Practice Consolidation Among US Medical Oncologists, 2015-2022.

PURPOSE: Health care consolidation has significantly affected cancer care delivery, with oncology practices undergoing substantial consolidation over the past two decades. This study investigates practice consolidation trends among medical oncologists (MOs), factors associated with consolidation, and changes in MO geographic distribution. METHODS: Medicare data from 2015 to 2022 were used to assess MO practice consolidation in hospital referral regions (HRRs), linked with regional health care market data and physician demographics. The Herfindahl-Hirschman Index (HHI) was used to measure consolidation, and the Gini coefficient was used to measure MO distribution across counties. Multivariable linear regression explored factors associated with MO practice consolidation. RESULTS: Between 2015 and 2022, the number of MOs increased by 14.5% (11,727-13,433), whereas the number of MO practices decreased by 18.0% (2,774-2,276). The mean number of MOs per practice increased by 40% (4.26-5.95; P < .001). The percentage of MOs in small practices decreased, whereas larger practices saw an increase. MO consolidation, as indicated by the HHI, increased by 9% (median HHI, 0.3204-0.3480). HRRs with higher baseline hospital consolidation and more hospital beds per capita were more likely to have MO practice consolidation. Despite MO practice consolidation, the county-level distribution of MOs did not change substantially. CONCLUSION: On the basis of Federal Trade Commission classifications, MO practices were highly concentrated in 2015 and consolidated even further by 2022. While distribution of MOs at the county level remained stable, further research is needed to assess the effects of rapid consolidation on cancer care cost, quality, and access. These data have important implications for policymakers and payers as they design programs that ensure high-quality, affordable cancer care.

Accreditation Standards-An Untapped Lever for Cancer Equity.

This Viewpoint describes how the Commission on Cancer and the National Cancer Institute can incorporate health equity benchmarks into existing standards to improve care and outcomes for all patients with cancer.

Assessment of Price Variation in Coronary Artery Bypass Surgery at US Hospitals.

BACKGROUND: Little is known about hospital pricing for coronary artery bypass grafting (CABG). Using new price transparency data, we assessed variation in CABG prices across US hospitals and the association between higher prices and hospital characteristics, including quality of care. METHODS AND RESULTS: Prices for diagnosis related group code 236 were obtained from the Turquoise database and linked by Medicare Facility ID to publicly available hospital characteristics. Univariate and multivariable analyses were performed to assess factors predictive of higher prices. Across 544 hospitals, median commercial and self-pay rates were 2.01 and 2.64 times the Medicare rate ($57 240 and $75 047, respectively, versus $28 398). Within hospitals, the 90th percentile insurer-negotiated price was 1.83 times the 10th percentile price. Across hospitals, the 90th percentile commercial rate was 2.91 times the 10th percentile hospital rate. Regional median hospital prices ranged from $35 624 in the East South Central to $84 080 in the Pacific. In univariate analysis, higher inpatient revenue, greater annual discharges, and major teaching status were significantly associated with higher prices. In multivariable analysis, major teaching and investor-owned status were associated with significantly higher prices (+$8653 and +$12 200, respectively). CABG prices were not related to death, readmissions, patient ratings, or overall Centers for Medicare and Medicaid Services hospital rating. CONCLUSIONS: There is significant variation in CABG pricing, with certain characteristics associated with higher rates, including major teaching status and investor ownership. Notably, higher CABG prices were not associated with better-quality care, suggesting a need for further investigation into drivers of pricing variation and the implications for health care spending and access.

Trends in Utilization and Medicare Spending on Short-Course Radiation Therapy for Breast and Prostate Cancer: An Episode-Based Analysis From 2015 to 2019.

PURPOSE: Evidence supports the value of shorter, similarly efficacious, and potentially more cost-effective hypofractionated radiation therapy (RT) regimens in many clinical scenarios for breast cancer (BC) and prostate cancer (PC). However, practice patterns vary considerably. We used the most recent Centers for Medicare and Medicaid Services data to assess trends in RT cost and practice patterns among episodes of BC and PC. METHODS AND MATERIALS: We performed a retrospective cohort analysis of all external beam RT episodes for BC and PC from 2015 to 2019 to assess predictors of short-course RT (SCRT) use and calculated spending differences. Multivariable logistic regression defined adjusted odds ratios of receipt of SCRT over longer-course RT (LCRT) by treatment modality, age, year of diagnosis, type of practice, and the interaction between year and treatment setting. Medicare spending was evaluated using multivariable linear regression controlling for duration of RT regimen (SCRT vs LCRT) in addition to the above covariables. RESULTS: Of 143,729 BC episodes and 114,214 PC episodes, 63,623 (44.27%) and 25,955 (22.72%) were SCRT regimens, respectively. Median total spending for SCRT regimens among BC episodes was $9418 (interquartile range [IQR], $7966-$10,983) versus $13,602 (IQR, $11,814-$15,499) for LCRT. Among PC episodes, median total spending was $6924 (IQR, $4,509-$12,905) for stereotactic body RT, $18,768 (IQR, $15,421-$20,740) for moderate hypofractionation, and $27,319 (IQR, $25,446-$29,421) for LCRT. On logistic regression, receipt of SCRT was associated with older age among both BC and PC episodes as well as treatment at hospital-affiliated over freestanding sites (P < .001 for all). CONCLUSIONS: In this evaluation of BC and PC RT episodes from 2015 to 2019, we found that shorter-course RT resulted in lower costs than longer-course RT. SCRT was also more common in hospital-affiliated sites. Future research focusing on potential payment incentives encouraging SCRT when clinically appropriate in the 2 most common cancers treated with RT will be valuable as the field continues to prospectively evaluate cost-effective hypofractionation in other disease sites.

Opportunities for Savings in Risk Arrangements for Oncologic Care.

Importance: As the US accelerates adoption of alternative payment through global payment models such as Accountable Care Organizations (ACOs) or Medicare Advantage (MA), high spending for cancer care is a potential target for savings. Objective: To quantify the extent to which ACOs and other risk-bearing organizations operating in a specific geographic area (hospital referral region [HRR]) could achieve savings by steering patients to efficient medical oncology practices. Design, Setting, and Participants: This observational study included serial cross-sections of Medicare beneficiaries with cancer from 2010 to 2018. Data were analyzed from August 2021 to March 2023. Main Outcomes and Measures: Total spending and spending by category in the 1-year period following an index visit for a patient with newly diagnosed (incident) or poor-prognosis cancer. Results: The incident cohort included 1 309 825 patients with a mean age of 74.0 years; the most common cancer types were breast (21.4%), lung (16.7%), and colorectal cancer (10.0%). The poor prognosis cohort included 1 429 973 (mean age, 72.7 years); the most common cancer types were lung (26.6%), lymphoma (11.7%), and leukemia (7.3%). Options for steering varied across markets; the top quartile market had 10 or more oncology practices, but the bottom quartile had 3 or fewer oncology practices. Total spending (including Medicare Part D) in the incident cohort increased from a mean of $57 314 in 2009 to 2010 to $66 028 in 2016 to 2017. Within markets, total spending for practices in the highest spending quartile was 19% higher than in the lowest quartile. Hospital spending was the single largest component of spending in both time periods ($20 390 and $19 718, respectively) followed by Part B (infused) chemotherapy ($8022 and $11 699). Correlations in practice-level spending between the first-year (2009) and second-year (2010) spending were high (>0.90 in all categories with most >0.98), but these attenuated over time. Conclusions and Relevance: These results suggest there may be opportunities for ACOs and other risk-bearing organizations to select or drive referrals to lower-spending oncology practices in many local markets.

Private Equity Acquisition of Oncology Clinics in the US From 2003 to 2022.

This cross-sectional study examines private equity­backed acquisitions of medical and radiation oncology clinics in the US from 2003 to 2022 using financial databases and publicly available data.

Variation in Cost of Echocardiography Within and Across United States Hospitals.

BACKGROUND: While transthoracic echocardiography (TTE) is responsible for more Medicare spending than any other cardiovascular imaging procedure, little is known about its commercial cost footprint. The 2021 Hospital Price Transparency Final Rule mandated that U.S. hospitals publish their insurer-negotiated and self-pay prices for services. This study sought to characterize and assess factors contributing to variation in TTE prices. METHODS: We used a commercial database containing hospital-disclosed prices to characterize variation in TTE prices within and across hospitals. We linked these price data to hospital and regional characteristics using Medicare Facility IDs. RESULTS: A total of 1,949 hospitals reported commercial prices. Among reporting hospitals, median commercial and self-pay prices were 2.93 and 3.06 times greater than the median Medicare price ($1,313 and $1,422, respectively, vs $464). Within hospitals, the 90th percentile payer-negotiated rate was 2.78 (interquartile range, 1.80-5.09) times the 10th percentile rate (within-center ratio). Across hospitals within the same hospital referral region, the median price at the 90th percentile hospital was 2.47 (interquartile range, 1.69-3.75) times that at the 10th percentile hospital (across-center ratio). On univariate analysis, for-profit (P = .04), teaching (P < .01), investor-owned (P < .01), and higher-rated hospitals (P < .01) charged higher prices, whereas rural referral centers (P = .01) and disproportionate share hospitals (P < .01) charged less. On multivariate analysis, the association between these characteristics and TTE prices persisted, except for investor ownership and rural referral centers. CONCLUSIONS: Self-pay and commercial TTE prices were higher than Medicare prices and varied significantly within and across hospitals. For-profit, teaching, and higher-rated hospitals had higher prices, in contrast to DSH hospitals. A better understanding of the relationship between this cost variation and quality of care is critical given the impact of cost on health care access and affordability.

Non-small cell lung cancer disparities in stage at presentation and treatment for Asian American, Native Hawaiian, and Pacific Islander women.

BACKGROUND AND OBJECTIVES: Asian Americans, Native Hawaiians, and Pacific Islanders (AANHPI) represent the fastest-growing group in the United States. While described in aggregate, great variations exist within the community. We aimed to determine whether there were differences in stage at presentation and treatment status among AANHPI women with non-small cell lung cancer (NSCLC). METHODS: Between 2004 and 2016, we identified 522 361 female patients with newly diagnosed NSCLC from the National Cancer Database. Multivariable logistic regression models were used to define adjusted odds ratios (aORs) of presenting with stage IV disease and not receiving treatment. RESULTS: AANHPI women were more likely to present with stage IV disease compared to White (54.32% vs. 40.28%, p < 0.001). Aside from Hawaiian, Pakistani, and Hmong women, all other ethnic groups had greater odds of presenting with stage IV disease than White women. AANHPI women <65 years were more likely to present with stage IV disease (p = 0.030). Only Vietnamese women showed a significant difference (aOR = 1.30 [1.06-1.58], p = 0.010) for likelihood of receiving treatment compared to White. CONCLUSIONS: Differences in stage at presentation and treatment status in women with NSCLC were observed among AANHPI ethnic groups when populations were disaggregated.

Determinants of Commercial Prices for Common Radiation Therapy Procedures.

PURPOSE: Using hospital-reported price data, we analyzed whether various market factors including radiation oncology practice consolidation were associated with higher commercial prices for radiation therapy (RT). METHODS AND MATERIALS: We evaluated commercial prices paid by private insurers for 4 common RT procedures-intensity modulated RT (IMRT) planning, IMRT delivery, 3-dimensional RT (3D-RT) planning, and 3D-RT delivery-reported among the 2096 hospitals in the United States that deliver RT according to the Medicare Provider of Service file. To assess price variation within hospitals, we evaluated the ratio of the 90th percentile price to the 10th percentile price among different private insurers. To assess regional variation, we similarly compared median commercial prices at the 90th and 10th percentile hospitals in each Hospital Referral Region. We generated multivariable models to test the association of various hospital, health system, regional, and market factors on median hospital commercial prices. RESULTS: A total of 1004 hospitals (47.9%) reported at least 1 commercial price for any of the 4 RT procedures considered in this study. National median commercial prices for IMRT planning and IMRT delivery were $4073 (interquartile ratio [IQR], $2242-$6305) and $1666 (IQR, $1014-$2619), respectively. Prices for 3D-RT planning and 3D-RT delivery were $2824 (IQR, $1339-$4738) and $616 (IQR, $419-877), respectively. Within hospitals, the 90th percentile price paid by a private insurer was 2.3 to 2.5 times higher on average than the 10th percentile price, depending on the procedure. Within each Hospital Referral Region, the median price at the 90th percentile hospital was between 2.4 and 3.2 times higher than at the 10th percentile hospital. On multivariable analysis, higher prices were generally observed at hospitals with for-profit ownership, teaching status, and affiliation with large health systems. Levels of radiation oncology practice consolidation were not significantly associated with any prices. CONCLUSIONS: Commercial prices for common RT procedures vary by more than a factor of 2 depending on a patient's private insurer and hospital of choice. Higher prices were more likely to be found at for-profit hospitals, teaching hospitals, and hospitals affiliated with large health systems.

Medicaid expansion and surgery for HPB/GI cancers: NCDB difference-in-difference analysis.

BACKGROUND: It is unclear if Medicaid expansion improved access to surgical resection for hepatopancreatobiliary (HPB) and gastrointestinal (GI) cancers. METHODS: This was a quasi-experimental, cohort study using difference-in-difference analysis to evaluate differences in surgical resection for HPB/GI cancers in the post-Medicaid expansion era compared to the pre-Medicaid expansion era among patients residing in states that had Medicaid expansion versus not. RESULTS: During the pre- (2011-2013) and post-Medicaid expansion (2015-2017) eras, there were 49,954 patients between the ages of 40-64 who had liver cancer (n = 19,384; 38.8%), pancreatic cancer (n = 14,351; 28.7%), colorectal liver metastasis (n = 7566; 15.1%), or gastric cancer (n = 8653; 17.3%). 43.2% resided in expansion states (n = 21,577). There were no significant differences in the overall rates of surgical resection between expansion and non-expansion states before and after Medicaid expansion. CONCLUSIONS: Medicaid expansion did not impact surgical resection for HPB/GI cancers.

Utilization of National Cancer Institute-Designated Cancer Centers by Medicare Beneficiaries with Cancer.

BACKGROUND: Little is known about which patients use National Cancer Institute-designated cancer centers (NCICCs) nationally. This study aimed to identify sociodemographic characteristics associated with decreased NCICC use among Medicare beneficiaries. METHODS: This study examined a national cohort of 534,008 Medicare beneficiaries with cancer in 2017 using multivariable logistic regressions for NCICC use. The covariates in the study were sex, age, cancer type, race/ethnicity, dual-eligibility status for Medicaid and Medicare, and NCICC presence in the home state. RESULTS: In 2017, 19.5 % of Medicare beneficiaries with cancer used an NCICC at least once. Dual-eligible beneficiaries had 29 % lower adjusted odds of NCICC use than non-dual-eligible beneficiaries (adjusted odds ratio [aOR], 0.71; 95 % confidence interval [CI], 0.70-0.73; p < 0.001). American Indian/Alaska Native beneficiaries had 40 % lower odds of NCICC use than non-Hispanic white (NHW) beneficiaries (aOR, 0.60; 95 % CI, 0.53-0.68; p < 0.001). Compared with NHW beneficiaries, the odds of NCICC use were higher for black beneficiaries by 15 % (aOR, 1.15; 95 % CI, 1.12-1.18; p < 0.001), for Hispanic beneficiaries by 31 % (aOR, 1.31; 95 % CI, 1.26-1.35; p < 0.001), and for Asian/Pacific Islander beneficiaries by 126 % (aOR, 2.26; 95 % CI, 2.16-2.36; p < 0.001). Utilization declined steadily in older groups, with beneficiaries older than 95 years showing 73 % lower odds of NCICC use than beneficiaries younger than 65 years (aOR, 0.27; 95 % CI, 0.24-0.29; p < 0.001). CONCLUSIONS: Medicaid-eligible, American Indian/Alaska Native, and older patients are substantially less likely to use NCICCs. Future research should focus on defining and addressing the barriers to NCICC access for these populations.

In pursuit of equity in cancer care: Moving beyond the Affordable Care Act.

Although Medicaid Expansion under the Patient Protection and Affordable Care Act (ACA) has been associated with many improvements for patients with cancer, Snyder et al. provide evidence demonstrating the persistence of racial disparities in cancer. This Editorial describes why insurance coverage alone does not ensure access to health care, highlights various manifestations of structural racism that constitute barriers to access beyond the direct costs of care, and calls for not just equality, but equity, in cancer care.

ACO Spending and Utilization Among Medicare Patients at the End of Life: an Observational Study.

BACKGROUND: End-of-life (EOL) costs constitute a substantial portion of healthcare spending in the USA and have been increasing. ACOs may offer an opportunity to improve quality and curtail EOL spending. OBJECTIVE: To examine whether practices that became ACOs altered spending and utilization at the EOL. DESIGN: Retrospective analysis of Medicare claims. PATIENTS: We assigned patients who died in 2012 and 2015 to an ACO or non-ACO practice. Practices that converted to ACOs in 2013 or 2014 were matched to non-ACOs in the same region. A total of 23,643 ACO patients were matched to 23,643 non-ACO patients. MAIN MEASURES: Using a difference-in-differences model, we examined changes in EOL spending and care utilization after ACO implementation. KEY RESULTS: The introduction of ACOs did not significantly impact overall spending for patients in the last 6 months of life (difference-in-difference (DID) = $192, 95%CI -$841 to $1125, P = 0.72). Changes in spending did not differ between ACO and non-ACO patients across spending categories (inpatient, outpatient, physician services, skilled nursing, home health, hospice). No differences were seen between ACO and non-ACO patients in rates of ED visits, inpatient admissions, ICU admission, mean healthy days at home, and mean hospice days at 180 and 30 days prior to death. However, non-ACO patients had a significantly greater increase in hospice utilization compared to ACO patients at 180 days (DID P-value = 0.02) and 30 days (DID P-value = 0.01) prior to death. CONCLUSIONS: With the exception of hospice care utilization, spending and utilization were not different between ACOs and non-ACO patients at the EOL. Longer follow-up may be necessary to evaluate the impact of ACOs on EOL spending and care.

Spending outcomes among patients with cancer in accountable care organizations 4 years after implementation.

BACKGROUND: The long-term impact of affordable care organizations (ACOs) on cancer spending remains unknown. The authors examined whether practices that became ACOs altered their spending for patients with cancer in the first 4 years after ACO implementation. METHODS: By using national Medicare data from 2011 to 2017, a random sample of 20% of fee-for-service Medicare beneficiaries aged 65 years and older with cancer was obtained (n = 866,532), and each patient was assigned to a practice. Practices that became ACOs in the Medicare Shared Savings Program were matched to non-ACO practices. Total, cancer-specific, and service category-specific yearly spending per patient was calculated. A difference-in-differences model was used to determine spending changes associated with ACO status for patients with cancer in the 4 years after ACO implementation. RESULTS: The introduction of ACOs did not have a significant impact on overall spending for patients with cancer in the 2 years after ACO implementation (difference, -$38; 95% CI, -$268, $191; P = .74). Changes in spending also did not differ between ACO and non-ACO patients within service categories or among the 11 cancer types examined. The lack of difference in spending for patients with cancer in ACO and non-ACO practices persisted in the third and fourth years after ACO implementation (difference, -$120; 95% CI, -$284, $525; P = .56). CONCLUSIONS: ACOs did not significantly change spending for patients with cancer in the first 4 years after their implementation compared with non-ACOs. This prompts a reevaluation of the current efficacy of ACOs in reducing spending for cancer care and may encourage policymakers to reconsider the incentive structures of ACOs. LAY SUMMARY: Accountable care organizations (ACOs) were developed to curtail health care spending and improve quality, but their effects on cancer spending in their first 2 years have been minimal. The long-term impact of ACOs on cancer spending remains unknown. By using data from 866,532 Medicare beneficiaries with cancer, the authors observed that the association of a practice with an ACO did not significantly change total yearly spending per patient in the first 4 years after ACO implementation. This finding prompts a reevaluation of the current efficacy of ACOs in reducing spending for cancer care.

Healthy days at home: A population-based quality measure for cancer patients at the end of life.

BACKGROUND: Healthy Days at Home (HDAH) is a novel population-based outcome measure. In this study, its use as a potential measure for cancer patients at the end of life (EOL) was explored. METHODS: Patient demographics and health care use among Medicare beneficiaries with cancer who died over the years 2014 to 2017 were identified. The HDAH was calculated by subtracting the following components from 180 days: number of days spent in inpatient and outpatient hospital observation, the emergency room, skilled nursing facilities (SNF), inpatient psychiatry, inpatient rehabilitation, long-term hospitals, and inpatient hospice. How HDAH and its components varied by beneficiary demographics and health care market were evaluated. A patient-level linear regression model with HDAH as the outcome, hospital referral region (HRR) random effects, and market fixed effects were specified, as well as beneficiary age, sex, and comorbidities as covariates. RESULTS: The 294,751 beneficiaries at the EOL showed a mean number of 154.0 HDAH (out of 180 days). Inpatient (10.7 days) and SNF (9.7 days) resulted in the most substantial reductions in HDAH. Males had fewer adjusted HDAH (153.1 vs 155.7, P < .001) than females; Medicaid-eligible patients had fewer HDAH compared with non-Medicaid-eligible patients (152.0 vs 154.9; P < .001). Those with hematologic malignancies had the fewest number of HDAH (148.9). Across HRRs, HDAH ranged from 10.8 fewer to 10.9 more days than the national mean. At the HRR-level, home hospice was associated with greater HDAH, whereas home health was associated with fewer HDAH. CONCLUSIONS: HDAH may be a useful measure to understand, quantify, and improve patient-centered outcomes for cancer patients at EOL.

Practice Consolidation Among U.S. Radiation Oncologists Over Time.

PURPOSE: Health care practices across the United States have been consolidating in response to various market forces. The degree of practice consolidation varies widely across specialties but has not been well studied within radiation oncology. This study used Medicare data to characterize the extent of practice consolidation among radiation oncologists and to investigate associated market factors. METHODS AND MATERIALS: We utilized Medicare Provider Enrollment, Chain, and Ownership System data to assess the practice size and billing patterns of U.S. radiation oncologists in 2013 and again in 2017. Individual practices were categorized by the number of radiation oncologists practicing together: solo practices had 1 radiation oncologist, small practices 2 to 10, and large practices 11 or more. Market consolidation within each hospital referral region (HRR) across the country was quantified using the Herfindahl-Hirschman Index. Hospital and market level data were obtained for each HRR, and factors associated with the growth of radiation oncology practices over time were calculated via multivariable linear regression. RESULTS: Across the United States, radiation oncology practices appear to be highly consolidated. The mean Herfindahl-Hirschman Index was 0.4711 in 2013-indicating high levels of consolidation at baseline-and increased further to 0.4865 by 2017. Between 2013 and 2017, the number of practices with radiation oncologists in the United States decreased 3.8%, from 1679 to 1615, whereas the number of practicing radiation oncologists increased 9.4%, from 4948 to 5415. Over the study period, the number of solo practices fell 11% (from 708 in 2013 to 627 in 2017), whereas the number of large practices (those with 11 or more radiation oncologists) increased 50% (from 60 to 90). Large practices likewise grew to employ a greater share of all radiation oncologists (23.9%-32.4%) and accounted for a larger proportion of total Medicare billing (21%-26%). Two market factors were predictive for increases in the mean radiation oncology practice size. HRRs with greater hospital market consolidation and those with lower levels of baseline radiation oncology consolidation were more likely to experience higher levels of growth over the study period. CONCLUSIONS: Radiation oncologists are increasingly working in larger practices. By 2017, nearly one-third of all practicing radiation oncologists in the United States were employed by just the 90 largest practices. Radiation oncology, as a field, is highly concentrated, and represents one of the most consolidated specialties across the country. The implications of practice consolidation among radiation oncologists warrants further investigation.