Comparing Targeted and Non-Targeted Approaches to Improving the Value of Cancer Care Services

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Amidst the revolution in personalized medicine and an exploding pipeline of new biologic treatments aimed at improving cancer outcomes while also decreasing the side effects of treatment, the cost of cancer care nationally is among the fastest growing segments of health care costs. Efforts to control escalating costs of care either can use more general payment reforms to encourage providers to change their overall approach to care or be targeted explicitly at specific clinical areas such as oncology. The Medicare Accountable Care Organization (ACO) programs represent the most important effort nationally to test the impact of a global payment model that is not focused on a particular clinical area. In contrast, in the area of cancer care, CMS launched in 2016 the Oncology Care Model (OCM), which is a targeted bundled payment approach that holds participating practices accountable for spending for a 6-month episode that is triggered by the receipt of chemotherapy. Both of these approaches provide flexibility for provider systems to customize treatment approaches while also providing strong incentives to reduce overuse of expensive and/or low value health care services that are not supported by good evidence. Yet, no data are available on the effectiveness of either approach for improving the value of cancer care delivery or of the comparative effectiveness of the two approaches. To date, over 500 participants have contracted with Medicare to participate in either the Pioneer or Medicare Shared Savings (MSSP) ACO programs and almost 200 oncology practices began participating in the OCM in July 2016. In previous work, we found that the first year of the ACO programs saved ~1% in overall costs through both use of less expensive care settings and decreased utilization of services, but savings were larger in year 2. The overall purpose of this research is to determine whether non-targeted payment reform policies such as those being used in the Medicare ACO program will be successful in promoting high value delivery of oncology services, including both abandonment of unproven therapies and adoption of proven, but historically underused ones, and to compare this with the targeted approach of the OCM. Our proposal has three specific aims that assess (1) the effects of ACOs on spending on cancer-related services overall, (2) the effects of ACOs on use and de-adoption of low value non-evidence-based services and use of high value services such as hospice and palliative care, and (3) comparison of these outcomes for ACO and OCM participants. Our proposed work will provide a nuanced understanding of the effect of global and targeted payment reforms on spending and the use of services for cancer patients. As new and ever more costly drugs and treatment approaches are developed, health care organizations will need to develop strategies to ensure that such costly treatments are used only when their net benefits justify the high cost. The scientific premise of our proposal is to provide important evidence comparing these two approaches to improving value to guide policy makers seeking to improve the value of cancer care services.