Study Models ASCO Alternative Payment Model in Advanced Ovarian Cancer Care

Each year, surveys show more physicians are interested in alternative payment models (APMs); however, taking on risk and concerns about interoperability remain unknowns.

With practices anxious to meet requirements of the Medicare Access and CHIP Reauthorization Act (MACRA), the American Society of Clinical Oncology proposed the Patient-Centered Oncology Payment (PCOP) model in 2015 to help practices meet requirements of an APM under the law. ASCO continues to seek physician-designed APMs under the Quality Payment Program as options to the Oncology Care Model (OCM), which is promoted by CMS.

A group of researchers from Duke University Medical Center and the Duke Cancer Institute, led by Haley A. Moss, MD, MBA, sought to test the PCOP. Their abstract, “Can the ASCO alternative payment model achieve cost savings in ovarian cancer care?” was part of session on “Reducing Cost and Pain” held Monday at the Society of Gynecologic Oncology’s 2018 Annual Meeting on Women’s Cancer, in New Orleans, Louisiana.

Using Surveillance, Epidemiology and End Results data linked with Medicare claims, the Duke researchers identified more than 4600 women who were diagnosed with stage III—IV epithelial ovarian cancer between 2000 and 2012. The women received primary debulking surgery (PDS), followed by adjuvant (ACT) or neoadjuvant chemotherapy (NACT). With actual costs in hand, they modeled what costs would have been under PCOP compared with fee-for-service (FFS).

Like the OCM, the PCOP model sought to hold practices accountable by having them take on risk to avoid unnecessary hospital stays and trips emergency department (ED), unnecessary medication, and excessive end-of-life care. PCOP had unique features and created new payments for key tasks previously not covered by FFS:

• New patient treatment planning ($750)
• Care management during treatment ($200 per month)
• Care management during active monitoring ($50 per month)
• Participation in clinical trials ($100 per month)

As Moss explained, the “carrots” of these new incentives would be offset by “sticks” for failing to meet quality standards.

The Duke study had a dual aim: (1) to compare the total cost difference in Medicare FFS with PCOP in patients with advanced ovarian cancer, and (2) to gauge how much ED visits, hospitalizations and imaging would need to be reduced to make the model achieve cost savings in ovarian cancer. The researchers calculated that the model provides approximately $2600 per ovarian cancer patient in additional practice payments.

Results

Of the 4643 women who met the study criteria, 3777 underwent PDS followed by ACT, and 866 followed with NACT. The mean cost of chemotherapy and surveillance was $71,763 in the PDS group compared to $90,058 in the NACT group.

For both groups, most FFS costs were related to chemotherapy or hospitalization. Hospitalizations were 62% for the PDS group and 60% for the NACT group. The modeling calculated that under PCOP, hospitalizations would drop 8% overall, to 54% for PDS and 52% for NACT. The study found that the PCOP could achieve overall savings in advanced ovarian cancer, but that this would need to be achieved by reducing hospitalizations during the active treatment period, because reducing imaging or ED visits on their own would likely not be enough to offset increased practice fees.

Financial Toxicity in Gynecological Cancer: A Distress Score

Researchers from at Columbia University Medical Center, Columbia University Medical College, and Weill Cornell Medical College and Columbia University College of Physicians and Surgeons collaborated on the abstract, “Evaluation of financial toxicity in women with gynecologic malignancies: a cross-sectional study,” also presented at the session on “Reducing Cost and Pain.” Sudeshna Chatterjee, MD, of New York Presbyterian Hospital-Weill Cornell Medical College presented results for the group.

The term “financial toxicity” has become well-known in cancer care, referring to the fact that medical costs are the leading driver of bankruptcy in the United States and that people with cancer were 2.5 times more likely to file for bankruptcy than other Americans. The link between financial concerns and health outcomes is now well-established. The study presented Monday focused specifically on the effect of financial concerns on women with gynecological cancers, in the wake of a wave of FDA approvals for new chemotherapy agents and targeted therapies, including poly (ADP-ribose) polymerase (PARP) inhibitors that can cost $13,000 to $20,000 per month.

Due to changing benefit designs—particularly the rise of high deductible plans—more costs are being transferred to patients, resulting in higher out-of-pocket costs. Patients experiencing financial toxicity are known to have poorer adherence, especially on oral therapy, and are more likely to neglect general overall medical care, the researchers said. Their pilot study sought to quantify this problem in women with gynecological cancers.

Over 10 months, they administered a 35-item questionnaire to patients during treatment based on the Federal Reserve Board’s Survey of Household Economics and Decision-making (SHED). From this, they created an 11-item validated Comprehensive Score for financial Toxicity or COST measure, with financial toxicity defined as ≥22. A total of 120 women completed the survey; their average age was 64, and 72 had an annual income of less than $60,000.One-third of the women (32%) reported a decline in income since diagnosis, with 10% earning less than half their prior income.

Problems with insurance were significant: 37% reported at least 1 denial for a recommended treatment, including 24 denials for medications, 5 denials for imaging, and 3 denials for genetic testing. This meant 47% had out-of-pocket costs, and 26% skipped some medical care due to cost concerns, with 22% saying they could not cover the cost of care.

As for scores, 43% of the survey takers had a score of 22 or higher, indicating distress from financial toxicity; 79% of these patients made $20,000 a year or less, but 20% made $100,000 a year or more. Risk factors for distress included being young, unmarried, or African American (compared with white).

Notably, the researchers found that while financial toxicity hit harder on those at lower income levels, those at higher incomes were not immune. Most of all, the role of the physician in the conversation, “continues to evolve.”