Association Between a National Insurer’s Pay-for-Performance Program for Oncology and Changes in Prescribing of Evidence-Based Cancer Drugs and Spending

Bekelman, Justin E.; Gupta, Atul; Fishman, Ezra; Debono, David; Fisch, Michael J.; Liu, Ying; Sylwestrzak, Gosia; Barron, John; Navathe, Amol S.

doi:10.1200/jco.20.00890

Cited by 7 publications

(3 citation statements)

References 23 publications

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“…We estimated within-practice changes before and after program participation, using episodes at physician practices that had not yet begun participating in the program during a given time period (but would go on to do so) as the control. This approach, which has been used previously to study private insurer payment programs with staggered rollouts, 9 , 10 mitigated bias from physician practice selection into the program on unobserved factors because all practices in our sample eventually elected to participate. It also allowed us to account for secular trends during the study period.…”

Section: Methodsmentioning

confidence: 99%

Association Between a Bundled Payment Program for Lower Extremity Joint Replacement and Patient Outcomes Among Medicare Advantage Beneficiaries

et al. 2023

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ImportanceMuch of the evidence for bundled payments has been drawn from models in the traditional Medicare program. Although private insurers are increasingly offering bundled payment programs, it is not known whether they are associated with changes in episode spending and quality.ObjectiveTo evaluate whether a voluntary bundled payment program offered by a national Medicare Advantage insurer was associated with changes in episode spending or quality of care for beneficiaries receiving lower extremity joint replacement (LEJR) surgery.Design, Setting, and ParticipantsCross-sectional study of 23 034 LEJR surgical episodes that emulated a stepped-wedge design by using the time-varying, geographically staggered rollout of the bundled payment program from January 1, 2012, to September 30, 2019. Episode-level multivariable regression models were estimated within practice to compare changes before and after program participation, using episodes at physician practices that had not yet begun participating in the program during a given time period (but would go on to do so) as the control. Data analyses were performed from July 1, 2021, to June 30, 2022.ExposuresPhysician practice participation in the bundled payment program.Main Outcomes and MeasuresThe primary outcome was episode spending (plan and beneficiary). Secondary outcomes included postacute care use (skilled nursing facility and home health care), surgical setting (inpatient vs outpatient), and quality (90-day complications [including deep vein thrombosis, wound infection, fracture, or dislocation] and readmissions).ResultsThe final analytic sample included 23 034 LEJR episodes (6355 bundled episodes and 16 679 control episodes) from 109 physician practices participating in the program. Of the beneficiaries, 7730 were male and 15 304 were female, 3057 were Black, 19 351 were White, 447 were of other race or ethnicity (assessed according to the Centers for Medicare &amp; Medicaid Services beneficiary race and ethnicity code, which reflects data reported to the Social Security Administration), and 179 were of unknown race and ethnicity. The mean (SD) age was 70.9 (7.2) years. Participation in the bundled payment program was associated with a 2.7% (95% CI, 1.3%-4.1%) decrease in spending per episode (mean episodic spending, $21 964 [95% CI, $21 636-$22 296] vs $22 562 [95% CI, $22 346-$22 779]), as well as reductions in skilled nursing facility use after discharge (21.3% for bundled episodes vs 25.0% for control episodes; odds ratio [OR], 0.81 [95% CI, 0.67-0.98]) and increased use of the outpatient surgical setting (14.1% for bundled episodes vs 8.4% for control episodes; OR, 1.79 [95% CI, 1.53-2.09]). The program was not associated with changes in quality outcomes, including 90-day complications (8.8% for bundled episodes vs 8.6% for control episodes; OR, 1.02 [95% CI, 0.86-1.20]) and readmissions (4.3% for bundled episodes vs 4.6% for control episodes; OR, 0.92 [95% CI, 0.75-1.13]).Conclusions and RelevanceIn this study of an LEJR bundled payment program offered by a national Medicare Advantage insurer, findings suggest that physician practice participation in the program was associated with a decrease in episode spending without changes in quality. Bundled payments offered by private insurers, including Medicare Advantage plans, are an alternate payment option to fee for service that may reduce spending for LEJR episodes while maintaining quality of care.

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Section: Methodsmentioning

confidence: 99%

Association Between a Bundled Payment Program for Lower Extremity Joint Replacement and Patient Outcomes Among Medicare Advantage Beneficiaries

et al. 2023

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“…(5,6) We defined five measures of low-value cancer care spanning the cancer care continuum ( Supplemental Table 2 ): 1) Positron Emission Tomography/Computed Tomography (PET/CT) instead of conventional CT imaging for initial staging; 2) conventional fractionation instead of hypofractionation for early-stage breast cancer; 3) non-guideline-based antiemetic use for minimal-, low-, or moderate-to-high-risk chemotherapies; 4) off-pathway systemic therapy; and 5) aggressive end-of-life care (chemotherapy in the last 14 days of life, multiple emergency department visits in the last 30 days of life, intensive care unit utilization in the last 30 days of life, hospice initiation ≤3 days before death, and/or no hospice receipt before death). These measures were identified from the American Society of Clinical Oncology and American Society for Radiation Oncology Choosing Wisely campaigns (7,8), the Hutchinson Institute for Cancer Outcomes Research (9), Anthem’s Cancer Care Quality Program treatment pathways (10), NCCN guidelines (11), and peer-reviewed literature on low-value antiemetic use (12). We intentionally chose measures of low-value care that involved both additional healthcare encounters (e.g.…”

Section: Methodsmentioning

confidence: 99%

Trends in Low-Value Cancer Care During the COVID-19 Pandemic

Parikh

Civelek

Ozluk

et al. 2022

Preprint

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Background Low-value services are common in cancer care. The onset of the COVID-19 pandemic caused a dramatic decrease in health care utilization, leading many to suspect that low-value cancer services may decrease. Methods In this retrospective cohort study, we used administrative claims from the HealthCore Integrated Research Environment, a repository of medical and pharmacy data from US health plans representing over 80 million members, to identify 204,581 patients diagnosed with breast, colorectal, and/or lung cancer between January 1, 2015, and March 31, 2021. We used linear probability models to investigate the relation between the onset of COVID-19 pandemic and 5 guideline-based metrics of low-value cancer care: 1) Positron Emission Tomography/Computed Tomography (PET/CT) instead of conventional CT imaging for initial staging; 2) conventional fractionation instead of hypofractionation for early-stage breast cancer; 3) non-guideline-based antiemetic use for minimal-, low-, or moderate-to-high-risk chemotherapies; 4) off-pathway systemic therapy; and 5) aggressive end-of-life care. Results Among 204,581 patients, the mean [SD] age was 63.1 [13.2], 68.1% were female, 83,593 (40.8%) had breast cancer, 56,373 (27.5%) had colon cancer, and 64,615 (31.5%) had lung cancer. Rates of low-value cancer services did not exhibit meaningful declines during the pandemic: PET/CT imaging, adjusted percentage point difference 1.87 (95% CI -0.13 to 3.87); conventional radiotherapy, adjusted percentage point difference 3.93 (95% CI 1.50 to 6.36); off-pathway systemic therapy, adjusted percentage point difference 0.82 (95% CI -0.62 to 2.25); non-guideline-based antiemetics, adjusted percentage point difference -3.62 (95% CI -4.97 to -2.27); aggressive end-of-life care, adjusted percentage point difference 2.71 (95% CI -0.59 to 6.02). Discussion Low-value cancer care remained prevalent through the pandemic. Policymakers should consider changes to payment and incentive design to turn the tide toward higher-value cancer care.

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“…Although early studies evaluating P4P in cancer care did not show expected results, a recent examination of the largest national cancer P4P program showed increased evidence-based prescribing. 5 Second, policy makers could redesign P4P around the elements that are most likely to improve care. Currently, programs such as MIPS aggregate performance across a number of specific care processes-in the context of MIPS, across quality, electronic health record use, cost, and improvement activities.…”

Section: Pay For Performance: Absence Of Policy Equipoisementioning

confidence: 99%