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

2021 ◽  
Author(s):  
Ryan B. Thomas ◽  
Vittorio Maio ◽  
Anna Chen ◽  
Seojin Park ◽  
Dexter Waters ◽  
...  
Keyword(s):  
Breast Cancer ◽  
Academic Medical Center ◽  
Stage Iv ◽  
Cost Of Care ◽  
Mean Difference ◽  
Cancer Stage ◽  
Care Model ◽  
Target Price ◽  
Old Patients ◽  
Oncology Care

PURPOSE: To explore mean difference between Oncology Care Model (OCM) total costs and target price among breast cancer episodes by stage under the Centers for Medicare and Medicaid Services OCM payment methodology. METHODS: Breast cancer episodes from OCM performance period 1-4 reconciliation reports (July 1, 2016-July 1, 2018) were linked with health record data from a large, academic medical center. Demographics, total cost of care (TCOC), and target price were measured by stage. Adjusted differences between TCOC and target price were compared across cancer stage using multivariable linear regression. RESULTS: A total of 539 episodes were evaluated from 252 unique patients with breast cancer, of which 235 (44%) were stage I, 124 (23%) stage II, 33 (6%) stage III, and 147 (27%) stage IV. About 37% of episodes exceeded target price. Mean differences from target price were –$1,782, $2,246, –$6,032, and $11,379 all in US dollars (USD) for stages I through IV, respectively. Stage IV episodes had highest mean TCOC ($44,210 USD) and mean target price ($32,831 USD) but also had higher rates of chemotherapy, inpatient admission, and novel therapy use. After adjusting for covariates, stage IV and ≥ 65-year-old patients had the highest mean difference from target price ($17,175 USD; 95% CI, $12,452 to $21,898 USD). CONCLUSION: Breast cancer episodes in older women with distant metastases most frequently exceeded target price, suggesting that target price did not adequately account for complexity of metastatic cancers. A metastatic adjustment introduced in PP7 represents a promising advancement in the target price methodology and an impact evaluation will be needed.

Factors associated with target price status within the oncology care model population.

2021 ◽  
Vol 39 (28_suppl) ◽  
pp. 72-72
Author(s):  
Matthew Molaei ◽  
Karen Walsh ◽  
Scott W. Keith ◽  
Valerie Pracilio Csik ◽  
Amy Leader ◽  
...  
Keyword(s):  
Drug Use ◽  
Radiation Treatment ◽  
Cost Of Care ◽  
Medicare Part ◽  
Cancer Type ◽  
Cancer Stage ◽  
Care Model ◽  
Target Price ◽  
Medicare Part B ◽  
Oncology Care

72 Background: The Oncology Care Model (OCM) is an alternative payment model put forth by the Centers for Medicare and Medicaid Services (CMS), which aims to improve quality of care for cancer beneficiaries, while reducing cost. One of the strategies implemented by CMS to achieve this goal was the development of an episode target price (TP), which uses historical data and episode specific adjusters to calculate a total cost of care goal for each episode. The goal of this analysis was to better understand how CMS risk adjustments could account for episode characteristics, as well as how these characteristics affect likelihood of meeting target price. Methods: OCM performance claims data were abstracted retrospectively from performance periods (PP) 1-6 (episodes initiated from 7/1/2016 – 12/31/2019), in which each episode captured 6 months of care. EHR data was linked to identify cancer staging for OCM Beneficiaries. Any OCM beneficiary with at least one episode in PP 1-6 was included. To assess odds of meeting TP, a logistic regression model with a generalized estimating equation was used to account for patients who contributed multiple episodes. Specific factors evaluated for their association with meeting TP included patient’s age and sex, cancer stage, cancer type, cancer related surgery, clinical trial participation, hospice status, inpatient admissions, observational stays, Medicare part B drug use and radiation therapy. Results: 4,612 episodes were included in analysis, which translated to 2,459 patients, who had an average age of 72 years old and were majority female (50.5%). 2,790 (60.5%) of the episodes met the TP set by OCM. When controlling for covariates, radiation treatment (OR = 1.75, 95%CI: 1.39-2.23), stage 2 compared to stage 4 cancers (OR = 1.86, 95%CI: 1.23-2.80), colorectal cancers (OR = 1.75, 95%CI: 1.11-2.77) and melanomas (OR = 4.35, 95%CI: 2.18-8.67) were significantly associated with increased odds of meeting TP. Novel therapies (OR = 0.19, 95%CI: 0.14-0.26), inpatient admissions (OR = 0.27, 95%CI: 0.22-0.33), observational stays (OR = 0.66, 95%CI: 0.51-0.87) and part B drug use (OR = 0.75, 95%CI: 0.60-0.93) were associated with significantly reduced odds of meeting TP. Conclusions: Our analysis suggests that radiation treatment, as well as selected cancer stage and types may contribute to increased likelihood of meeting TP, which may point to potential areas of cost savings. Conversely, specific resource utilizations such as novel therapy use, inpatient admissions, observational stays, and Medicare part B drug use may decrease the odds of meeting TP, despite being adjusted for in the OCM model. While CMS has recognized that late stage cancers require a more sensitive TP with the metastatic adjustment, other adjustments should also be considered to adequately account for episode characteristics. External validation at other OCM-participating practices is needed to corroborate these results.

Pursuit of performance: An exploration of predictors associated with achieving performance based payments for breast cancer episodes under the Oncology Care Model.

2019 ◽  
Vol 37 (15_suppl) ◽  
pp. e18035-e18035
Author(s):  
Andrew Jehyun Song ◽  
Arianna Kee ◽  
Jared Minetola ◽  
Karen Walsh ◽  
Valerie P Csik ◽  
...  
Keyword(s):  
Breast Cancer ◽  
Logistic Regression ◽  
Systemic Therapy ◽  
Medical Center ◽  
Academic Medical Center ◽  
Novel Therapies ◽  
Care Model ◽  
Logistic Regression Models ◽  
Multivariable Logistic Regression ◽  
Oncology Care

e18035 Background: The Oncology Care Model (OCM) captures patient costs in a 6-month episode triggered by administration of systemic therapy. Most breast cancer (BC) patients will receive systemic therapy, with variations depending on stage and hormonal status, which makes BC an ideal indication to study costs in the OCM. Practices earn performance based payments (PBP) if aggregate episodic expenditures are managed below set target prices. We investigated predictors for episodic expenditures exceeding target prices, thus reducing potential for PBP. Methods: We identified BC episodes with non-decedent beneficiaries attributable to our academic medical center from OCM Reconciliation Reports during 7/1/16-6/30/17. Cohorts were defined as episodes whose costs were above target (Cohort 1) and those below (Cohort 2). The Wilcoxon Rank-Sum test was used to compare actual and target episode expenditure between cohorts. Multivariable logistic regression models were used to assess association of maintaining costs below target due to various predictors. Results: A total of 369 episodes were included in the study, with 124 episodes in Cohort 1 and 245 in Cohort 2. Median actual and target episode expenditures were higher in Cohort 1 (actual: $23,466 vs. $2,691, p < 0.0001; target: $8,425 vs. $5,870, p < 0.0001). In multivariable logistic regression, episodes were more likely to be below target if novel therapies, Part B drugs, or inpatient admissions were not utilized, controlling for other predictors (see Table). Conclusions: Large disparities exist for both actual expenditures and target prices for BC episodes in the OCM. Novel therapies, Part B drugs, and inpatient admissions are negatively associated with maintaining episode expenditures below target. Risk-adjustments for these expenditures need to be overhauled in OCM to accurately capture costs associated with management of cancer patients, and provide practical target prices for institutions to continue delivery of value based care. [Table: see text]

scholarly journals PCN214 WHAT FACTORS ARE ASSOCIATED WITH EXCEEDING TARGET PRICE IN BREAST CANCER EPISODES UNDER THE ONCOLOGY CARE MODEL?

2020 ◽  
Vol 23 ◽  
pp. S60
Author(s):  
R. Thomas ◽  
S. Park ◽  
D.D. Waters ◽  
A. Song ◽  
V. Csik ◽  
...  
Keyword(s):  
Breast Cancer ◽  
Care Model ◽  
Target Price ◽  
Oncology Care

scholarly journals Influence of Pomalidomide and Lenalidomide on Total Cost of Care for Medicare Beneficiaries with Multiple Myeloma Under the Oncology Care Model (OCM)

Blood ◽  
2018 ◽  
Vol 132 (Supplement 1) ◽  
pp. 2252-2252 ◽  
Author(s):  
Haley Hines Theroux ◽  
Luis M Isola ◽  
Mark Liu ◽  
Alaysia Williams
Keyword(s):  
Multiple Myeloma ◽  
Bone Marrow ◽  
Cost Of Care ◽  
Cancer Type ◽  
Novel Therapies ◽  
Care Model ◽  
Target Price ◽  
Total Cost ◽  
Oncology Care ◽  
The Impact

Abstract Background: In July of 2016, CMMI started a five year bundled payment program called OCM. Beneficiaries are attributed to practices providing their cancer care for a 6 month episode triggered by the administration or distribution of specified cancer drugs. The model provides risk adjustments to the target price based on risk factors such as age, chemotherapy and the receipt of certain treatments (radiation or bone marrow transplant). Target prices are adjusted by geographic region, novel therapy use, and a trend factor. Multiple Myeloma was identified in our practice as a cancer type with high variance on expenditures after the first Performance Period within the model (July 2016-December 2016). Chemotherapy represented 52% of total episode expenditures with oral chemotherapy and hormone therapy representing 24%. The average cost of lenalidomide for one year is $115,000. The model adjusts for novel therapies, including new drugs approved by the FDA after December 31, 2014 with status lasting two years. However, literature demonstrates that this does not fully adjust for the high costs of novel therapies (Muldoon et at., Health Affairs, 2018). Unlike solid tumors, Multiple Myeloma staging may not improve risk adjustment and target price. Methods: We analyzed the total cost of care of beneficiaries who triggered an OCM episode for Performance Period 1 (PP1). Beneficiaries were identified by diagnosis of Multiple Myeloma, and then segregated into cohorts of those who received lenalidomide and/or pomalidomide and those who did not. Observed vs. Expected (O/E) target price for each episode was determined for both cohorts comparing the actual episode expenditures and the target price per episode calculated by the Oncology Care Model. A two sample t-test was conducted followed by a linear regression to determine relation between drug days prescribed and O/E. Results: There were 125 attributed beneficiaries with a Multiple Myeloma diagnosis who triggered an episode during PP1. The average O/E of the cohort which received the chemotherapy, Cohort A, was 1.624 compared to 0.986 for those that did not, Cohort B. The difference in average O/E in the two cohorts was 39% higher in Cohort A, p<0.001. There were no significant differences in the amount of inpatient claims, ED visits, or Bone Marrow Transplants between the two cohorts (Table 1). Figure 1 demonstrates the positive linear relationship (p<0.01, r=.40) between number of days supplied and O/E. Discussion: This is the first report on the impact of lenalidomide and pomalidomide on the total cost of care in an OCM practice. The results demonstrate the lack of adequate adjustment to the CMS target price for episodes in which one or both of these drugs were prescribed. Lenalidomide and pomalidomide are first and second line drugs used both for induction and maintenance. Both drugs are frequently used for prolonged periods of time in patients and trigger more than one episode in OCM. Therefore, the use of these agents greatly affects the total cost of care against a target price that is not adequately adjusted. Academic Medical Centers that care for larger populations of multiple myeloma patients may be disproportionately affected and this will impede their success under the OCM methodology. Additional analysis similar to this will inform CMMI as to further refinements to the OCM adjusters. Disclosures No relevant conflicts of interest to declare.

scholarly journals Multiple Myeloma Cost of Care Under the Oncology Care Model: The Influence of High-Cost Therapies

2020 ◽  
pp. JOP.19.00569 ◽  
Author(s):  
Haley Theroux ◽  
Alaysia Williams ◽  
Mark Liu ◽  
Alyssa Dahl ◽  
Theresa Dreyer ◽  
...  
Keyword(s):  
Multiple Myeloma ◽  
Primary Objective ◽  
Cost Of Care ◽  
Care Model ◽  
Target Price ◽  
Chemotherapy Agent ◽  
Significant Difference ◽  
Episodes Of Care ◽  
Oncology Care ◽  
The Impact

PURPOSE: As expenditures for cancer care continue to grow substantially, value-based payment models are being tested to control costs. The Oncology Care Model (OCM) is the largest value-based payment program in oncology. The primary objective of this analysis was to determine the impact of high-cost novel agents on total cost of care for multiple myeloma (MM) episodes of care in the OCM. METHODS: This was a retrospective analysis using Medicare claims data for 258 MM OCM episodes initiated between July 1, 2016, and July 1, 2017. Patients were organized into 3 cohorts: those who received pomalidomide (cohort A), those who received lenalidomide (cohort B), and those who did not receive either drug but had received another chemotherapy agent (cohort C). We compared the actual episode expenditures and the Centers for Medicare and Medicaid target price to create an observed versus expected (O/E) ratio. RESULTS: The average O/E for cohort A (n = 73) was 1.73, compared with 1.31 for cohort B (n = 84) and 1.01 for cohort C (n = 101). The difference the in O/E ratio among the groups was statistically significant ( P < .001). The average episode target price for cohorts A, B, and C was $66,149, $63,483, and $63,937, respectively. Despite the high cost of pomalidomide and lenalidomide, there was no significant difference in the average episode target prices of the cohorts. CONCLUSION: The O/E ratio and target prices of the cohorts demonstrate a lack of adequate adjustment to the OCM target price for episodes in which pomalidomide and lenalidomide were used to treat patients with MM.

Relationships among patients’ ability to identify their cancer stage, knowledge of care options, and management of transitions.

2014 ◽  
Vol 32 (31_suppl) ◽  
pp. 224-224
Author(s):  
Jenna Hinchey ◽  
Jessica Goldberg ◽  
Sarah Linsky ◽  
Rebecca Linsky ◽  
Sangchoon Jeon ◽  
...  
Keyword(s):  
Breast Cancer ◽  
Depression Scale ◽  
Metastatic Breast ◽  
Stage Iv ◽  
Stage I ◽  
Self Management ◽  
Future Research ◽  
Cancer Stage ◽  
Younger Age ◽  
Stage Iv Breast Cancer

224 Background: Discrepancies may exist between what oncologists communicate and what patients understand about their cancer stage. We explored women’s ability to correctly identify their stage of breast cancer among a sample of women recently diagnosed with nonmetastatic (Stage I-III) disease. Methods: As part of a cancer self-management study, we asked women with non-metastatic breast cancer to identify their stage of disease. Participants’ responses were compared to their electronic medical record (EMR) for validation. We calculated descriptive statistics and used logistic regression to examine relationships between knowledge of stage, demographic and clinical variables, and study outcomes (Control Preferences Scale- CPS, Knowledge of Care Options Test- KOCO, Measurement of Transitions Scale- MOT, Medical Communication Competence Scale- MCCS, Chronic Disease Self-Efficacy Scale- CDSE, Uncertainty in Illness Scale- MUIS-C, and Hospital Anxiety and Depression Scale- HADS). Results: Participants (n= 100) had a mean age of 52.3 years (range 27-72). Per the EMR, 19 participants (19%) had Stage I breast cancer, 57 (57%) had Stage II, and 24 (24%) had Stage III. Twenty-nine participants (29%) were unable to correctly identify their stage of cancer. Of this group, 11 (39.3%) provided vague responses, 11 (39.3%) reported an incorrect stage, and 7 (25%) did not know/want to know their stage. Younger age (p=.0412) and earlier cancer stage (p=.0136) were predictive of correctly identifying cancer stage. Participants who at baseline had a greater knowledge of care options were more likely to correctly identify their cancer stage (KOCO, p=.0482). Those who correctly identified their cancer stage were better able to manage transitions over time (MOT, p=.0564) than those unable to identify their stage. Conclusions: Women who cannot correctly identify their cancer stage may neither understand its implications nor effectively participate in cancer self-management. Conversations about cancer stage should be revisited to ensure patients’ understanding. Future research should include women with Stage IV breast cancer to more completely investigate ability to identify cancer stage.

The Oncology Care Model: A Critique

2016 ◽  
pp. e109-e114 ◽  
Author(s):  
Christian A. Thomas ◽  
Jeffrey C. Ward
Keyword(s):  
Health Care ◽  
Health Care Expenditures ◽  
Critical Discussion ◽  
Cost Of Care ◽  
Fee For Service ◽  
Care Model ◽  
Patient Admissions ◽  
Pilot Model ◽  
Oncology Care ◽  
The Cost

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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