Aggressive Care near the End of Life for Cancer Patients in Medicare Accountable Care Organizations

Abstract

OBJECTIVES To compare aggressiveness of end‐of‐life (EoL) care for older cancer patients attributed to Medicare Shared Savings Programs with that for similar fee for service (FFS) beneficiaries not in an accountable care organization (ACO) and examine whether observed differences in EoL care utilization vary across markets that differ in ACO penetration. DESIGN Cross‐sectional observational study comparing ACO‐attributed beneficiaries with propensity score–matched beneficiaries not attributed to an ACO. SETTING A total of 21 hospital referral regions (HRRs) in the United States. PARTICIPANTS Medicare FFS beneficiaries with a cancer diagnosis who were 66 years or older and died in 2013‐2014. MEASUREMENTS Outcome measures were claims‐based quality measures of aggressive EoL care: (1) one or more intensive care unit (ICU) admissions in the last month of life, (2) two or more hospitalizations in the last month of life, (3) two or more emergency department visits in the last month of life, (4) chemotherapy 2 weeks or less before death, and (5) no hospice enrollment or hospice enrollment within 3 days of death. Analyses were adjusted for demographic and clinical characteristics of beneficiaries and practice characteristics. RESULTS Compared with beneficiaries not in an ACO, ACO‐attributed beneficiaries had a higher rate of ICU admission during the last month of life (37.7% vs 34.0%; adjusted difference = +2.8 percentage points; 95% confidence interval (CI) = 1.0‐4.6) but fewer repeated hospitalizations (14.5% vs 15.2%; adjusted difference = −1.7 percentage points; CI = −3.1 to −.3). Other measures did not differ for the two groups. Although the ICU admission rates tended to decrease as ACO‐penetration rates increased (P < .01), ACO patients had higher rates of ICU admission than non‐ACO patients in both medium and high ACO‐penetration HRRs. CONCLUSION Cancer patients attributed to ACOs had fewer repeated hospitalizations but more ICU admissions in the last month of life than non‐ACO patients; they had similar rates of other measures of aggressive care at the EoL. This suggests opportunities for ACOs to improve EoL care for cancer patients. J Am Geriatr Soc 67:961–968, 2019.

The Affordable Care Act and access to care across the cancer control continuum: A review at 10 years

“…Significant improvements in screening for CRC have been reported for Medicare beneficiaries attributed to ACOs, although declines or no effects were observed for mammography screening in women 110,111 . There are no cancer‐specific ACOs, although several studies have noted modest or no effects on treatment intensity or spending at the end of life for Medicare beneficiaries with a cancer diagnosis 112,113 . An early evaluation of the OCM during the first performance period compared volunteer practices with propensity score‐matched control practices before and after implementation using a DID approach 69 .…”

Integration of End‐of‐Life Care into Accountable Care Organization's Quality Measures

“…As alternative payment models take shape, Kim et al are to be commended for exploring the end‐of‐life (EoL) care in the patient population served by accountable care organizations (ACOs) . The authors’ efforts enter an area where there is limited literature and understanding because commonly accepted quality metrics of EoL care such as those laid out by the National Quality Forum and American Society of Clinical Oncology are not among the 33 ACO quality measures set by the Centers for Medicare & Medicaid Services .…”

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This editorial comments on the Clinical Investigation by Kim et al in this issue.A s alternative payment models take shape, Kim et al are to be commended for exploring the end-of-life (EoL) care in the patient population served by accountable care organizations (ACOs). 1 The authors' efforts enter an area where there is limited literature and understanding because commonly accepted quality metrics of EoL care such as those laid out by the National Quality Forum and American Society of Clinical Oncology are not among the 33 ACO quality measures set by the Centers for Medicare & Medicaid Services. 2 The authors conduct this observational study across 21 hospital referral regions in the eastern United States by matching ACO-attributed beneficiaries with those non-ACO associated through propensity score matching.The authors report findings that were not as compelling as we would have expected (or hoped).

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Geriatric Oncology: Getting Even Better with Age

“…As the evidence base develops, next steps will include providing data to support personalized management, developing novel trial designs, pioneering new approaches to care delivery, and ultimately implementing results into practice at the level of the individual and the healthcare system. Research presented in this issue highlights challenges and opportunities in effecting change, which includes implementing geriatric screening, testing rehabilitation for vulnerable older adults with cancer, and decreasing aggressive care at the end of life …”

“…Research presented in this issue highlights challenges and opportunities in effecting change, which includes implementing geriatric screening, testing rehabilitation for vulnerable older adults with cancer, and decreasing aggressive care at the end of life. [25][26][27] Geriatric oncology is coming of age. Its success will continue to be fostered by the dedication of a passionate and collaborative national and international community of investigators, clinicians, educators, and advocates.…”