What happens when the MFN pharmaceutical policy goes into effect?

Jan 25, 2021

Examining the consequences on access to care for Medicare beneficiaries and on the viability of frontline community oncology practices.

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Alternative Payment Models During A Pandemic: Suspending Down-Side Risk During This Time Of National Crisis

Health Affairs | Apr 6, 2020

There have been a number of unprecedented regulatory flexibilities issued by the Centers for Medicare and Medicaid Services (CMS) in recent weeks given the COVID-19 pandemic, done with the intention of easing the burdens on the health care system to be more responsive to our patients’ needs. But one issue that has been left in limbo is the status of a number of value-based programs at CMS and its Center for Medicare and Medicaid Innovation (the Innovation Center). Where possible by regulatory action, the Department of Health and Human Services should suspend all down-side risk mechanisms in alternative payment models given the current mass scale disruption of the US health care system caused by the novel coronavirus.

There are three major reasons why suspension of financial risk is warranted during this time of unprecedented challenge. First, policies exposing providers to financial risk during the pandemic are at odds with the national interest, particularly given the declaration of a national emergency. Second, such risk-related policies are no longer equitable among health care providers during the pandemic. Third, methodologically, the policy-related hypotheses informing the rationale and design of down-side risk mechanisms no longer hold true. Therefore, the related evaluations of those policy hypotheses are now subject to a myriad of threats to internal validity due to the effects of the pandemic, severely compromising the quality of inference that can be drawn from down-side risk mechanisms.

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The Oncology Care Model—Why It Works and Why It Could Work Better: Accounting for Novel Therapies in Value-Based Payment

JAMA Oncology | Jan 25, 2021

Value-based payment models (VBPMs) have become increasingly prevalent in oncology. The most robust example is the Oncology Care Model (OCM), a cancer-specific, 5-year experimental VBPM implemented by the Center for Medicare & Medicaid Innovation (CMMI). Medical oncologists participating in the OCM are held accountable for the total cost of 6-month episodes of care for patients with cancer receiving antineoplastic therapies. These costs are compared with target costs partially derived from historical cancer care spending measured during a baseline period spanning 2012 to 2015.1 This accountability, along with Monthly Enhanced Oncology Services (MEOS) payments, is intended to foster care coordination to reduce preventable emergency department visits, inpatient hospitalizations, and inpatient postacute care.

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Effects of rising drug costs on efforts to control overall cost at a large academic cancer center

Journal of Clinical Oncology | Oct 16, 2019

Background: Value-based payment programs like the Oncology Care Model (OCM) have focused efforts to reduce costly acute care use through improvements in access and coordination rather than targeting the exponential rise in pharmaceutical pricing. We assessed how participation in OCM affected total cost of cancer care at a large academic cancer center. Methods: Using Medicare claims for Yale-Smilow Cancer Hospital, an NCI-designated cancer center with an academic hub and 10 community practices, we identified episodes for chemotherapy initiated during a historical period (pre-OCM, 2012-2015) and performance period (post-OCM, 2016-2017) following OCM criteria to identify total cost of care. We reported frequency of utilization categories, the mean cost per episode, the proportion of total cost attributed to each utilization category and compared pre- and post-participation periods. Results: There were 8,843 episodes during the historical period and 6,679 episodes during the performance period. The mean total cost per episode increased from $28,645 to $32,666, but this was less than the Medicare-defined expected increase (target price). Between the two periods, the percentage of total episodes decreased for emergency department (ED) use from 36% to 33%, inpatient care from 33% to 29%, and post-acute care from 28% to 25% (p < 0.01). Mean costs of drugs per episode increased by 27% between periods, and from 52% to 58% of total cost of care (p < 0.01). While mean cost per episode for ED, inpatient, and post-acute care remained stable, the mean cost per episode for antineoplastics increased 39% from $10,676 to $14,843. Conclusions: After implementing OCM, we beat the Medicare target largely by decreasing acute care use and stabilizing the cost of hospitalizations and ED; however, actual cost increased largely due to pharmaceutical spending. Because drug costs were the largest proportion of overall cost of care, future value-based models must address the rising cost of pharmaceuticals.

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The effect of guideline-concordant novel therapy use on meeting cost targets in OCM: Results from a large community oncology network.

Journal of Clinical Oncology | May 26, 2019

Background: The Oncology Care Model (OCM) is intended to incentivize physicians to improve the quality and reduce the cost of cancer care. In OCM, providers are accountable for all costs during six month episodes of care relative to target costs (TC) derived from a baseline spending period (BSP; 2013-2015). This accountability is intended to foster care coordination to reduce preventable emergency department visits and hospitalizations (EDH). Benefits of reducing EDH may be diluted when new treatment indications for costly immunotherapies (IO) are introduced into clinical practice after BSP. Methods: We identified all non-small cell lung cancer (NSCLC) and bladder cancer (BC) OCM episodes attributed to Tennessee Oncology (TO), a large community oncology network of over 90 oncologists, during performance period 2 (PP2; the most recent PP with available data). We selected NSCLC and BC because both diseases have IO indications that became standard of care after BSP. Using claims data analytics software, we identified all NSCLC and BC episodes with spending above TC, and found a subset of these above target episodes (ATEs) without any EDH that remained above TC due to IO use. Two medical oncologists reviewed these cases in duplicate to assess guideline concordance of IO. Results: During PP2 there were 2,623 OCM episodes attributed to TO, including 240 NSCLC and 31 BC episodes. Spending was above TC in 118 (49%) and 13 (42%) of NSCLC and BC episodes, respectively. For these NSCLC and BC ATEs, EDH was prevented in 62 (53%) and 5 (38%) of cases, respectively. In NSCLC and BC ATEs without EDH, 43 (69%) and 5 (100%) of episodes included IO, respectively. Clinician review in duplicate (S.M.S.; C.A.W.) found that the use of IO was NCCN guideline concordant in 33 (77%) and 4 (80%) of these NSCLC and BC cases, respectively (K = 0.87). Conclusions: Guideline-concordant use of expensive IO as its treatment indications expand poses substantial challenges to meeting cost targets in OCM, even when practices prevent EDH.

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Preparing for Value-Based Payment: A Stepwise Approach for Cancer Centers

Journal of Clinical Oncology — Oncology Practice | Oct 23, 2016

Most cancer centers are ill-equipped to pursue value-based payment (VBP) because of limited information on their population’s cost of care. Herein, we outline the stepwise approach used by Smilow Cancer Hospital at Yale-New Haven in our pursuit of better value care. First, we addressed institutional barriers. A move toward value required demonstration to Yale-New Haven Health System leadership that OCM would improve patient care, fund new infrastructure, and provide the opportunity to gain experience with VBP without a major threat to the financial stability of the health system. We evaluated patterns of care and found that of patients presenting to the emergency department (ED), 88% were admitted, 62% arrived during the workday, and 50% could have been stabilized with urgent care services. Within 30 days of death, 27% were admitted to the intensive care unit, 38% presented to the ED, and 52% were admitted. To quantify total cost of care, we accessed the 5% Medicare Limited Data Set to map out total cost of care for patients receiving chemotherapy at Smilow Cancer Hospital. Costs increased as patients moved through 6-month episodes, used the ED (patients with two or more visits were twice as expensive as those with one or fewer), or died during an episode (costs were twice as high as episodes in which the patient lived). To determine strategic interventions to improve value, we targeted investments in urgent care to reduce ED utilization, care management to prevent hospital admissions, and referral to palliative care for clarification of goals of care and avoidance of costly futile treatment. Developing internal metrics to evaluate success will require monitoring our interventions by having utilization measures for each site of care and individual provider.

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