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Mullangi S, Ukert B, Devries A, Debono D, Santos J, Fisch MJ, Schleicher SM, Navathe AS, Bekelman JE, Schwartz AL, Parikh RB. Association of Participation in Medicare's Oncology Care Model With Spending, Utilization, and Quality Outcomes Among Commercially Insured and Medicare Advantage Members. J Clin Oncol 2024:JCO2400502. [PMID: 39356984 DOI: 10.1200/jco.24.00502] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2024] [Revised: 07/13/2024] [Accepted: 08/23/2024] [Indexed: 10/04/2024] Open
Abstract
PURPOSE The Oncology Care Model (OCM), a value-based payment model for traditional Medicare beneficiaries with cancer, yielded total spending reductions that were outweighed by incentive payments, resulting in net losses to the Centers for Medicare & Medicaid Services. We studied whether the OCM yielded spillover effects in total episode spending, utilization, and quality among commercially insured and Medicare Advantage (MA) members, who were not targeted by the program. PATIENTS AND METHODS This observational study used administrative claims from a large national payer, yielding 157,189 total patients with commercial insurance or MA with solid malignancies who initiated 229,376 systemic anticancer therapy episodes before (2012-2015) and during (2016-2021) the OCM at 125 OCM-participating practices (a subset of total OCM practices) and a 1:10 propensity-matched set of 860 non-OCM practices. We used difference-in-differences analyses to assess the association between the OCM and total episode spending, defined as medical spending during a 6-month episode. Secondary outcomes included hospitalization and emergency department (ED) utilization and quality measures. RESULTS From the pre-OCM to the OCM period, mean total episode payments increased from $45,504 in US dollars (USD) to $46,239 USD for OCM-participating practices, and increased from $50,519 USD to $58,591 USD for non-OCM practices (adjusted difference-in-differences -$6,287 USD [95% CI, -$10,076 USD to -$2,498 USD], P = .001). The OCM was associated with adjusted spending decreases for both high-risk (-$6,756 USD [95% CI, -$10,731 USD to -$2,781 USD], P = .001) and low-risk (-$4,171 USD [95% CI, -$7,799 USD to -$543 USD], P = .025) episodes. OCM-associated spending reductions were strongest for outpatient (-$5,243 USD [95% CI, -$8,589 USD to -$1,897 USD], P = .002) and infused/injected anticancer drug (-$3,031 USD [95% CI, -$5,193 USD to -$869 USD], P = .006) spending. There were no associations between OCM participation and changes in hospital or ED utilization nor quality of care. CONCLUSION The OCM was associated with reductions in spending for nontargeted members, a spillover effect.
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Affiliation(s)
| | - Benjamin Ukert
- Texas A&M University, College Station, TX
- Elevance Health, Inc, Indianapolis, IN
| | | | | | | | | | | | - Amol S Navathe
- Department of Medical Ethics and Health Policy, University of Pennsylvania, Philadelphia, PA
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA
| | - Justin E Bekelman
- Department of Medical Ethics and Health Policy, University of Pennsylvania, Philadelphia, PA
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA
- Penn Center for Cancer Care Innovation, Abramson Cancer Center, University of Pennsylvania, Philadelphia, PA
| | - Aaron L Schwartz
- Department of Medical Ethics and Health Policy, University of Pennsylvania, Philadelphia, PA
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA
| | - Ravi B Parikh
- Department of Medical Ethics and Health Policy, University of Pennsylvania, Philadelphia, PA
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA
- Penn Center for Cancer Care Innovation, Abramson Cancer Center, University of Pennsylvania, Philadelphia, PA
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Conic J, Reske T. Trends in Medicare utilization and reimbursement for hematology/oncology procedures from 2012 to 2023: A geriatric oncology perspective. Aging Med (Milton) 2024; 7:171-178. [PMID: 38725700 PMCID: PMC11077331 DOI: 10.1002/agm2.12298] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2023] [Revised: 02/05/2024] [Accepted: 03/28/2024] [Indexed: 05/12/2024] Open
Abstract
Objectives Given the scarcity of data exploring reimbursement trends in the field of hematology/oncology, we sought to characterize these trends for common procedures in this field from 2012 to 2023. Methods Using the Centers for Medicare and Medicaid Services' Physician Fee Schedule Look-Up Tool we collected reimbursement data for 40 hematology/oncology procedure codes from 2012 to 2023. Data was adjusted to 2023 United States (US) dollars using the Consumer Price Index (CPI). Results From 2012 to 2023 gross reimbursement for the facility price decreased 4.4% and increased 9.2% for the non-facility price. When adjusted for inflation, compensation decreased 96.1% and 96.6%, respectively. None of the 40 examined Current Procedural Terminology (CPT) codes increased in net reimbursement over the study period. Conclusions Medicare reimbursement for common hematology/oncology procedures decreased from 2012 to 2023. Further research is necessary to explore the implications of these trends on the delivery of patient care.
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Affiliation(s)
- J. Conic
- Department of Internal Medicine, Section of Geriatric MedicineLouisiana State University Health Sciences CenterNew OrleansLouisianaUSA
| | - T. Reske
- Department of Internal Medicine, Section of Geriatric Medicine and Section of Hematology/OncologyLouisiana State University Health Sciences CenterNew OrleansLouisianaUSA
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Kolodziej MA, Klein I. Private Payers and Cancer Care: Revisiting the Land of Opportunity. JCO Oncol Pract 2024; 20:318-322. [PMID: 38181309 DOI: 10.1200/op.23.00632] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2023] [Revised: 11/08/2023] [Accepted: 11/11/2023] [Indexed: 01/07/2024] Open
Abstract
Ten years ago we charted a course for oncology payment reform. We summarize what went wrong and propose ways to fix it.
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Pickard T, Williams S, Tetzlaff E, Petraitis C, Hylton H. Team-Based Care in Oncology: The Impact of the Advanced Practice Provider. Am Soc Clin Oncol Educ Book 2023; 43:e390572. [PMID: 37279437 DOI: 10.1200/edbk_390572] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
Integration of APPs into care teams affects quality and safety for the oncology patient. Learn the best practices and understand the concepts of onboarding, orientation, mentorship, scope of practice, and top of license. Review how productivity and other incentive programs can be adapted to integrate APPs and focus on team-based metrics.
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Affiliation(s)
- Todd Pickard
- University of Texas MD Anderson Cancer Center, Houston, TX
| | | | - Eric Tetzlaff
- Levine Cancer Institute Within Atrium Health, Charlotte, NC
- Department of Hematology Oncology, the Fox Chase Cancer Center, Philadelphia, PA
| | - Camille Petraitis
- Department of Hematology Oncology, the Fox Chase Cancer Center, Philadelphia, PA
| | - Heather Hylton
- Quality Assurance and Patient Safety at K Health, New York, NY
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Nagarajah S, Powis ML, Fazelzad R, Krzyzanowska MK, Kukreti V. Implementation and Impact of Choosing Wisely Recommendations in Oncology. JCO Oncol Pract 2022; 18:703-712. [DOI: 10.1200/op.22.00130] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
The Choosing Wisely (CW) campaign, launched in 2012, includes oncology-specific recommendations to promote evidence-based care and deimplementation of low-value practices. However, it is unclear to what extent the campaign has prompted practice change. We systematically reviewed the literature to evaluate the uptake of cancer-specific CW recommendations focusing on the period before the declaration of the COVID-19 pandemic. We used Grimshaw's deimplementation framework to thematically group the findings and extracted information on implementation strategies, barriers, and facilitators from articles reporting on active implementation. In the 98 articles addressing 32 unique recommendations, most reported on passive changes in adherence pre-post publication of CW recommendations. Use of active surveillance for low-risk prostate cancer and reduction in staging imaging for early breast cancer were the most commonly evaluated recommendations. Most articles assessing passive changes in adherence pre-post CW publication reported improvement. All articles evaluating active implementation (10 of 98) reported improved compliance (range: 3%-73% improvement). Most common implementation strategies included provider education and/or stakeholder engagement. Preconceived views and reluctance to adopt new practices were common barriers; common facilitators included the use of technology and provider education to increase provider buy-in. Given the limited uptake of oncology-specific CW recommendations thus far, more attention toward supporting active implementation is needed. Effective adoption of CW likely requires a multipronged approach that includes building stakeholder buy-in through engagement and education, using technology-enabled forced functions to facilitate change along with policy and reimbursement models that disincentivize low-value care. Professional societies have a role to play in supporting this next phase of CW.
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Affiliation(s)
- Sonieya Nagarajah
- Cancer Quality Lab (CQuaL), Princess Margaret Cancer Center, University Health Network, Toronto, Ontario, Canada
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Melanie Lynn Powis
- Cancer Quality Lab (CQuaL), Princess Margaret Cancer Center, University Health Network, Toronto, Ontario, Canada
| | - Rouhi Fazelzad
- Library and Information Services, University Health Network, Toronto, Ontario, Canada
| | - Monika K. Krzyzanowska
- Cancer Quality Lab (CQuaL), Princess Margaret Cancer Center, University Health Network, Toronto, Ontario, Canada
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Vishal Kukreti
- Cancer Quality Lab (CQuaL), Princess Margaret Cancer Center, University Health Network, Toronto, Ontario, Canada
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
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Chong A, Witherspoon E, Honig B, Ela E, Cavanagh H, Strawbridge L. Reflections on the Oncology Care Model and Looking Ahead to the Enhancing Oncology Model. JCO Oncol Pract 2022; 18:685-690. [DOI: 10.1200/op.22.00329] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Affiliation(s)
- Alexandra Chong
- Center for Medicare and Medicaid Innovation, Baltimore, MD
- The Centers for Medicare & Medicaid Services, Baltimore, MD
| | - Eileen Witherspoon
- Center for Medicare and Medicaid Innovation, Baltimore, MD
- The Centers for Medicare & Medicaid Services, Baltimore, MD
| | - Batsheva Honig
- Center for Medicare and Medicaid Innovation, Baltimore, MD
- The Centers for Medicare & Medicaid Services, Baltimore, MD
| | - Elizabeth Ela
- Center for Medicare and Medicaid Innovation, Baltimore, MD
- The Centers for Medicare & Medicaid Services, Baltimore, MD
| | - Hillary Cavanagh
- Center for Medicare and Medicaid Innovation, Baltimore, MD
- The Centers for Medicare & Medicaid Services, Baltimore, MD
| | - Lara Strawbridge
- Center for Medicare and Medicaid Innovation, Baltimore, MD
- The Centers for Medicare & Medicaid Services, Baltimore, MD
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Hoda D, Richards R, Faber EA, Deol A, Hunter BD, Weber E, DiFilippo H, Henderson-Clark T, Meaux L, Crivera C, Riccobono C, Garrett A, Jackson CC, Fowler J, Theocharous P, Stewart R, Lorden AL, Porter DL, Berger A. Process, resource and success factors associated with chimeric antigen receptor T-cell therapy for multiple myeloma. Future Oncol 2022; 18:2415-2431. [PMID: 35583358 DOI: 10.2217/fon-2022-0162] [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
Background: Chimeric antigen receptor T-cell (CAR-T) therapy represents a new frontier in multiple myeloma. It is important to understand critical success factors (CSFs) that may optimize its use in this therapeutic area. Methods: We estimated the CAR-T process using time-driven activity-based costing. Information was obtained through interviews at four US oncology centers and with payer representatives, and through publicly available data. Results: The CAR-T process comprises 13 steps which take 177 days; it was estimated to include 46 professionals and ten care settings. CSFs included proactive collaboration, streamlined reimbursement and CAR-T administration in alternative settings when possible. Implementing CSFs may reduce episode time and costs by 14.4 and 13.2%, respectively. Conclusion: Our research provides a blueprint for improving efficiencies in CAR-T therapy, thereby increasing its sustainability for multiple myeloma.
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Affiliation(s)
- Daanish Hoda
- Intermountain Healthcare, Salt Lake City, UT, USA
| | - Robert Richards
- Cell Therapy & Transplant Program, Division of Hematology-Oncology & Abramson Cancer Center, University of Pennsylvania, Philadelphia, PA 19104, USA
| | - Edward A Faber
- Transplant & Cellular Therapy Program, Oncology/Hematology Care, USA.,Adult BMT & Cellular Therapy Program, University of Cincinnati, 2600 Clifton Ave, Cincinnati, OH 45221, USA
| | - Abhinav Deol
- Karmanos Cancer Center, 4100 John R St, Detroit, MI 48201, USA
| | | | - Elizabeth Weber
- Cell Therapy & Transplant Program, Division of Hematology-Oncology & Abramson Cancer Center, University of Pennsylvania, Philadelphia, PA 19104, USA
| | - Heather DiFilippo
- Cell Therapy & Transplant Program, Division of Hematology-Oncology & Abramson Cancer Center, University of Pennsylvania, Philadelphia, PA 19104, USA
| | | | - Linda Meaux
- Intermountain Healthcare, Salt Lake City, UT, USA
| | - Concetta Crivera
- Janssen Scientific Affairs, LLC, 1125 Trenton-Harbourton Road, Titusville, NJ 08560, USA
| | - Carrie Riccobono
- US Medical Affairs, Legend Biotech, 2101 Cottontail Lane Somerset, NJ 08873, USA
| | - Ashraf Garrett
- US Medical Affairs, Legend Biotech, 2101 Cottontail Lane Somerset, NJ 08873, USA
| | - Carolyn C Jackson
- Janssen Pharmaceutical Research & Development, 1125 Trenton-Harbourton Road, Titusville, NJ 08560, USA
| | - Jessica Fowler
- Janssen Scientific Affairs, LLC, 1125 Trenton-Harbourton Road, Titusville, NJ 08560, USA
| | | | - Raj Stewart
- Evidera
- PPD, 7101 Wisconsin AvenueSuite 1400Bethesda, MD 20814, USA
| | - Andrea L Lorden
- Evidera
- PPD, 7101 Wisconsin AvenueSuite 1400Bethesda, MD 20814, USA
| | - David L Porter
- Cell Therapy & Transplant Program, Division of Hematology-Oncology & Abramson Cancer Center, University of Pennsylvania, Philadelphia, PA 19104, USA
| | - Ariel Berger
- Evidera
- PPD, 7101 Wisconsin AvenueSuite 1400Bethesda, MD 20814, USA
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