Factors Associated With Exceeding Target Price Under OCM for Episodes of Breast Cancer

Study findings show breast cancer episodes in older women with distant metastases frequently exceeded the target price under the Centers for Medicare and Medicaid Services Oncology Care Model (OCM) payment methodology, suggesting the target price did not adequately account for the complexity of metastatic cancers (JCO Oncol Pract. 2021;17[11]:e1660-e1667. doi:10.1200/OP.21.00270).

The study, by Ryan B. Thomas, PharmD, Jefferson College of Population Health, Philadelphia, PA, and colleagues, explored the mean difference between total costs and target price among breast cancer episodes by stage under OCM.

Researchers linked breast cancer episodes from OCM performance period 1-4 reconciliation reports with health record data from a large academic medical center. Demographics, total cost of care, and target price were measured by stage. Multivariable linear regression was used to compare adjusted differences between total cost of care and target price across cancer stage.

A total of 252 patients with breast cancer accounting for 539 episodes were evaluated in the study. Of these 539 episodes, 235 (44%) were stage I, 124 (23%) were stage II, 33 (6%) were stage III, and 147 (27%) were stage IV.

Overall, 37% of episodes exceeded the target price. Mean differences from target price were -$1782 for stage I, $2246 for stage II, -$6032 for stage III, and $11379 for stage IV. Stage IV episodes had the highest mean total cost of care ($44,210) and mean target price ($32,831). Stage IV episodes also had higher rates of chemotherapy, inpatient admission, and novel therapy use.

After adjusting for covariates, stage IV episodes and patients aged ≥65 years had the highest mean difference from target price ($17,175).

“Breast cancer episodes in older women with distant metastases most frequently exceeded target price, suggesting that target price did not adequately account for complexity of metastatic cancers,” concluded Dr Thomas and colleagues.

“A metastatic adjustment introduced in PP7 represents a promising advancement in the target price methodology and an impact evaluation will be needed,” they added.