Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts.
Division of General Internal Medicine, Brigham and Women's Hospital, Boston, Massachusetts.
JAMA. 2021 Nov 9;326(18):1829-1839. doi: 10.1001/jama.2021.17642.
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.
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.
OCM participation.
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.
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.
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.
重要性：2016 年，美国医疗保险和医疗补助服务中心启动了肿瘤学护理模式（Oncology Care Model，OCM），这是一种旨在提高癌症医疗保险受益人生存质量的替代支付模式。
目的：评估 OCM 在其实施的前 3 年对医疗保险支出、利用、质量和患者体验的影响。
设计、地点和参与者：本研究为探索性差异差异研究，比较了在 OCM 参与实践中进行的 6 个月化疗期间的护理，以及在 OCM 启动之前（2014 年 1 月至 2015 年 6 月）和之后（2016 年 7 月至 2018 年 12 月）开始的倾向匹配的对照实践。参与者包括在这些实践中接受治疗的通过 2019 年 6 月的 Medicare 收费服务受益人的癌症患者。
暴露因素：OCM 参与。
主要结果和测量：总发作支付（医疗保险 A、B 和 D 部分的支出，不包括每月增强肿瘤服务的支付）；住院、急诊（ED）就诊、门诊就诊、化疗、支持性护理和影像学的利用和支付；质量（与化疗相关的住院和 ED 就诊、及时化疗、临终关怀和生存）；以及患者体验。
结果：在接受化疗的 Medicare 收费服务癌症患者中，有 483319 名患者（平均年龄为 73.0[标准差为 8.7]岁；60.1%为女性；987332 个疗程）在 201 个 OCM 参与实践中接受治疗，有 557354 名患者（平均年龄为 72.9[标准差为 9.0]岁；57.4%为女性；1122597 个疗程）在 534 个对照实践中接受治疗。从基线期到干预期，OCM 期总发作支付从 28681 美元增加到 33211 美元，对照期从 28421 美元增加到 33249 美元（差异为-297；90%CI：-504 至-91），低于每月 704 美元的增强肿瘤服务支付。总发作支付的相对减少主要是因为 B 部分非化疗药物的支付（差异为-145；90%CI：-218 至-72），尤其是支持性护理药物（差异为-150；90%CI：-216 至-84）。OCM 与较高风险发作的总发作支付相对减少（差异为-503；90%CI：-802 至-204）和较低风险发作的总发作支付相对增加（差异为 151；90%CI：39 至 264）有统计学意义。OCM 与住院、ED 就诊或生存的差异无统计学意义。在 22 项利用率措施、10 项质量措施和 7 项护理体验措施中，只有 5 项有显著差异。
结论和相关性：在这项探索性分析中，OCM 与接受化疗的癌症医疗保险受益人的 6 个月发作期间的适度支付减少显著相关，但在 OCM 的前 3 年中，这并没有抵消每月增强肿瘤服务的支付。大多数利用率、质量和患者体验结果均无统计学差异。
