The Impact of a Changing Health Care Delivery System on the Quality of Oncology Care

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Project Summary The cancer care delivery system frequently provides care that is not patient-centered, evidence-based, or accessible to vulnerable and underserved populations. Cancer care and outcomes are particularly poor for patients living in rural areas, areas with high poverty, racial/ethnic minorities, and patients with multimorbidity. Recent advances such as genomic testing, targeted therapy, immunotherapy, and CAR T cell therapy have made oncology care more complex. Concurrently, there has been substantial integration and consolidation of the delivery of cancer care, and little is known about how consolidation impacts cancer care and outcomes. As part of an Agency for Health Care Research and Quality initiative on Health Systems Organization and Performance, our team created a novel national database (Enhanced DataBase [EDB]). The EDB combines a wide variety of governmental and non-governmental proprietary sources to identify health systems as groups of commonly owned providers and contains microdata on physicians, physician practices, hospitals, and health systems. We propose to leverage longitudinal data from the EDB to characterize the integration of cancer care over time, using these changes to understand effects on care delivery, including quality, diffusion of new therapies, utilization, and outcomes. We will study care for patients enrolled in fee-for-service Medicare and those enrolled in Medicaid. In addition to studying claims-based measures of quality and utilization, we will link with clinical data about genetic testing and test results from Foundation Medicine, one of the country's largest providers of somatic genomic testing. Specifically, we will: 1. Describe changes in integration and ownership of oncology care providers since 2010 and assess differences in these trends for providers serving large numbers of vulnerable or disadvantaged populations, including rural and urban poor patients, racial/ethnic minorities, and individuals with multimorbidity. 2. Leverage changes in the organization of care to assess the impact of integration and health system affiliation on quality of care, outcomes, utilization, and spending for patients with cancer. We will examine quality across multiple domains, including care coordination, guideline recommended care, avoidance of low-value care, and patient experiences. 3. Understand the extent to which quality and value of cancer care delivered within vs. outside of integrated systems differs for various disadvantaged populations, including individuals living in rural and urban poor areas, racial/ethnic minorities, and individuals with multi-morbidity. Our study will provide oncology practitioners, payers, and policy makers valuable information to improve access, quality and outcomes of oncology care. Our results will inform policies and practices related to the value of integration of oncology care, quality measurement, and design of alternative payment models.