradual increase in targeted oral anticancer medications; targeted therapies accounted for 63% of all chemotherapy expenditures in 2011. Insurance payments per patient per month and in the first year of chemotherapy for targeted oral anticancer medications more than doubled in 10 years, surpassing payments for targeted intravenous anticancer medications, which remained fairly constant throughout. Substitution toward targeted therapies and growth in drug prices both at launch and postlaunch contributed to payer spending growth. Out-of-pocket spending for targeted oral anticancer medications was ≤ half of the amount for targeted intravenous anticancer medications. CONCLUSION Targeted therapies now dominate anticancer drug spending. More aggressive management of pharmacy benefits for targeted oral anticancer medications and payment reform for injectable drugs hold promise. Restraining the rapid rise in spending will require more than current oral drug parity laws, such as value-based insurance that makes the benefits and costs transparent and involves the patient directly in the choice of treatment.
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Affiliation(s)
- Ya-Chen Tina Shih
- Ya-Chen Tina Shih, University of Texas MD Anderson Cancer Center, Houston, TX; Fabrice Smieliauskas, University of Chicago, Chicago, IL; Daniel M. Geynisman, Fox Chase Cancer Center, Philadelphia, PA; Ronan J. Kelly and Thomas J. Smith, Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University, Baltimore, MD.
| | - Fabrice Smieliauskas
- Ya-Chen Tina Shih, University of Texas MD Anderson Cancer Center, Houston, TX; Fabrice Smieliauskas, University of Chicago, Chicago, IL; Daniel M. Geynisman, Fox Chase Cancer Center, Philadelphia, PA; Ronan J. Kelly and Thomas J. Smith, Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University, Baltimore, MD
| | - Daniel M Geynisman
- Ya-Chen Tina Shih, University of Texas MD Anderson Cancer Center, Houston, TX; Fabrice Smieliauskas, University of Chicago, Chicago, IL; Daniel M. Geynisman, Fox Chase Cancer Center, Philadelphia, PA; Ronan J. Kelly and Thomas J. Smith, Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University, Baltimore, MD
| | - Ronan J Kelly
- Ya-Chen Tina Shih, University of Texas MD Anderson Cancer Center, Houston, TX; Fabrice Smieliauskas, University of Chicago, Chicago, IL; Daniel M. Geynisman, Fox Chase Cancer Center, Philadelphia, PA; Ronan J. Kelly and Thomas J. Smith, Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University, Baltimore, MD
| | - Thomas J Smith
- Ya-Chen Tina Shih, University of Texas MD Anderson Cancer Center, Houston, TX; Fabrice Smieliauskas, University of Chicago, Chicago, IL; Daniel M. Geynisman, Fox Chase Cancer Center, Philadelphia, PA; Ronan J. Kelly and Thomas J. Smith, Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University, Baltimore, MD
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24
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The State of Cancer Care in America, 2015: A Report by the American Society of Clinical Oncology. J Oncol Pract 2015; 11:79-113. [DOI: 10.1200/jop.2015.003772] [Citation(s) in RCA: 65] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
In this second annual State of Cancer Care in America report, ASCO provides background and context to help understand what is happening today in cancer care and describes trends in the cancer care workforce that may affect cancer care in the coming years.
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25
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Abstract
The rising cost of health care in the United States is on an unsustainable trajectory. Payment models that reward cost-effective and high-quality care are desperately needed.
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Lotvin AM, Shrank WH, Singh SC, Falit BP, Brennan TA. Specialty Medications: Traditional And Novel Tools Can Address Rising Spending On These Costly Drugs. Health Aff (Millwood) 2014; 33:1736-44. [DOI: 10.1377/hlthaff.2014.0511] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
- Alan M. Lotvin
- Alan M. Lotvin is executive vice president for specialty pharmacy at CVS Caremark, in Woonsocket, Rhode Island
| | - William H. Shrank
- William H. Shrank (
) is chief scientific officer and chief medical officer of provider innovation at CVS Caremark
| | - Surya C. Singh
- Surya C. Singh is corporate vice president for specialty client solutions and trend management at CVS Caremark
| | - Benjamin P. Falit
- Benjamin P. Falit is a resident physician in the Harvard Radiation Oncology Program at Brigham and Women’s Hospital, in Boston, Massachusetts, and a consultant to CVS Caremark on matters related to oncology and specialty pharmacy strategy
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27
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Falit BP, Chernew ME, Mantz CA. Design and implementation of bundled payment systems for cancer care and radiation therapy. Int J Radiat Oncol Biol Phys 2014; 89:950-953. [PMID: 25035197 DOI: 10.1016/j.ijrobp.2014.04.023] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2014] [Revised: 04/02/2014] [Accepted: 04/11/2014] [Indexed: 10/25/2022]
Affiliation(s)
| | - Michael E Chernew
- Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts
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28
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Goldberg P, Conti RM. Problems with public reporting of cancer quality outcomes data. J Oncol Pract 2014; 10:215-8. [PMID: 24839285 DOI: 10.1200/jop.2014.001405] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
The authors say public reporting of even the most well-defined end points—survival after treatment—can be misleading when used to compare outcomes across providers, and these data can suffer from patient-selection and treatment-intensity biases.
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Affiliation(s)
- Paul Goldberg
- The Cancer Letter, Washington, DC; and University of Chicago, Chicago, IL
| | - Rena M Conti
- The Cancer Letter, Washington, DC; and University of Chicago, Chicago, IL
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29
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Kreys ED, Kim TY, Delgado A, Koeller JM. Impact of Cancer Supportive Care Pathways Compliance on Emergency Department Visits and Hospitalizations. J Oncol Pract 2014; 10:168-73. [DOI: 10.1200/jop.2014.001376] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Granulocyte colony-stimulating factor pathway compliance was associated with a significant decrease in the rate of neutropenia-related emergency department visits/hospitalizations and resulting costs.
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Affiliation(s)
- Eugene D. Kreys
- University of Texas at Austin, Austin; and The University of Texas Health Science Center at San Antonio, San Antonio, TX
| | - Ted Y. Kim
- University of Texas at Austin, Austin; and The University of Texas Health Science Center at San Antonio, San Antonio, TX
| | - Andrew Delgado
- University of Texas at Austin, Austin; and The University of Texas Health Science Center at San Antonio, San Antonio, TX
| | - Jim M. Koeller
- University of Texas at Austin, Austin; and The University of Texas Health Science Center at San Antonio, San Antonio, TX
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30
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Abstract
The authors conclude that future changes in payment for oncology services mandated by CMS can be sustained within the infrastructures being built today through payer-provider collaborations.
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