Do Case Rates Affect Physicians' Clinical Practice in Radiation Oncology?: An Observational Study

Abstract

Case rate payments combined with utilization monitoring may have the potential to improve the quality of care by reducing over and under-treatment. Thus, a national managed care organization introduced case rate payments at one multi-site radiation oncology provider while maintaining only fee-for-service payments at others. This study examined whether the introduction of the payment method had an effect on radiation fractions administered when compared to clinical guidelines. The number of fractions of radiation therapy delivered to patients with bone metastases, breast, lung, prostate, and skin cancer was assessed for concordance with clinical guidelines. The proportion of guideline-based care ascertained from the payer's claims database was compared before (2011) and after (2013) the payment method introduction using relative risks (RR). After the introduction of case rates, there were no significant changes in guideline-based care in breast, lung, and skin cancer; however, patients with bone metastases and prostate cancer were significantly more likely to have received guideline-based care (RR = 2.0 and 1.1, respectively, p<0.05). For the aggregate of all cancers, the under-treatment rate significantly declined (p = 0.008) from 4% to 0% after the introduction of case rate payments, while the over-treatment rate remained steady at 9%, with no significant change (p = 0.20). These findings suggest that the introduction of case rate payments did not adversely affect the rate of guideline-based care at the provider examined. Additional research is needed to isolate the effect of the payment model and assess implications in other populations.

Alternative payment and care‐delivery models in oncology: A systematic review

“…The Blue Cross Blue Shield (BCBS) of Florida radical prostatectomy bundle for early stage prostatectomy was the only bundle that covered exclusively surgical therapy . Two bundles covered radiation therapy: the BCBS of California bundle covered radiation therapy for early stage breast cancer, and the 21st Century Oncology external‐beam radiation therapy (EBRT) bundle covered radiation therapy for 13 common cancers with an episode duration of 90 days . The Cancer Treatment Centers of America (CTCA) bundle included services associated with diagnosis and care planning, but excluded treatment services .…”

“…Only 2 bundled payment interventions reported results. The 21st Oncology EBRT bundle demonstrated improved guideline adherence for patients with bone metastases and prostate cancer but no effect for patients with breast, lung, and skin cancers . Costs were not assessed.…”

“…In contrast, only 2 studies investigated the impact of the intervention on measures of care quality, an important component of the value equation . The 21st Oncology EBRT bundle measured guideline concordance (a process measure), and Herrel et al studied the impact of Medicare ACOs on 30‐day mortality and surgical complications . No interventions included an analysis of patient‐reported outcomes, although it recently was demonstrated that the collection of these outcomes improves the survival of patients with cancer .…”

“…Table 3 summarizes the quality of evidence assessments conducted on the 13 studies that reported outcomes. 12,13,[18][19][20][21][22][26][27][28][29][30]32,34 Over one-half (n 5 7; 54%) received a weak global rating, and the remaining studies (n 5 6; 46%) received a moderate global rating. No studies evaluating alternative payment or care-delivery models in cancer received a strong global rating.…”

“…14 Two bundles covered radiation therapy: the BCBS of California bundle covered radiation therapy for early stage breast cancer, 16 and the 21st Century Oncology external-beam radiation therapy (EBRT) bundle covered radiation therapy for 13 common cancers with an episode duration of 90 days. 18 The Cancer Treatment Centers of America (CTCA) bundle included services associated with diagnosis and care planning, but excluded treatment services. 15 The United Healthcare (UHC) bundle Review Article included physician hospital care, hospice services, and case management for breast, colon, and lung cancer with chemotherapy medications reimbursed at average sales price and all other physician services reimbursed as FFS.…”