Designing a commercial medical bundle for cancer care: Hawaii Medical Service Association's Cancer Episode Model

Urwin, John W.; Caldarella, Kristen; Matloubieh, Shireen; Lee, Emily; Mugiishi, Mark; Kohatsu, Lauren; Yoshimoto, Justin; Tom, Jeffery; Okamura, Sherly; Wang, Erkuan; Zhu, Jingsan; Emanuel, Ezekiel J.; Volpp, Kevin G.; Navathe, Amol S.

doi:10.1016/j.hjdsi.2020.100422

Cited by 2 publications

(2 citation statements)

References 17 publications

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“…22 Private sector oncology models have adopted this approach to assess and reward adherence to treatment guidelines, rather than cost alone. 23 The use of clinical pathways meets payers' goals to reduce the total cost of care, while also recognizing the imperative to deliver the most clinically appropriate care for each patient.…”

Section: Discussionmentioning

confidence: 99%

Evaluating the Addition of Clinical and Staging Data to Improve the Pricing Methodology of the Oncology Care Model

Dreyer

Hamilton²,

Dahl³

et al. 2022

JCO Oncology Practice

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PURPOSE: The Oncology Care Model (OCM) is the largest value-based care model focusing on oncology, but the current pricing methodology excludes relevant data on the cancer stage and current clinical status, limiting the precision of the risk adjustment. METHODS: This analysis evaluated 15,580 episodes of breast cancer, lung cancer, and multiple myeloma, starting between July 1, 2016, and January 1, 2020, with data from a cohort of OCM practices affiliated with academic medical centers. The authors merged clinical data with claims for OCM episodes defined by the Center for Medicare and Medicaid Innovation to identify potential quality improvement opportunities. The regression model evaluated the association of the cancer stage at initial diagnosis and current clinical status with variance to the OCM target price. RESULTS: Cancer stage at the time of initial diagnosis was significant for breast and lung cancers, with stage IV episodes having the highest losses of –$6,700 (USD) for breast cancer ( P < .001) and –$18,470 (USD) for lung cancer ( P < .001). Current clinical status had a significant impact for all three cancers in the analysis, with losses correlated with clinical complexity. Breast cancer and multiple myeloma episodes categorized as recurrent or progressive disease had significantly higher losses than stable episodes, at –$6,755 (USD) for breast ( P < .001) and –$19,448 (USD) for multiple myeloma ( P < .001). Lung cancer episodes categorized as initial diagnosis had significantly fewer losses than stable episodes, at –$3,751 (USD) ( P = .001). CONCLUSION: As the Center for Medicare and Medicaid Innovation designs and launches new oncology-related models, the agency should adopt methodologies that more accurately set target prices, by incorporating relevant clinical data within cancer types to minimize penalizing practices that provide guideline-concordant cancer care.

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Section: Discussionmentioning

confidence: 99%

Evaluating the Addition of Clinical and Staging Data to Improve the Pricing Methodology of the Oncology Care Model

Dreyer

Hamilton²,

Dahl³

et al. 2022

JCO Oncology Practice

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“…Surgical procedures occurring at least 6 months after the practice began participating were considered bundled episodes. Consistent with prior research, 11 , 12 a 6-month washout period was included to allow for practice-level changes initiated by newly participating physician practices in response to program incentives. Episodes performed during the washout period were excluded from the analysis.…”

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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Designing a commercial medical bundle for cancer care: Hawaii Medical Service Association's Cancer Episode Model

Cited by 2 publications

References 17 publications

Evaluating the Addition of Clinical and Staging Data to Improve the Pricing Methodology of the Oncology Care Model

Evaluating the Addition of Clinical and Staging Data to Improve the Pricing Methodology of the Oncology Care Model

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

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