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

Abstract

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.

Mapping Patient Encounters in Breast Cancer Care

“…Patients with metastatic disease had nearly 8 more encounters per year compared with patients with early-stage breast cancer. This higher encounter complexity with higher stage parallels prior financial studies demonstrating that increasing breast cancer stage and triple negative status are associated with increasing overall costs of care, 23,24 and that patients with metastatic breast cancer have the highest total cost of care and greatest likelihood of exceeding target price in Oncology Care Models 23 . Put into the context of these studies, our data suggest that future value-based models must adjust for various tumor and treatment characteristics, particularly breast cancer stage, such that these models accurately reflect overall complexity of encounter volume and provider effort.…”

Direct and Indirect Costs of Breast Cancer and Associated Implications: A Systematic Review

“…Thirty-six (68%) of our included studies reported costs for early-stage cancer [ 19 , 20 , 22 , 24 – 27 , 29 – 31 , 34 – 40 , 44 – 48 , 53 – 58 , 60 – 62 , 65 – 67 , 70 , 71 ]; 17 (32%) included metastatic cancer [ 20 – 23 , 25 , 27 , 30 , 33 , 36 , 38 – 40 , 50 , 53 , 60 , 68 , 70 ]; 12 (23%) included both early and metastatic cancer [ 20 , 22 , 25 , 27 , 30 , 36 , 38 – 40 , 53 , 60 , 70 ]; for 12 (23%), the cancer stage was not reported [ 28 , 32 , 41 – 43 , 49 , 51 , 52 , 59 , 63 , 64 , 69 ]. Generally, across our included studies, metastatic breast cancer was associated with higher costs than earlier stage cancer (see Figs.…”

“…Breast cancer stage is an important predictor of costs: previous studies have shown the amount and intensity of treatment tends to be higher at more advanced than earlier stages [ 8 , 9 ]. Our identified studies generally suggested that metastatic (Stage IV) cancer was more costly than early (Stage I–III) cancer [ 20 , 22 , 25 , 27 , 30 , 36 , 38 – 40 , 53 , 60 , 70 ]. However, it is important to recognise the heterogeneous nature of these costing studies and that our suggestion comes particularly from the range of costs rather than the median across cost estimates and studies; although the three identified studies by Brezden-Masley et al [ 38 – 40 ] greatly aided with direct comparisons of costs by breast cancer stage across three cancer types (triple-negative, HER2-positive, HER2-negative).…”

“…As an example, our review identified that the economic burden of late-stage breast cancer costs is generally estimated to be higher than early-stage breast cancer costs [ 20 , 22 , 25 , 27 , 30 , 36 , 38 – 40 , 53 , 60 , 70 ]. Although these costs differed by country, this overall result generally remained consistent across countries.…”

“…The WHO suggests the implementation of their framework could save 2.5 million lives by 2040, which is focussed particularly on the patient health-related benefit side of the considerations, rather than the financial side which is the purview of our review. However, based on the cost evidence identified by our review and reflecting on related modelling-based economic studies [ 1 , 20 , 22 , 25 , 27 , 30 , 36 , 38 – 40 , 53 , 60 , 70 , 77 ], it could be that this type of early intervention initiative could also potentially be cost saving over the longer term alongside these patient-focussed life-saving benefits, the exact financial impact of which should be a focus for future research [ 78 ].…”