Tacking upwind: reducing spending among high-risk commercially insured patients

OBJECTIVES

The study examined a commercial accountable care organization (ACO) population and then assessed the impact of an integrated care management program on medical spending and clinical event rates.

STUDY DESIGN

Retrospective cohort study of high-risk individuals (n = 487) in a population of 365,413 individuals aged 18 to 64 years within the Mass General Brigham health system who were part of commercial ACO contracts with 3 large insurers between 2015 and 2019.

METHODS

Using medical spending claims and other enrollment data, the study assessed the demographic and clinical characteristics, medical spending, and clinical event rates of patients in the ACO and its high-risk care management program. The study then examined the impact of the program using a staggered difference-in-difference design with individual-level fixed effects and compared outcomes of those who had entered the program with those of similar patients who had not entered.

RESULTS

The commercially insured ACO population was healthy on average but included several hundred high-risk patients (n = 487). After adjustment, patients within the ACO's integrated care management program for high-risk patients had lower monthly medical spending (by $1361 per person per month) as well as lower emergency department visit and hospitalization rates compared with similar patients who had yet to start the program. Accounting for early ACO departure decreased the magnitude of the program effects as expected.

CONCLUSIONS

Commercial ACO populations may be healthy on average but still include some high-risk patients. Identifying which patients might benefit from more intensive care management could be critical for reaping the potential savings.

Population turnover and leakage in commercial ACOs

OBJECTIVES

Commercial accountable care organization (ACO) contracts attempt to mitigate spending growth, but past evaluations have been limited to continuously enrolled ACO members in health maintenance organization (HMO) plans, excluding many members. The objective of this study was to examine the magnitude of turnover and leakage within a commercial ACO.

STUDY DESIGN

A historical cohort study using detailed information from multiple commercial ACO contracts within a large health care system between 2015 and 2019.

METHODS

Individuals insured through 1 of the 3 largest commercial ACO contracts during the study period, 2015-2019, were included. We examined patterns of entry and exit and the characteristics that predicted remaining in the ACO compared with leaving the ACO. We also examined predictors of the amount of care delivered in the ACO compared with outside the ACO.

RESULTS

Among the 453,573 commercially insured individuals in the ACO, approximately half left the ACO within the initial 24 months after entry. Approximately one-third of spending was for care occurring outside the ACO. Patients who remained in the ACO differed from those who left earlier, including being older, having a non-HMO plan, having lower predicted spending at entry, and having more medical spending for care performed within the ACO during the initial quarter of membership.

CONCLUSIONS

Both turnover and leakage hamper the ability of ACOs to manage spending. Modifications that address potentially intrinsic vs avoidable sources of population turnover and increase patient incentives for care within vs outside of ACOs could help address medical spending growth within commercial ACO programs.

Enhancing employer coverage of smoking cessation treatment: A randomized trial of the Partners in Helping You Quit (PiHQ) program

The workplace is a key channel for delivering tobacco cessation treatment to a population. Employers can provide workplace-based programs and/or financial incentives such as health insurance benefits that cover the cost of treatment accessed outside the workplace. Little is known about the effect of combining these strategies. We tested the benefit of adding a workplace cessation program, Partners in Helping You Quit (PiHQ), to comprehensive health insurance coverage of smoking cessation medications by Partners HealthCare, a large Boston-based healthcare delivery system. PiHQ offers biweekly telephone-based behavioral support, additional automated calls, and medication care coordination for 3 months then monthly telephone monitoring for 9 months. In a pragmatic randomized trial, employees who smoked were informed about the insurance benefit, then randomly assigned (2:1) to PiHQ or to active referral to a free 3-month phone-based community program, Massachusetts Quitline (QL). Outcomes were assessed at 3, 6, and 12 months. During 2015-2018, 106 smokers (n = 73 PiHQ, n = 33 QL) enrolled (64% female; 75% white, 21% black; mean age 46 years, mean cigarettes/day = 13). More PiHQ than QL participants made a quit attempt by 3 months (82 vs. 61%, p < .02) and achieved the primary outcome, verified past 7-day cigarette abstinence at 6 months (31 vs. 12%, odds ratio 3.34, 95% CI, 1.05-10.60). Among participants using behavioral support, PiHQ participants completed more scheduled calls and rated counseling helpfulness higher than did QL participants. These results suggest that employers can enhance the impact of providing comprehensive health insurance coverage of smoking cessation medication by adding a phone-based worksite cessation program.

Abstract 28: Identification of multisite real-world patient cohorts to enable immunotherapy utilization and safety assessment

Currently, five classes of Immunotherapy (IT) agents are available for over 20 cancer types, including a powerful new class utilizing T cells genetically engineered to express a chimeric antigen receptor (CAR-T). Additional classes include bi-specific T-cell engagers (BiTEs), immune checkpoint inhibitors (ICIs), cancer vaccines, and oncolytic viruses. Despite promising antitumor activity, significant immune-related adverse events (irAE) have been reported. The most common CAR-T toxicity is cytokine release syndrome (CRS), and management typically includes supportive care and immunosuppression with corticosteroids or the IL-6 inhibitor tocilizumab. Documented CRS and tocilizumab use outside of CAR-T is rare, but recent evidence suggests that tocilizumab is emerging for management of other steroid-refractory irAE. Given the rapid evolution of this field, there remains a need to understand the utilization of IT and the pathophysiology of irAE in real-world settings. To identify cohorts of interest, a retrospective, multicenter review was conducted using Health Catalyst’s extended real-world data database, Touchstone, which includes &gt;300 sources of data and over 70 multipayer and geographically diverse provider clients. Cohorts were selected from representative provider networks, including large and specialty academic medical centers (AMCs), integrated delivery networks, accountable care organizations, and community hospitals in the US. A total of 10 clients’ de-identified electronic medical records were searched for presence of cancer-associated diagnosis codes. The cohort was then restricted by the presence of medication order or administration of any IT-class drug, and among these, first administration of tocilizumab within 21 days. Across ten provider networks containing data for ~5.6 million cancer patients, 9,029 patients were identified: CAR-T, 116 patients (0-102); BiTEs, 112 patients (0-64); ICIs, 8,402 patients (0-4520); cancer vaccines, 182 patients (0-143); and oncolytic viruses, 217 patients (0-214). As expected, CAR-T administration was limited to approved treatment centers. Among the other classes, an average of 26% of identified patients were from the community setting. Additionally, of the 116 patients receiving CAR-T therapy, 75 patients (64.7%) were administered tocilizumab within 21 days. Evidence of tocilizumab use outside of CAR-T irAE was also identified, occurring in 21 patients (0.3%) receiving another class of IT within AMCs, and did not occur at other provider types. Together this analysis identified several real-world IT patient cohorts comprising diverse populations from a range of provider types, with corresponding access to rich patient-level clinical, molecular, and financial real-world data (RWD) elements. Immediate downstream applications will involve developing integrated methods for the real-time identification of patients who may be at risk for adverse events and standardization of toxicity management guidelines.

Citation Format: Catherine Del Vecchio Fitz, Elizabeth Eldridge, Alyssa Antonopoulos, Paula Petrone, Will Caldwell, Ed Corbett, Amy Flaster, Holly Rimmasch, Adem Albayrak, Dale Sanders, Sadiqa Mahmood, Elia Stupka. Identification of multisite real-world patient cohorts to enable immunotherapy utilization and safety assessment [abstract]. In: Proceedings of the AACR Special Conference on Advancing Precision Medicine Drug Development: Incorporation of Real-World Data and Other Novel Strategies; Jan 9-12, 2020; San Diego, CA. Philadelphia (PA): AACR; Clin Cancer Res 2020;26(12_Suppl_1):Abstract nr 28.