IMPORTANCE Bundled Payments for Care Improvement (BPCI) is a voluntary initiative of the Centers for Medicare & Medicaid Services to test the effect of holding an entity accountable for all services provided during an episode of care on episode payments and quality of care. OBJECTIVE To evaluate whether BPCI was associated with a greater reduction in Medicare payments without loss of quality of care for lower extremity joint (primarily hip and knee) replacement episodes initiated in BPCI-participating hospitals that are accountable for total episode payments (for the hospitalization and Medicare-covered services during the 90 days after discharge). DESIGN, SETTING, AND PARTICIPANTS A difference-indifferences approach estimated the differential change in outcomes for Medicare fee-for-service beneficiaries who had a lower extremity joint replacement at a BPCI-participating hospital between the baseline (October 2011 through September 2012) and intervention (October 2013 through June 2015) periods and beneficiaries with the same surgical procedure at matched comparison hospitals. EXPOSURE Lower extremity joint replacement at a BPCI-participating hospital. MAIN OUTCOMES AND MEASURES Standardized Medicare-allowed payments (Medicare payments), utilization, and quality (unplanned readmissions, emergency department visits, and mortality) during hospitalization and the 90-day postdischarge period. RESULTS There were 29 441 lower extremity joint replacement episodes in the baseline period and 31 700 in the intervention period (mean [SD] age, 74.1 [8.89] years; 65.2% women) at 176 BPCI-participating hospitals, compared with 29 440 episodes in the baseline period (768 hospitals) and 31 696 episodes in the intervention period (841 hospitals

The Centers for Medicare & Medicaid Services developed the Oncology Care Model as an episode-based payment model to encourage participating practitioners to provide higher-quality, better-coordinated care at a lower cost to the nearly three-quarter million fee-for-service Medicare beneficiaries with cancer who receive chemotherapy each year. Episode payment models can be complex. They combine into a single benchmark price all payments for services during an episode of illness, many of which may be delivered at different times by different providers in different locations. Policy and technical decisions include the definition of the episode, including its initiation, duration, and included services; the identification of beneficiaries included in the model; and beneficiary attribution to practitioners with overall responsibility for managing their care. In addition, the calculation and risk adjustment of benchmark episode prices for the bundle of services must reflect geographic cost variations and diverse patient populations, including varying disease subtypes, medical comorbidities, changes in standards of care over time, the adoption of expensive new drugs (especially in oncology), as well as diverse practice patterns. Other steps include timely monitoring and intervention as needed to avoid shifting the attribution of beneficiaries on the basis of their expected episode expenditures as well as to ensure the provision of necessary medical services and the development of a meaningful link to quality measurement and improvement through the episode-based payment methodology. The complex and diverse nature of oncology business relationships and the specific rules and requirements of Medicare payment systems for different types of providers intensify these issues. The Centers for Medicare & Medicaid Services believes that by sharing its approach to addressing these decisions and challenges, it may facilitate greater understanding of the model within the oncology community and provide insight to others considering the development of episode-based payment models in the commercial or government sectors.

New oncology therapies can contribute to survival or quality of life, but payers and policy makers have raised concerns about the cost of these therapies. Similar concerns extend beyond cancer. In seeking a solution, payers are increasingly turning toward value-based payment models in which providers take financial risk for costs and outcomes. These models, including episode payment and bundled payment, create financial gains for providers who reduce cost, but they also create concerns about potential stinting on necessary treatments. One approach, which the Centers for Medicare and Medicaid Services adopted in the Oncology Care Model (OCM), is to partially adjust medical practices' budgets for their use of novel therapies, defined in this case as new oncology drugs or new indications for existing drugs approved after December 31, 2014. In an analysis of the OCM novel therapies adjustment using historical Medicare claims data, we found that the adjustment may provide important financial protection for practices. In a simulation we performed, the adjustment reduced the average loss per treatment episode by $758 (from $807 to $49) for large practices that use novel therapies often. Lessons from the OCM can have implications for other alternative payment models.

High Medicaid burden hospital status is associated with an attenuation of IBR use and increased total inpatient costs. Structures of care such as hospital resources partially explain disparities in IBR delivery. Cancer 2018;124:346-55. © 2017 American Cancer Society.

Background: Safety-net hospitals serve vulnerable populations; however, care delivery may be of lower quality. Microvascular immediate breast reconstruction, relative to other breast reconstruction subtypes, is sensitive to the performance of safety-net hospitals and an important quality marker. The authors’ aim was to assess the quality of care associated with safety-net hospital setting. Methods: The 2012 to 2014 National Inpatient Sample was used to identify patients who underwent microvascular immediate breast reconstruction after mastectomy. Primary outcomes of interest were rates of medical complications, surgical inpatient complications, and prolonged length of stay. A doubly-robust approach (i.e., propensity score and multivariate regression) was used to analyze the impact of patient and hospital-level characteristics on outcomes. Results: A total of 858 patients constituted our analytic cohort following propensity matching. There were no significant differences in the odds of surgical and medical inpatient complications among safety-net hospital patients relative to their matched counterparts. Black (OR, 2.95; p < 0.001) and uninsured patients (OR, 2.623; p = 0.032) had higher odds of surgical inpatient complications. Safety-net hospitals (OR, 1.745; p = 0.005), large bedsize hospitals (OR, 2.170; p = 0.023), and Medicaid patients (OR, 1.973; p = 0.008) had higher odds of prolonged length of stay. Conclusions: Safety-net hospitals had comparable odds of adverse clinical outcomes but higher odds of prolonged length of stay, relative to non–safety-net hospitals. Institution-level deficiencies in staffing and clinical processes of care might underpin the latter. Ongoing financial support of these institutions will ensure delivery of needed breast cancer care to economically disadvantaged patients. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

interpretation are the most detailed, and include examples to facilitate application. Conclusions: The guidelines provide detailed recommendations for use of the IL, from the early stage of item selection to the analysis and reporting of results, thereby responding directly to the needs of commercial and academic users while promoting scientific rigor.

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e18365 Background: Real-world evidence is lacking regarding costs for FDA-approved/NCCN Category 1 treatments for patients with metastatic pancreatic cancer (m-PANC). We analyzed costs by service in the Medicare fee-for-service (FFS) population by chemotherapy regimen and line of therapy (LOT). Methods: Patients with m-PANC were identified using ICD-9/10 diagnosis codes in the 2013-2017 Medicare 100% Limited Data Set claims, which include all Medicare paid FFS claims, except professional services, for 45 million Medicare FFS beneficiaries. We studied mean monthly costs by service category, regimen, and LOT. Patients in our study had two or more claims with a pancreatic cancer (PANC) diagnosis more than 30 days apart and one or more claims with a secondary malignancy (metastasis) diagnosis on or after the first PANC diagnosis date. We defined index date as the earliest metastasis diagnosis date. We excluded patients with pre-index non-PANC malignancies and those without 6 months pre-index and 3 months (or until death, if earlier) post-index Medicare FFS enrollment. LOTs were assigned based on therapies used. LOTs ended the day before a new chemotherapy began, 28 days after the last chemotherapy (if no new chemotherapy), or upon death. We analyzed the FDA-approved/NCCN Category 1 treatments used most commonly in first line (1L): gemcitabine monotherapy, gemcitabine/nab-paclitaxel, and FOLFIRINOX; and in second or third line (2L, 3L): liposomal irinotecan. Results: Mean monthly Parts A and B (excluding professional) costs for 1L gemcitabine monotherapy were lower than gemcitabine/nab-paclitaxel or FOLFIRINOX ($5,267, $9,116, and $8,046, respectively). Part B drug costs other than chemotherapy were higher for FOLFIRINOX than gemcitabine/nab-paclitaxel or gemcitabine monotherapy ($3,881, $1,155, and $827, respectively). Inpatient services were similar across 1L regimens ($2,721-$3,303). Despite disease progression, mean monthly 2L and 3L costs for liposomal irinotecan were $10,809 and $12,225, respectively. Part B drugs other than chemotherapy ($2,133-$2,509) were comparable to 1L regimens, but inpatient services ($2,306-$2,405) were lower. Conclusions: The mean monthly cost increased by LOT for m-PANC FDA-approved/NCCN category 1 regimens. Interestingly, Part A inpatient costs decreased in 2L and 3L, while Part B drug costs other than chemotherapy were comparable.