Specialty Payment Model Opportunities and Assessment
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Specialty Payment Model Opportunities and Assessment Oncology Model Design Report A product of the CMS Alliance to Modernize Healthcare (CAMH) Federally Funded Research and Development Center Sponsored by the Centers for Medicare & Medicaid Services (CMS) Peter Huckfeldt, Chris Chan, Samuel Hirshman, Aaron Kofner, Jodi L. Liu, Andrew W. Mulcahy, Ioana Popescu, Clare Stevens, Justin W. Timbie, Peter S. Hussey Published by the RAND Corporation, Santa Monica, Calif. and The MITRE Corporation, McLean, Va. © Copyright 2015 RAND Corporation RAND® and MITRE® are registered trademarks. For more information on this publication, visit www.rand.org/t/rr763 Specialty Payment Model Opportunities and Assessment: Oncology Model Design Report Limited Print and Electronic Distribution Rights This document and trademark(s) contained herein are protected by law. This representation of RAND intellectual property is provided for noncommercial use only. 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MITRE provides innovative, practical solutions for some of our nation’s most critical challenges in defense and intelligence, aviation, civil systems, homeland security, the judiciary, and healthcare. www.rand.org www.mitre.org A project of the CMS Alliance to Modernize Healthcare ii Specialty Payment Model Opportunities and Assessment: Oncology Model Design Report Preface In August 2013, the Centers for Medicare & Medicaid Services (CMS) issued a task order to The MITRE Corporation (MITRE), operator of the CMS Alliance to Modernize Healthcare (CAMH) Federally Funded Research and Development Center (FFRDC). The goal of this task order was to inform the development of alternative payment models for specialty health care services. Mary Kapp serves as the Government Task Lead (GTL) and Claire Schreiber serves as the CMS project manager for this work. This report includes analyses of claims data to inform the development of a payment model related to oncology care. The research addressed in this report was conducted in RAND Health, a division of the RAND Corporation, under a subcontract to MITRE. A profile of RAND Health, abstracts of its publications, and ordering information can be found at http://www.rand.org/health. A project of the CMS Alliance to Modernize Healthcare iii Specialty Payment Model Opportunities and Assessment: Oncology Model Design Report Table of Contents Preface .............................................................................................................................................. i Table of Contents ........................................................................................................................... iv Figures............................................................................................................................................ vi Tables ............................................................................................................................................. ix Summary ...................................................................................................................................... xiv Methods .................................................................................................................................................. xv Definition of an Episode of Chemotherapy ............................................................................................ xv Spending Patterns ................................................................................................................................. xvii Attribution of Episodes to Practices ..................................................................................................... xvii Characteristics of Practices with Attributed Oncology Episodes ........................................................ xviii Conclusion ............................................................................................................................................. xix Acknowledgments......................................................................................................................... xx Abbreviations ............................................................................................................................... xxi 1. Background ................................................................................................................................. 1 2. Methods....................................................................................................................................... 4 Data Sources ............................................................................................................................................. 4 Population ................................................................................................................................................. 5 Definition of Chemotherapy and Related Drug Categories .................................................................... 12 Categorization of Health Care Services .................................................................................................. 16 3. Definition of an Episode of Chemotherapy .............................................................................. 19 Initiation of an Episode .......................................................................................................................... 19 Termination of an Episode ..................................................................................................................... 28 4. Spending Patterns for Chemotherapy Treatment and Implications for Savings Opportunities........................................................................................................................... 37 Spending by Type of Service Preceding and Following Initiation of Episodes of Chemotherapy ........ 37 Variation in Medicare Payments ............................................................................................................ 59 Implications for Medicare Savings Opportunities .................................................................................. 68 5. Attribution of Episodes to Practices ......................................................................................... 70 A project of the CMS Alliance to Modernize Healthcare iv Specialty Payment Model Opportunities and Assessment: Oncology Model Design Report Development of Attribution Rules ......................................................................................................... 70 Comparison of Attribution Rules ........................................................................................................... 73 Selection of a Preferred Attribution Rule ............................................................................................... 76 Characteristics of Practices with Attributed Oncology Episodes ........................................................... 78 Summary of Attribution Analyses .......................................................................................................... 84 Conclusion .................................................................................................................................... 85 References ..................................................................................................................................... 86 Appendix ....................................................................................................................................... 88 A project of the CMS Alliance to Modernize Healthcare v Specialty Payment Model Opportunities and Assessment: Oncology Model Design Report Figures Figure 2.1. Methods for Classifying Drugs into Five Categories ................................................. 14 Figure 3.1. Three Events That Could Be Used to Define Episode Initiation ................................ 21 Figure 4.1. Average Monthly Total Medicare Payments for Beneficiaries Initiating Chemotherapy in 2010 .......................................................................................................... 38 Figure 4.2. Cumulative Proportion of Total 24-Month Medicare Payments Occurring in Each Month Relative to Chemotherapy Initiation ......................................................................... 39 Figure 4.3. Percentage of Beneficiaries with Positive Physician-Administered or DME Chemotherapy Payments per Month Relative to Chemotherapy Initiation .......................... 41 Figure 4.4. Average Payments for Physician-Administered and DME Chemotherapy per Month Relative to Chemotherapy Initiation ........................................................................