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

在个性化医疗革命和爆炸性的新生物治疗管道中 在改善癌症预后的同时减少治疗的副作用和癌症护理的成本 全国是医疗保健成本增长最快的部分之一。努力控制不断攀升的成本 CARE或者可以使用更全面的支付改革来鼓励提供者改变他们的总体方法 护理或明确针对特定的临床领域，如肿瘤学。《联邦医疗保险责任医疗》 组织(ACO)计划是在全国范围内测试全球 不专注于特定临床领域的支付模式。相比之下，在癌症护理领域，CMS 于2016年推出肿瘤学护理模式(OCM)，这是一种有针对性的捆绑支付方式， 参与实践对6个月插曲的支出负责，该插曲由收到 化疗。这两种方法都为提供者系统提供了定制治疗的灵活性 方法，同时也提供强有力的激励措施，以减少过度使用昂贵和/或低价值的医疗保健 没有充分证据支持的服务。然而，目前还没有关于这两种方法有效性的数据。 提高癌症护理服务的价值或两者的比较效果的方法 接近了。到目前为止，已有500多名参与者与联邦医疗保险签订了合同，参加其中一项先锋计划 或Medicare Shared Savings(MSSP)ACO计划和近200家肿瘤学诊所开始参与 2016年7月举行的OCM。在以前的工作中，我们发现ACO计划的第一年总体上节省了~1% 通过使用更便宜的护理环境和降低服务利用率来降低成本，但节省的成本 这项研究的总体目的是确定非定向支付改革是否 像Medicare ACO计划中使用的那些政策将成功地促进高价值 提供肿瘤学服务，包括放弃未经验证的治疗方法和采用已证实的、但 历史上未得到充分利用的方法，并将其与海洋管理组织有针对性的方法进行比较。我们的建议已经 评估(1)ACO对整体癌症相关服务支出的影响的三个具体目标，(2) ACOs对低价值、非循证服务和高价值服务使用和停用的影响 临终关怀和姑息治疗等服务，以及(3)ACO和OCM这些结果的比较 参与者。我们提议的工作将提供对全球和有针对性影响的细微差别的理解 对癌症患者的支出和服务使用进行支付改革。作为新的和越来越昂贵的药物 和治疗方法的发展，卫生保健组织将需要制定战略，以确保 只有当它们的净收益与高昂的成本相称时，才会使用这种昂贵的治疗方法。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，以指导 寻求提高癌症护理服务价值的政策制定者。

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.