Influence of Pomalidomide and Lenalidomide on Total Cost of Care for Medicare Beneficiaries with Multiple Myeloma Under the Oncology Care Model (OCM)

Abstract

Background: In July of 2016, CMMI started a five year bundled payment program called OCM. Beneficiaries are attributed to practices providing their cancer care for a 6 month episode triggered by the administration or distribution of specified cancer drugs. The model provides risk adjustments to the target price based on risk factors such as age, chemotherapy and the receipt of certain treatments (radiation or bone marrow transplant). Target prices are adjusted by geographic region, novel therapy use, and a trend factor. Multiple Myeloma was identified in our practice as a cancer type with high variance on expenditures after the first Performance Period within the model (July 2016-December 2016). Chemotherapy represented 52% of total episode expenditures with oral chemotherapy and hormone therapy representing 24%. The average cost of lenalidomide for one year is $115,000. The model adjusts for novel therapies, including new drugs approved by the FDA after December 31, 2014 with status lasting two years. However, literature demonstrates that this does not fully adjust for the high costs of novel therapies (Muldoon et at., Health Affairs, 2018). Unlike solid tumors, Multiple Myeloma staging may not improve risk adjustment and target price. Methods: We analyzed the total cost of care of beneficiaries who triggered an OCM episode for Performance Period 1 (PP1). Beneficiaries were identified by diagnosis of Multiple Myeloma, and then segregated into cohorts of those who received lenalidomide and/or pomalidomide and those who did not. Observed vs. Expected (O/E) target price for each episode was determined for both cohorts comparing the actual episode expenditures and the target price per episode calculated by the Oncology Care Model. A two sample t-test was conducted followed by a linear regression to determine relation between drug days prescribed and O/E. Results: There were 125 attributed beneficiaries with a Multiple Myeloma diagnosis who triggered an episode during PP1. The average O/E of the cohort which received the chemotherapy, Cohort A, was 1.624 compared to 0.986 for those that did not, Cohort B. The difference in average O/E in the two cohorts was 39% higher in Cohort A, p<0.001. There were no significant differences in the amount of inpatient claims, ED visits, or Bone Marrow Transplants between the two cohorts (Table 1). Figure 1 demonstrates the positive linear relationship (p<0.01, r=.40) between number of days supplied and O/E. Discussion: This is the first report on the impact of lenalidomide and pomalidomide on the total cost of care in an OCM practice. The results demonstrate the lack of adequate adjustment to the CMS target price for episodes in which one or both of these drugs were prescribed. Lenalidomide and pomalidomide are first and second line drugs used both for induction and maintenance. Both drugs are frequently used for prolonged periods of time in patients and trigger more than one episode in OCM. Therefore, the use of these agents greatly affects the total cost of care against a target price that is not adequately adjusted. Academic Medical Centers that care for larger populations of multiple myeloma patients may be disproportionately affected and this will impede their success under the OCM methodology. Additional analysis similar to this will inform CMMI as to further refinements to the OCM adjusters. Disclosures No relevant conflicts of interest to declare.

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

“…However, some studies have suggested that this adjustment still does not fully account for the costs of these treatments, and further assessment of novel therapy use and achievement of target price in OCM is warranted. 12 The introduction of the metastatic adjustment recognizes that variability by stage may be too significant to ignore in the methodology. While stage I episodes mean TCOC was 20% lower than mean target price, stage III mean TCOC was 31% lower than mean target price, suggesting adequate trending by OCM for earlier breast cancer episodes (caution should be taken regarding the stage III results of this analysis because of lower representation in this cohort and the unique clientele of the single academic cancer center where this analysis was conducted).…”

The Oncology Care Model—Why It Works and Why It Could Work Better

“…These studies suggest that by holding oncologists accountable for the total cost of drugs used during an episode, guideline-concordant use of novel therapies could pose significant challenges to success in the OCM. This is an especially acute concern for practices that could be required to transition to 2-sided risk in January 2020 to remain in the model.…”

“…1 To date, OCM performance-based payment methodology represents the most sophisticated attempt in oncology payment reform to account for the rising cost of innovation in cancer treatment. Despite CMMI's impressive efforts to account for the rising cost of care, recently published studies spanning academic and community cancer care organizations have suggested that the OCM methodology may not accurately account for the consequences of new and expensive treatments on appropriately expected costs, 3 especially when considering guideline-recommended treatments that became the SOC after the OCM baseline period. In a study of our large oncology network, more than 90 oncologists treated 2623 patients assigned to the OCM during the second performance period, which included 6-month episodes of care starting between January and June 2017.…”

“…However, in over two-thirds of these cases, the costs of care remained higher than target costs solely because of the use of National Comprehensive Cancer Network-recommended nivolumab or pembrolizumab in second-line treatment, both of which became SOC treatment based on overall survival improvements 5,6 after the OCM baseline period. 4 These studies 3,4 suggest that by holding oncologists accountable for the total cost of drugs used during an episode, guideline-concordant use of novel therapies could pose significant challenges to success in the OCM. This is an especially acute concern for practices that could be required to transition to 2-sided risk in January 2020 to remain in the model.…”

Evaluation of Practice Patterns Among Oncologists Participating in the Oncology Care Model

“…3 For the OCM specifically, a 2018 study 14 simulated the benchmarks on Medicare data and found that the ratio of actual-to-predicted costs varied by tumor type. Another 2018 study 15 found that within the first year of OCM implementation, episode costs were highly sensitive to the use of high-cost therapies. Taken together, these results suggest that tumor mix may drive success within the model.…”