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

在个性化医疗的革命和新生物治疗的爆炸性管道中， 改善癌症的结果，同时也减少治疗的副作用，癌症护理的成本 在全国范围内，这是医疗保健费用增长最快的部分之一。努力控制不断上升的 护理也可以使用更普遍的支付改革，以鼓励提供者改变他们的整体方法， 护理或明确针对特定的临床领域，如肿瘤学。Medicare责任关怀 组织（ACO）计划代表了国家最重要的努力，以测试全球气候变化的影响。 不专注于特定临床领域的支付模式。相反，在癌症护理领域，CMS 2016年推出了肿瘤护理模式（OCM），这是一种有针对性的捆绑支付方法， 参与的做法，负责支出为6个月的插曲，是由收到 化疗这两种方法都为供应商系统提供了定制治疗的灵活性 同时还提供强有力的激励措施，以减少过度使用昂贵和/或低价值的卫生保健 没有良好证据支持的服务。然而，没有关于这两种方法的有效性的数据。 提高癌症护理提供价值或两者相对有效性的方法 接近。到目前为止，已有500多名参与者与医疗保险签订了合同， 或医疗保险共享储蓄（MSSP）ACO计划和近200个肿瘤学实践开始参与 OCM于2016年7月。在以前的工作中，我们发现ACO计划的第一年总体节省了约1% 通过使用较便宜的护理环境和减少服务利用率来降低成本，但节省的费用 在第二年更大。本研究的总体目的是确定非定向支付改革 医疗保险ACO计划中使用的政策将成功促进高价值 提供肿瘤学服务，包括放弃未经证实的疗法和采用经证实的疗法， 历史上未被充分利用的方法，并将其与OCM的目标方法进行比较。我们的建议 三个具体目标，评估（1）ACO对癌症相关服务整体支出的影响，（2） ACO对低价值非循证服务的使用和停用以及高价值服务的使用的影响 临终关怀和姑息治疗等服务，以及（3）ACO和OCM的这些结果比较 参与者我们建议的工作将提供对全球和有针对性的影响的微妙理解。 对癌症患者的支出和服务使用进行支付改革。作为新的和更昂贵的药物 和治疗方法的发展，卫生保健组织将需要制定战略，以确保 这种昂贵的治疗方法只有在其净效益证明高成本是合理的情况下才使用。科学的前提是 我们的建议是提供重要的证据，比较这两种方法，以提高价值， 政策制定者寻求提高癌症护理服务的价值。

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.