Physician Behavior Impact When Revenue Shifted From Drugs to Services | Page 2
Published Online: April 21, 2014
Bruce Feinberg, DO; Scott Milligan, PhD; Tim Olson, MBA; Winston Wong, PharmD; Daniel Winn, MD; Ram Trehan, MD; and Jeffrey Scott, MD
The Oncology Medical Home program was offered to a subset of first-generation pathways participants, who had recently organized to form a membership association, Therapeutics and Research in Oncology (TRIO). The TRIO practices operate independently, retaining their individual tax identification numbers, and consist of providers from small and large practices, urban and rural geography, representing the payer’s 2 largest metro areas. The initial membership in TRIO included 42 physicians in 16 practices, all of whom participated in the first-generation pathway program. Thirty-three physicians in 13 practices subsequently chose to participate in the Oncology Medical Home. Reasons for nonparticipation included sale of practice to hospital, retirement, and distrust of program.
Selection of the Study and Control Groups for Comparative Analyses
Of the 50 practices that participated in the first-generation pathways program, 32 were chosen for initial data evaluation based on the following criteria: (1) consistent data volume throughout the baseline and evaluation periods, defined as April 2010 to March 2012; (2) volume of >100 patients during the baseline period; and (3) location in Virginia, Maryland, or Washington, DC. Ten of these 32 practices were TRIO practices that participated in the Oncology Medical Home. Data from all 32 practices in the baseline year were used to create propensity scores via logistic regression.
K-nearest neighbor analysis of scores and 1-1 matching with replacement resulted in the pairing of 8 Oncology Medical Home practices to 7 first-generation pathways control practices.18 The logistic regression for Oncology Medical Home participation included the covariates of cancer and chemotherapy-treated patient volumes, cancer type, patient age group, extent of treatment, and Charlson comorbidity scores.19
Comparisons of physician behavior were made between the Oncology Medical Home participating practices and the first-generation pathways control group for the year prior to (year –1) and the year following (year +1) Oncology Medical Home implementation. Behavioral comparisons included number of patients per practice, number of visits per patient, number of patients receiving chemotherapy, chemotherapy administrations per patient, and use of all generic chemotherapy regimens. Claims data from the insurance network database were collected for year –1 (representing April 1, 2010, to March 31, 2011) and for year +1 (representing April 1, 2011, to March 31, 2012).
To measure extent of treatment, therapy lines were assigned based upon grouping of chemotherapy drugs. Drugs given within 30 days of each other were grouped as a drug combination. Changes that occurred beyond 30 days triggered drug combination reassignment and incremented the line of therapy. Exceptions were made for sequential therapies, which were accounted for by distinct grouping rules. Cormorbidity scores were calculated according to Charlson using Deyo’s mapping of International Classification of Diseases, Ninth Revision, Clinical Modification (ICD- 9-CM) codes.20 A single modification to the mapping was implemented in flagging claims likely to represent solid tumors with metastases. In addition to using claims with ICD-9 codes 196.x through 199.1, patients with solid tumors who received 2 or more lines of chemotherapy were marked as with metastatic solid tumor.
All statistical analyses were conducted using SPSS 19 statistical software (IBM, Armonk, New York) with the exception of k-nearest neighbor analyses, which were performed using SPSS Modeler 14.2. Due to the large sample sizes, χ² analyses were not used for categorical comparisons. Instead, individual measures were calculated at the practice level and group means were compared by independent t tests. All chemotherapy evaluations were based on intravenous chemotherapy claim code 96413. New and established patient visit claim codes 99201-99205, 99241- 99245, and 99211-99215 were used in these analyses.
A total of 33 physicians from 13 TRIO practices within the insurance network who participated in the first-generation pathways project chose to join the Oncology Medical Home program. Propensity score analysis identified 8 Oncology Medical Home practices and 7 firstgeneration pathways practices that were well matched for use in these analyses (Figure 2). The matching variables were chosen as a reflection of practice disease focus, treatment preferences, and overall patient volume. After matching, baseline demographics and characteristics were similar in the 2 groups (Table). The first-generation pathways control group treated 4847 patients at baseline versus 7213 for the Oncology Medical Home. The ages of patients were similarly distributed between the 2 groups. Approximately 13.5% of patients were under age 50 years, 35% were aged 50 to 64 years, approximately 25% were aged 65 to 74 years, and 25% were aged 75 years or older. Both study groups treated primarily solid tumors (85%). Other tumor types were hematologic (11%) and gynecologic (5%). Seventy percent of patients recieved first-line chemotherapy, 22% percent recieved second-line chemotherapy, and approximatley 9% recieved third-line or higher chemotherapy.
There was minimal difference in behavior change between the Oncology Medical Home and first-generation pathways providers and between study years among providers (Figure 3). The number of established patient visits in the Oncology Medical Home group remained stable from year –1 to year +1, with a mean of 3.7 and 3.8 patient visits, respectively. The same was true for the firstgeneration pathways control group, with a mean of 4.6 and 5 patient visits, respectively. New patient visits increased 2% from year –1 to year +1 for Oncology Medical Home providers compared with a decrease of 2% for the first-generation pathways control group. The percentage of chemotherapy administrations per patient remained stable among study years for both groups, with approximately 8 chemotherapy administrations per patient in each group for each year. The percentage of patients who received chemotherapy remained stable for each group among study years at approximately 15%.
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