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Specialty Payment Model Opportunities and Assessment

Specialty Payment Model Opportunities and Assessment: Oncology Model Design Report

Peter Huckfeldt
Chris Chan
Samuel Hirshman
Aaron Kofner
Jodi L. Liu
Andrew W. Mulcahy
Ioana Popescu
Clare Stevens
Justin W. Timbie
Peter S. Hussey
Copyright Date: 2015
Published by: RAND Corporation
Pages: 226
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  • Book Info
    Specialty Payment Model Opportunities and Assessment
    Book Description:

    This report describes research related to the design of a payment model for specialty oncology services for possible testing by the Center for Medicare and Medicaid Innovation at the Centers for Medicare & Medicaid Services. It focuses on analyses of Medicare claims data related to the definition of the initiation of an episode of chemotherapy, patterns of spending, and attribution of episodes to practices.

    eISBN: 978-0-8330-9019-5
    Subjects: Health Sciences, Public Health, History

Table of Contents

  1. Front Matter
    (pp. i-ii)
  2. Preface
    (pp. iii-iii)
  3. Table of Contents
    (pp. iv-v)
  4. Figures
    (pp. vi-viii)
  5. Tables
    (pp. ix-xiii)
  6. Summary
    (pp. xiv-xix)
  7. Acknowledgments
    (pp. xx-xx)
  8. Abbreviations
    (pp. xxi-xxii)
  9. 1. Background
    (pp. 1-3)

    This report describes research related to the design of a payment model for specialty oncology services for possible testing by the Center for Medicare and Medicaid Innovation at the Centers for Medicare & Medicaid Services (CMS). Cancer is a common and costly condition; due to increases in the costs and extent of available therapies, treatment costs are projected to nearly double between 2006 and 2020 (Mariotto et al., 2011; McClellan et al., 2013a; Smith and Hillner, 2011). However, the predominant payment methods for oncology care have not changed substantially since the 1970s (Newcomer, 2012).

    Episode-based payment, which aims to create...

  10. 2. Methods
    (pp. 4-18)

    The primary data source was Medicare claims data from the Chronic Conditions Warehouse (CCW) for 100 percent of Medicare FFS beneficiaries in 2009–2012. We used claims data for all types of Medicare covered services, including the Carrier,¹ Medicare Provider Analysis and Review (MedPAR), Outpatient, Durable Medical Equipment (DME), Home Health, Hospice, and Part D files. We also used the Master Beneficiary Summary File as a source of beneficiary demographics and information on Medicare eligibility. While the CCW claims data provide a thorough record of Medicare’s payments for services, the clinical information available from claims is limited.

    To address this...

  11. 3. Definition of an Episode of Chemotherapy
    (pp. 19-36)

    Oncology care entails a full range of health care services, provided by many clinicians in a variety of settings, over a potentially long period of time. Defining an “episode” of care requires careful consideration of each of these dimensions.

    An episode of care can be defined mainly by three parameters: the initiation of the episode, the termination of the episode, and the rules for sorting health care services that occur during this time period into those attributed to the episode and those that are independent of it. The oncology provider would directly provide some of these services and would also...

  12. 4. Spending Patterns for Chemotherapy Treatment and Implications for Savings Opportunities
    (pp. 37-69)

    In this section, we examine Medicare payments for various service categories to inform the design of an episode of care, the length of an episode, and services to be included in an episode. These results are based on analysis of average Medicare payments occurring in each month relative to the initiation of chemotherapy. For most analyses, we used the CCW study sample of patients with cancer and chemotherapy initiation in 2010; where indicated, we used the SEER-Medicare study sample to allow for analysis by cancer stage. We dropped beneficiary-months that occurred after the month of death or with either incomplete...

  13. 5. Attribution of Episodes to Practices
    (pp. 70-84)

    Attribution methodologies are needed to associate patients undergoing episodes of chemotherapy treatment with physician practices that could participate in a payment model. There is no single attribution methodology recognized as the “gold standard,” and prior studies have shown that alternative rules typically produce different results (Mehrotra et al., 2010). In this section, we describe two claims data–based attribution rules that RAND developed and tested for the oncology payment model. We then compare the rates at which the two rules successfully attribute episodes to practices and the concordance between the results from the two rules. Next, we describe four criteria...

  14. Conclusion
    (pp. 85-85)

    The results of this study provide one source of information for consideration in the design of an oncology payment model. The analyses in this report describe the initiation and termination of episodes of chemotherapy, spending patterns for patients initiating chemotherapy, and the results of claims-based methods for attributing chemotherapy patients to oncology practices. In future analyses, we will simulate the potential effects of an oncology payment models and identify key design considerations....

  15. References
    (pp. 86-87)
  16. Appendix
    (pp. 88-204)