In the most recent issue of the Journal of Clinical Oncology, Mullangi et al examine whether the Medicare Oncology Care Model led to spillover and practice pattern changes within participating clinics for non-Medicare patients. This is a fascinating question. A spillover occurs when a change in practice occurs that impacts people who are not targeted by the intervention. We know spillovers are quite common in Medicare Advantage. Once a county reaches sufficient Medicare Advantage enrollment (usually just under 20%) traditional Medicare costs decrease as well. The observed logic is that doctors typically practice as if they are indifferent to insurance type so once they get told by a big enough payer to do something in a certain way in order to get paid, they’ll do that for basically everyone.
The Oncology Care Model is a bundled payment project. It gives oncologists a set of cash to care for a cancer patient for six months. Initial research found clinical cost savings but not programmatic cost savings as these models require a lot of bonuses and administrative complexity to run. But the initial research only looked at costs within traditional Medicare Fee for Service. This paper looks at a broader range of payers.
So what did it do and how did the researchers try to figure this out:
This observational study used administrative claims from a large national payer, yielding 157,189 total patients with commercial insurance or MA with solid malignancies who initiated 229,376 systemic anticancer therapy episodes before (2012-2015) and during (2016-2021) the OCM at 125 OCM-participating practices (a subset of total OCM practices) and a 1:10 propensity-matched set of 860 non-OCM practices. We used difference-in-differences analyses to assess the association between the OCM and total episode spending…
The OCM was associated with adjusted spending decreases for both high-risk (–$6,756 USD [95% CI, –$10,731 USD to –$2,781 USD], P = .001) and low-risk (–$4,171 USD [95% CI, –$7,799 USD to –$543 USD], P = .025) episodes. OCM-associated spending reductions were strongest for outpatient (–$5,243 USD [95% CI, –$8,589 USD to –$1,897 USD], P = .002) and infused/injected anticancer drug (–$3,031 USD [95% CI, –$5,193 USD to –$869 USD], P = .006) spending. There were no associations between OCM participation and changes in hospital or ED utilization nor quality of care.
WHAT?
The short version is that costs went up everywhere BUT for the practices in the Oncology Care Model, costs for commercially insured patients went up far less and far slower than patients who were treated by docs who were not in the OCM. There were no differences in quality of care that would make us wary of these cost savings.
Methodologically, this is a reasonable way of asking this question.
Spillovers are fascinating (the R&R I’m sending back this afternoon is a spillover paper) as most policies are not evaluated on their spillovers even if we have reason to believe that spillovers can drive a substantial portion of total results. Furthermore, once we have evidence of spillovers happening, it changes the policy creation and modification incentives — do we change something in the primary program just to modify the spillover effect? That is a tough question.
I think I’ll be thinking hard about this paper on my next couple of long walks.
MazeDancer
Seems like good news.
But releasing control isn’t a known insurance company trait.
Did not having to clear every decision result in increased time for care at the doc offices?
David Anderson
@MazeDancer: Good question but it is not one that this study examined. I don’t know.
MazeDancer
@David Anderson: Just saw this on Twitter. 26 steps for an oncologist to get drug approval.
Seems like a giant waste of time.
May this new study trigger further investigation.
Mai Naem mobile
Did COVID have an effect on the 2019-2021 part of the study? People wanting less contact with medical facilities and medical staff minimizing contact with patients, especially vulnerable people.
David Anderson
@Mai Naem mobile: The design (difference in differences (DID)) is used to control for common shocks in the post-period. Unless we have a really strong reason to think that COVID hit the service areas of OCM clinics very differently than the matched controls, we should not worry much above COVID. DiD compares the change in the distance between the two groups outcomes after the intervention relative to the difference in the two groups outcomes prior to the intervention as the causal identification. The big assumption is that in the pre-period the two groups are moving in the same direction even if not at the same level and that the change in directions afterwards can be attributed to the policy intervention.
sab
OT: I know OT is not usual (or even allowed) on Mayhew Anderson threads.
Back when we were young naive olds my husband opted for medicare advantagw because it was cheap and all of his doctors were in network. And our hospital chain and our health onsurance were linked. Coverage was great and not too expensive.
Ten years later, totally changed. My husband has medicare advantage, but also many health conditiona, preexisting, so he can’t opt out of his medicare advantage.
His hospital limnked to the insurance decided to reorganize, and ia now a for-profit linked to a hedge fund.
All of husband’s doctors have quit, leaving forwarding addresses. They have hundreds of thousands of med school debt, and they cannot work for non-profits and have their tuition debt not mbe forgiven,