Association of Participation in the Oncology Care Model With Medicare Payments, Utilization, Care Delivery, and Quality Outcomes.

IMPORTANCE: In 2016, the US Centers for Medicare & Medicaid Services initiated the Oncology Care Model (OCM), an alternative payment model designed to improve the value of care delivered to Medicare beneficiaries with cancer. OBJECTIVE: To assess the association of the OCM with changes in Medicare spending, utilization, quality, and patient experience during the OCM's first 3 years. DESIGN, SETTING, AND PARTICIPANTS: Exploratory difference-in-differences study comparing care during 6-month chemotherapy episodes in OCM participating practices and propensity-matched comparison practices initiated before (January 2014 through June 2015) and after (July 2016 through December 2018) the start of the OCM. Participants included Medicare fee-for-service beneficiaries with cancer treated at these practices through June 2019. EXPOSURES: OCM participation. MAIN OUTCOMES AND MEASURES: Total episode payments (Medicare spending for Parts A, B, and D, not including monthly payments for enhanced oncology services); utilization and payments for hospitalizations, emergency department (ED) visits, office visits, chemotherapy, supportive care, and imaging; quality (chemotherapy-associated hospitalizations and ED visits, timely chemotherapy, end-of-life care, and survival); and patient experiences. RESULTS: Among Medicare fee-for-service beneficiaries with cancer undergoing chemotherapy, 483 319 beneficiaries (mean age, 73.0 [SD, 8.7] years; 60.1% women; 987 332 episodes) were treated at 201 OCM participating practices, and 557 354 beneficiaries (mean age, 72.9 [SD, 9.0] years; 57.4% women; 1 122 597 episodes) were treated at 534 comparison practices. From the baseline period, total episode payments increased from $28 681 for OCM episodes and $28 421 for comparison episodes to $33 211 for OCM episodes and $33 249 for comparison episodes during the intervention period (difference in differences, -$297; 90% CI, -$504 to -$91), less than the mean $704 Monthly Enhanced Oncology Services payments. Relative decreases in total episode payments were primarily for Part B nonchemotherapy drug payments (difference in differences, -$145; 90% CI, -$218 to -$72), especially supportive care drugs (difference in differences, -$150; 90% CI, -$216 to -$84). The OCM was associated with statistically significant relative reductions in total episode payments among higher-risk episodes (difference in differences, -$503; 90% CI, -$802 to -$204) and statistically significant relative increases in total episode payments among lower-risk episodes (difference in differences, $151; 90% CI, $39-$264). The OCM was not significantly associated with differences in hospitalizations, ED visits, or survival. Of 22 measures of utilization, 10 measures of quality, and 7 measures of care experiences, only 5 were significantly different. CONCLUSIONS AND RELEVANCE: In this exploratory analysis, the OCM was significantly associated with modest payment reductions during 6-month episodes for Medicare beneficiaries receiving chemotherapy for cancer in the first 3 years of the OCM that did not offset the monthly payments for enhanced oncology services. There were no statistically significant differences for most utilization, quality, and patient experience outcomes.

How Do Claims-Based Measures of End-of-Life Care Compare to Family Ratings of Care Quality?

OBJECTIVES: Assess whether frequently-used claims-based end-of-life (EOL) measures are associated with higher ratings of care quality. DESIGN: Retrospective cohort study. SETTING/PARTICIPANTS: Deceased fee-for-service Medicare beneficiaries with cancer who underwent chemotherapy during July 2016 to January 2017 and died within 12 months and their caregiver respondents to an after-death survey (n = 2,559). MEASUREMENTS: We examined claims-based measures of EOL care: chemotherapy 14 days or more before death; inpatient admissions, intensive care unit (ICU) use, and emergency department (ED) visits 30 days or more before death; hospice election and the timing of election before death. Primary outcomes are family ratings of "excellent" care in the last month of life and reports that hospice care began "at the right time." Associations were assessed with logistic regression, adjusted by patient characteristics. RESULTS: Family rated EOL care as excellent less often, if within 30 days before death the cancer patient had inpatient admissions (1 hospitalization = 41.5% vs 51.5% none, adjusted difference -10.1 percentage points), ICU use (38.6% for any ICU use vs 47.4% none; adjusted difference -8.8 percentage points), ED visits (41.0% 1 visit vs 51.6% no visits; adjusted difference -10.6 percentage points), or elected hospice within 7 days before death. Among hospice enrollees, family more often reported that hospice began at the right time if it started at least 7 days before death (hospice 1-2 days before death 60.2% vs hospice 7-13 days 74.9%; adjusted difference +14.7 percentage points). CONCLUSIONS: Claims-based measures of EOL care for cancer patients that reflect avoidance of hospital-based care and earlier hospice enrollment are associated with higher ratings of care quality by bereaved family members.

Early Findings From the Oncology Care Model Evaluation.

PURPOSE: The Oncology Care Model (OCM) is an alternative payment model administered by the Centers for Medicare & Medicaid Services (CMS) that is structured around 6-month chemotherapy treatment episodes. This report describes the CMS-sponsored OCM evaluation and summarizes early evaluation findings. METHODS: The OCM evaluation examines health care spending and use, quality of care, and patient experience during chemotherapy treatment episodes. Because OCM participation is voluntary, the evaluation compares participating physician practices with a propensity-matched group of nonparticipating practices by using a difference-in-differences approach. This report examines 6-month episodes initiated during the first OCM performance period (July 1, 2016, through January 1, 2017). RESULTS: During the first OCM performance period, there was no statistically significant impact of OCM on total episode payments. There were small declines in intensive care unit (ICU) admissions (7 per 1,000 episodes) and emergency department visits (15 per 1,000 episodes); there was no statistically significant impact on hospitalizations or 30-day readmissions. Analyses of care quality and end-of-life care showed statistically significant impacts of OCM on the proportion of patients with inpatient hospitalizations in the last 30 days of life (1.5% absolute decrease) and ICU admissions in the last 30 days of life (2.1% decrease). There was no significant OCM impact on measures of hospice use. CONCLUSION: Early findings from the OCM evaluation demonstrate modest program-related impacts on some acute care services and no change in total episode payments. Early findings may not reflect practice redesign efforts that were phased in after the beginning of OCM.

Proportion and Patterns of Hospice Discharges in Medicare Advantage Compared to Medicare Fee-for-Service.

BACKGROUND: When Medicare Advantage (MA) patients elect hospice, all covered services are reimbursed under the Medicare fee-for-service (FFS) program. This financial arrangement may incentivize MA plans to refer persons to hospice near end of life when costs of care typically rise. OBJECTIVE: To characterize hospice discharge patterns for MA versus FFS patients and examine whether patterns differ by MA concentration across hospital referral regions (HRRs). DESIGN AND MEASUREMENT: The rate and pattern of live discharges and length of stay (LOS) between FFS and MA patients were examined. A multivariate mixed-effects model examined whether hospice patients in MA versus FFS had differential patterns of discharges. In addition, we tested whether concentrations of MA hospice patients in a patient's HRR were associated with different patterns of discharges. RESULTS: In fiscal year 2014, there were 1,199,533 hospice discharges with 331,142 MA patients having a slightly higher live discharge rate (15.8%) compared to 868,391 FFS hospice discharges (15.4%). After controlling for patient characteristics, the adjusted odds ratio (AOR) was 1.01 (95% CI 0.99-1.02). MA patients were less likely to have early live discharges (AOR 0.87 95% CI 0.84-0.91) and burdensome transitions (AOR 0.61 95% CI 0.58-0.64) but did not differ in live discharges post 210 days. Among hospice deaths, MA hospice patients were less likely to have a three-day or less LOS (AOR 0.95 95% 0.94-0.96) and a LOS exceeding 180 days (AOR 0.97 95% 0.96-0.99). The concentration of MA patients in a HRR had minimal impact. CONCLUSION: MA hospice patients' discharge patterns raised less concerns than FFS.

An Examination of the First 30 Days After Patients are Discharged to the Community From Hip Fracture Postacute Care.

BACKGROUND: Postacute care (PAC) rehabilitation aims to maximize independence and facilitate a safe community transition. Yet little is known about PAC patients' success in staying home after discharge or differences on this outcome across PAC providers. OBJECTIVES: Examine the percentage of PAC patients who remain in the community at least 30 days after discharge (ie, successful community discharge) after hip fracture rehabilitation and describe differences among PAC facilities based on this outcome. RESEARCH DESIGN: Retrospective observational study. SUBJECTS: Community-dwelling, Medicare fee-for-service beneficiaries 75 years of age and above who experienced their first hip fracture between 1999 and 2007 (n=880,779). PAC facilities admitting hip fracture patients in 2006. MEASURES: Successful community discharge, sites of readmission after PAC discharge. RESULTS: Between 1999 and 2007, 57% of patients achieved successful community discharge. Black were less likely (adjusted odds ratios=0.84; 95% confidence interval, 0.82-0.86) than similar whites to achieve successful community discharge. Among all who reentered the community (n=581,095), 14% remained in the community <30 days. Acute hospitals (67.5%) and institutional PAC (16.8%) were the most common sites of reentry. The median proportion of successful community discharge among facilities was 49% (interquartile range, 33%-66%). Lowest-quartile facilities admitted older (85.9 vs. 84.1 y of age), sicker patients (eg, higher rates of hospital complications 6.0% vs. 4.6%), but admitted fewer annually (7.1 vs. 19.3), compared with the highest quartile. CONCLUSIONS: Reentry into the health care system after PAC community discharge is common. Because of the distinct care needs of the PAC population there is a need for a quality measure that complements the current 30-day hospital readmission outcome and captures the objectives of PAC rehabilitation.

What happens to patients when they fracture their hip during a skilled nursing facility stay?

OBJECTIVES: To characterize outcomes of patients experiencing a fall and subsequent hip fracture while in a nursing home receiving skilled nursing facility (SNF) services. DESIGN: Observational study. PARTICIPANTS: Short-stay fee-for-service Medicare beneficiaries who experienced their first hip fracture during an SNF stay. MEASUREMENTS: Outcomes measured in the 90 days after the hip fracture hospitalization included community discharge (with a stay in the community <30 days), successful community discharge (in the community ≥30 days), death, and institutionalization. RESULTS: Between 1999 and 2007, 27,305 hip fractures occurred among short-stay nursing home patients receiving SNF care. After surgical repair of the hip fracture, 83.9% of these patients were discharged from the hospital back to an SNF, with most (99%) returning to the facility where the hip fracture occurred. In the first 90 days after hospitalization, 24.1% of patients died, 7.3% were discharged to the community but remained fewer than 30 days, 14.0% achieved successful community discharge, and 54.6% were still in a health care institution with almost 46.4% having transitioned to long-term care. CONCLUSION: SNF care aims to maximize the short-stay patient's independence and facilitate a safe community transition. However, experiencing a fall and hip fracture during the SNF stay was a sentinel event that limited the achievement of this goal. There is an urgent need to ensure the integration of fall prevention into the patient's plan of care. Further, falls among SNF patients may serve as indicator of quality, which consumers and payers can use to make informed health care decisions.