Susan Weidner, MS

 Typically, a community-based specialty practice is prepared for a limited public health crisis that is driven by a natural disaster or a localized environment event. This article describes the unexpected impact that the coronavirus disease 2019 (COVID-19) pandemic has had on community-based specialty practices across the United States, especially oncology practices.

 We conducted an electronic national survey of community-based specialty practice administrators to determine the impact of COVID-19 on their practices and their ability to manage through a global pandemic. The 22-question survey focused on an initial observation period of March 15, 2020, to May 15, 2020, compared with a second period of May 16, 2020, to August 15, 2020.

 Oncology practices accounted for 46% of the 155 specialty practices that participated in the survey. Overall, 57% of respondents saw at least a 30% decline in total patient volume and/or financial impact during the initial observation period, compared with a 38% decline for the oncology practices. More than 70% of all practices experienced improvement after May 15, 2020, with at least 60% improving regardless of specialty. The initial decline was primarily driven by declines in new patient volume and procedures. Approximately 62% of practices anticipate a moderate-to-significant impact on patient outcomes over the next 12 months. The impact expected was slightly higher in retina and ophthalmology practices than oncology.

 Although unexpectedly impacted in delivering care for their patients, specialty practices generally and oncology practices especially have been resilient by leveraging federal funds and adopting operational enhancements.

It is estimated that the coronavirus disease 2019 (COVID-19) pandemic generated at least $202.6 billion in losses for health care systems and hospitals during the first 4 months of the public health crisis.

 From the start of the pandemic to the end of April, there was a nearly 60% decline in ambulatory care.

 It is anticipated that the reduction in health care utilization will more than cover the incremental costs of testing for and treating COVID-19.

 However, such reductions in utilization, chiefly in preventive care in oncology, may have ripple effects, leading to delayed diagnosis, stage migration, and the potential for increased morbidity and mortality.

 This impact can vary by geography as well as differ based on the type of care. It was identified that breast cancer screenings had declined by as much as 86% by the end of April, followed by increased volume since then.

 An initial report in oncology demonstrated a nearly 40% drop in new patient visits for community oncology practices.

However, it is not clearly understood how community-based care has been impacted across the various specialties—especially oncology. The implication for patient outcomes will need to be evaluated for the foreseeable future. To assist in putting the impact into perspective, we will share the results of a national survey to understand the impact and recovery of the initial wave of COVID-19 on specialty practices.

We conducted an electronic survey of specialty practices across the United States. These practices encompassed the following specialties: oncology; retina and ophthalmology (referred to as vision practices); rheumatology, gastroenterology, urology, and neurology (referred to as other large specialty practices); and other clinics such as orthopedics and acute care. The survey consisted of up to 22 questions that compared the impact of COVID-19 on key performance measures, the adoption of operational enhancements, and federal stimulus between the initial observation period of March 15, 2020, to May 15, 2020, and the next 90-day period of May 16, 2020, to August 15, 2020. The survey was conducted at the end of the second period over a 15-day period.

The survey was distributed to practice administrators of 1500 specialty practices geographically dispersed. This anonymous survey was conducted through the QuestionPro survey service and analyzed using descriptive statistics. Survey responses were compared with both electronic medical record and practice billing information to address any potential response biases.

A total of 155 specialty practices participated in the survey. Of these, 46% were oncology community practices. Vision and other large specialty practices represented 21% each. Approximately 74% of practices had 1 to 6 physicians. The majority were in suburban locations, with varied geographic distribution among the specialties. These differences are illustrated in 

Overall, more than 50% of specialty practices experienced at least a 30% decline in total patient volume within the initial 60-day period, while approximately 38% of oncology practices saw similar declines as displayed in Table 2. More than 70% of practices have seen improvements in patient volume since the middle of May. One of the primary drivers in the initial decline between March 15 and May 15 was the decline in new patient visits; more than 50% of practices had a decline of greater than 30%. Similar declines were seen in 43% of oncology practices. Oncology practices observed the greatest level of rebound with 77% having improvements in the second observation period. Although the other specialty segments saw patient volumes increase, the majority were starting from a more significant deficit. The declines of more than 30% in existing patient encounters were seen in 39% and 72% of oncology and vision practices, respectively. In the second observation period, approximately 69% of practices had experienced some level of improvement, with at least 45% of oncology practices returning to normal patient volumes within the second period.

The majority of oncology practices had less than a 30% decline in oncology drug infusions (79%) and nononcology drug infusions (67%) during the initial period. Increases in drug infusions were experienced in at least 46% of oncology practices during the second period. Approximately 57% of other specialty practices had less than 30% declines in medication infusions during the initial period with improvements observed in 66% of these practices. Increases in medical and diagnostic procedure volume was observed in 68% and 73% of vision and other large specialty practices, respectively. Less than 20% of practices with in-office dispensing capabilities saw significant declines of more than 30%. Of those, 50% of the other large specialty practices continued to be impacted compared with 3% of oncology practices.

Only 42 participating practices conducted clinical trials. Of these, a reduction of more than 30% of new patient enrollment occurred in 26% of practices, and 12% of practices saw a similar reduction in scheduled patient trial encounters. Oncology practices were the least impacted from new patient enrollment. Trial enrollment had still only improved for 35% through mid-August.

Delays in diagnosis and treatment can have substantial impact on patient outcomes. Based on the participating practices, approximately 62% of respondents feel there will be a moderate-to-significant impact on patient outcomes over the next 12 months. This was consistent across all specialty segments as demonstrated in the 

The adoption of telemedicine for care delivery was a significant advancement. Approximately 72% of practices implemented telehealth services within the first 30 days of the pandemic. However, more than 60% of vision practices did not use these services due to their inability to conduct the appropriate patient assessments through this technology. Other than in vision practices, telemedicine was primarily used for follow-up visits due to similar challenges. Seventy-eight percent of practices were using secure, Health Insurance Portability and Accountability Act-compliant telemedicine platforms.

At least 70% of responding practices (Table 3) were able to use federal stimulus relief; the most common was the Paycheck Protection Program. This included 67% of oncology practices. The initial Provider Relief Fund program, the next most frequently used program, was used by 51% of all practices and 54% of oncology practices. Approximately 59% of oncology practices are still not sure that the federal stimulus programs will be enough to cover unexpected operational expenses for another 6 to 9 months. Only 28% of all practices felt it would be sufficient to cover these expenses through the next wave of the pandemic.

More than 80% of each specialty practice segment has adopted necessary COVID-19 testing and return-to-work protocols. However, 30% felt that their practices were not prepared to address the Families First Coronavirus Response Act requirements.

Overall, the highest ranked activity practice desired to have in place in 2021 was the forgiveness of all Paycheck Protection Program payments. However, oncology and other large specialty practices felt that telehealth at reasonable reimbursement was the most important, followed closely by Part B drug sequestration relief for oncology practices.

Based on the results of this national survey, we have seen how resilient our community-based specialty practices are. Although all were challenged with the initial onslaught of the COVID-19 constraints, they collectively identified ways to modify their operational approaches. The government took steps to allow for broader use of telemedicine, which most specialty practices adopted within the first 30 days of the pandemic. However, not all specialties were able to leverage telemedicine to the same level of operations due to the complexity of new patient assessments and some types of follow-up visits, especially in patients with retinal disorders and cancer. It is estimated that one-third of older adults are still not ready to use telemedicine,

 which has continued implications for oncology and vision-based specialties.

New patient visits, both from a conduct and referral perspective, have had significant impact on specialty practices. Some reports have published declines of up to 47% in patient visits for oncology practices by the beginning of April, with 20% improvement by early May.

 Recently analyzed information of 104 oncology practices who utilize InfoDive showed that oncology practices had seen an average decline of 30% in new patients by end of April and have rebounded back to 6% below the rates in February. New patient visits declined by 44.6% and 68.0% in April for urology and vision practices, respectively, compared with February. And, those practices have come back to within 6.3% and 12.3% of their pre–COVID-19 new patient volumes.

This situation translated into an average decline in reimbursement of 17.1%, with the most significantly impacted practices being those that conduct surgical and medical procedures, including orthopedic, urology, and vision practices. Approximately 35% of oncology practices observed declines in reimbursement within the first period, while 37% were still dealing with declines in August compared with pre–COVID-19 reimbursement rates. These declines can be attributed to the delays in cancer screening and diagnostic procedures that result in new patient referrals. Weekly visits to oncologists are approximately 2% below prepandemic levels, compared with improvements of 4% for ophthalmology and urology.

The impact on specialty practices is widely varied based on the type of services provided. Those specialties that are primarily delivering medical care along with drug administrations were less impacted initially; however, they continue to be challenged with the delays in newly diagnosed patients. Those practices whose services are primarily associated with surgical or medical procedures were able to rebound quickly once state and local restrictions were removed. Although at least 70% of surveyed practices reported utilization of federal stimulus packages, only about 30% felt some form of these options should be available in 2021. Some considerations should be made for these variations in service delivery. Importantly, the majority of community-oncology based practices maintained the best possible access to patient care, implementing and using telehealth services more frequently than institutional health systems did. However, hospital systems were extremely involved in the actual care of acutely ill patients with COVID-19. Regardless, the majority of community practices were able to remain open and to provide some level of service, unlike those within the hospital and health system settings.

 Continued focus of key activities should be strongly considered to strengthen oncology practices throughout the pandemic, including but not limited to elimination of sequester to part B drugs; securing telehealth reimbursement at reasonable levels; continued government financial assistance with personal protective equipment costs; and reducing barriers to screening procedures for prevention of cancer by payers, such as elimination of co-pays or suspension of prior authorization processes that delay care.

Lucio N. Gordan, MD, is the president and managing physician of Florida Cancer Specialists and Research Institute. Contact: 

Susan Weidner, MS, is the senior vice president, analytics, for IntrinsiQ Specialty Solutions, Inc.

1. Hospitals and health systems face unprecedented financial pressures due to COVID-19. American Hospital Association. May 2020. Accessed November 1, 2020. https://www.aha.org/guidesreports/2020-05-05-hospitals-and-health-systems-face-unprecedented-financial-pressures-due

2. Mehrotra A, Chernew M, Linetsky D, Hatch H, Cutler D. The impact of the COVID-19 pandemic on outpatient visits: a rebound emerges. To the Point (blog). Commonwealth Fund. May 19, 2020. Accessed November 1, 2020. https://www.commonwealthfund.org/publications/2020/apr/impact-covid-19-outpatient-visits

3. White paper: the up and down impact of the pandemic on health care costs. Willis Towers Watson. September 29, 2020. Accessed November 1, 2020. https://www.willistowerswatson.com/en-US/Insights/2020/09/the-up-and-down-impact-of-the-pandemic-on-health-care-costs

4. Patt D, Gordan L, Diaz M, et al. The impact of COVID-19 on cancer care: how the pandemic is delaying cancer diagnosis and treatment for American seniors. JCO Clin Cancer Inform. Published online October 21, 2020. doi:10.1200/CCI.20.00134

5. Ong MBH. Real-world evidence: COVID-19 vs. community oncology: Flatiron’s data provides first damage assessment. The Cancer Letter. May 1, 2020. Accessed November 1, 2020. https://cancerletter.com/articles/20200501_1/

6. Admin_NH. Telemedicine for seniors: helping patients get the most out of their visits. swyMed™ Newsletter. October 23, 2020. Accessed November 1, 2020. http://swymed.com/telemedicine-for-seniors-getmost-visits/

7. InfoDive COVID impact analysis. IntrinsiQ Specialty Solutions. October 13, 2020. Accessed November 1, 2020.

8. Mehrotra A, Chernew M, Linetsky D, Hatch H, Cutler D. The impact of the COVID-19 pandemic on outpatient care: visits return to prepandemic levels, but not for all providers and patients. To the Point (blog). Commonwealth Fund. October 15, 2020. Accessed November 1, 2020. https://www.commonwealthfund.org/publications/2020/apr/impact-covid-19-outpatient-visits

Articles

The COVID-19 pandemic has impacted specialty practices generally and oncology practices especially have been resilient throughout the pandemic. 

Impact of the COVID-19 Pandemic on Specialty Community Practices: An Oncology Perspective

 The site of cancer care delivery has been shown to be associated with the total cost of care. The magnitude of this effect in patients receiving expensive immuno-oncology (I-O) therapies has not been evaluated. We evaluated cost differentials between community-based and hospital-based outpatient clinics among patients receiving I-O therapies.

 This was a retrospective analysis utilizing Truven MarketScan Commercial and Supplemental Medicare claims databases.

 Cost data for 3135 patients with non—small cell lung cancer, squamous cell carcinoma of the head and neck, bladder cancer, renal cell carcinoma, or melanoma who received pembrolizumab, nivolumab, and/or ipilimumab between January 1, 2015, and February 14, 2017, were analyzed as cost per patient per month (PPPM). Patients treated within a community setting were matched 2:1 with those treated at a hospital clinic based on cancer type, specific I-O therapy, receipt of radiation therapy, evidence of metastatic disease, gender, age, and evidence of surgery in the preindex period.

 Mean (SD) total (medical plus pharmacy) PPPM cost was significantly lower for patients treated in a community- versus hospital-based clinic ($22,685 [$16,205] vs $26,343 [$22,832]; 

<.001). Lower PPPM medical cost in the community versus hospital setting ($21,382 [$15,667] vs $24,831 [$22,102]; 

<.001) was the major driver of this cost differential. Lower total cost was seen regardless of cancer type or I-O therapy administered.

 Treatment with I-O therapies in community practice is associated with a lower total cost of care compared with that in hospital-based outpatient practices. With the expanding indications of these agents, future research is needed.

Cost data for 3135 patients treated with pembrolizumab, nivolumab, and/or ipilimumab were analyzed in a cohort matched 2:1 (patients treated in a community vs hospital clinic setting).

Patients were matched based on gender, age, cancer type, immunotherapeutic agent, receipt of radiation, and evidence of metastatic disease and surgery history.

Our analysis revealed that the mean (SD) total cost per patient per month was significantly lower for patients treated in a community- versus hospital-based clinic ($22,685 [$16,205] vs $26,343 [$22,832]; 

With the expanding indications of these agents and newer agents becoming available, future research is needed.

Oncology treatment advances continue to evolve at a rapid pace, with immuno-oncology (I-O) therapy at the forefront given its efficacy and tolerability across different tumor types. The last few years have seen fast-track approvals, promising clinical responses, and significant investment from both pharmaceutical companies and venture capital firms. Various forms of I-O therapy exist, including checkpoint inhibitors targeting the programmed cell death protein 1 receptor or its ligand (PD-1/PD-L1), cytotoxic T-lymphocyte—associated antigen 4, chimeric antigen receptor T-cell therapy, and vaccines. Much of the current research has focused on PD-L1 agents; recent forecasts indicate that combined sales of all current agents in this subclass of I-O therapy are estimated to reach $22 billion by 2025.

 Comparing PD-1/PD-L1 agents with conventional chemotherapy, significant improvements in overall survival have been shown in several types of malignancies.

 However, these advances are coupled with considerable treatment costs, which can reach more than $100,000 per patient per year.

 With the expanding number of indications of these agents, cost is a major concern in an already tenuous climate, with a cost trajectory for cancer care that is estimated to surpass $170 billion in just 2 years.

The site of cancer care delivery has been shown to be associated with differences in cost of care; a recent systematic literature review revealed that costs were substantially higher for patients treated in hospital-based versus community-based practices.

 Further, a matched cohort analysis of patients with non—small cell lung cancer (NSCLC), breast cancer, and colorectal cancer revealed that the cost of cancer care was significantly higher in the hospital clinic setting versus the community clinic setting.

 Although compelling, this previous analysis utilized a hospital data source with limited Medicare representation and evaluated patients receiving standard first-line chemotherapy agents, which did not include I-O agents. Given the increased costs associated with I-O therapy and the expansion of approved indications, we sought to examine cost differences associated with site of care delivery for patients receiving these agents; these data included a Medicare-enrolled population.

The Truven MarketScan Commercial and Supplemental Medicare claims databases were used to conduct this analysis (see 

Included patients were adults (≥18 years) who (1) had either NSCLC, squamous cell carcinoma of the head and neck (SCCHN), bladder cancer, renal cell carcinoma (RCC), or melanoma; and (2) received 1 of the I-O agents pembrolizumab, nivolumab, or ipilimumab between January 1, 2015, and February 14, 2017. Healthcare Common Procedure Coding System codes were used for identifying the I-O agents. Cancer diagnosis was identified using 

International Classification of Diseases, Ninth Revision, Clinical Modification,

), using medical claims. The date of first I-O therapy administration was the index date. Patients were required to have continuous enrollment for the 6 months prior to the index date and at least 45 days post index date. Patients were followed until unenrollment or loss to follow-up for a maximum of 6 months post index date.

Patients were grouped into the community clinic (CC) cohort or the hospital—outpatient clinic (HC) cohort based on place of service codes for administered I-O therapy. The practices associated with the HC cohort were owned by the hospital, and claims (which included oncologist visits and other oncologist-related services) were submitted through the hospital billing system. Patients must have received all I-O therapy in either the CC or the HC setting; patients treated at both settings were excluded.

The costs represent the total dollars received by each provider of care, including the insurer payment, patient out-of-pocket payment (co-payment, coinsurance, and deductible), and any coordination of benefits. Total healthcare costs were captured from the index I-O therapy administration date and included both medical and pharmacy costs. Pharmacy costs included all costs associated with dispensing of outpatient prescriptions under patients’ prescription drug plans; total medical costs included all costs (ie, inpatient, outpatient, emergency department, and physician visits; radiation therapy; and cost of I-O therapy) except those covered under pharmacy costs. The cost for I-O therapy was defined as the cost of the I-O agent plus any other costs incurred on the same day as the I-O therapy administration. Patients with more than one I-O therapy received on the index date were included but categorized separately. All costs were standardized to 2017 US dollars using the medical care component of the Consumer Price Index for all urban consumers and analyzed as cost per patient per month (PPPM) using the following method: Total days in the postindex period were calculated for each patient and were divided by 30.4 to obtain total months of follow-up; the total costs were summed for that entire period and then divided by the total number of months of follow-up. Healthcare costs were also calculated for patient subgroups based on type of cancer and the index I-O therapy received; however, due to very small sample sizes, healthcare costs were not reported separately for bladder cancer and RCC subgroups.

Patients in the CC cohort were matched 2:1 with replacement with those in the HC cohort based on cancer type (NSCLC vs SCCHN vs RCC vs bladder cancer vs melanoma); matched patients had only 1 of these diagnoses throughout the study period. Other characteristics used for matching included specific I-O therapy received, receipt of radiation therapy during follow-up, presence of metastatic disease (identified via diagnosis codes) (

), gender, age, and evidence of surgery (yes vs no) in the preindex period. Charlson Comorbidity Index (CCI) scores were computed to assess comorbidity burden between cohorts; mean CCI scores were similar in the 2 cohorts and not included in the match (

Categorical measures were presented as counts and percentages; continuous outcomes were presented as means and SDs. For testing the differences between the cohorts, the Wilcoxon signed rank sum test for continuous variables and McNemar’s test for categorical variables were conducted using SAS version 9.2 (SAS Institute; Cary, North Carolina).

A total of 6568 patients received 1 or more I-O therapy of interest during the study period; of these, 4183 patients met all the inclusion and exclusion criteria and 3135 patients were matched 2:1 (CC cohort, n = 2090; HC cohort, n = 1045) based on the characteristics previously described (

The demographic and clinical characteristics for matched patients are described in 

. The mean (SD) age in both of the cohorts was 65 (9) years; the majority (91%) in both cohorts had metastatic disease. The mean (SD) CCI score was similar between cohorts: 4.2 (2.2) in the CC cohort and 4.8 (2.4) in the HC cohort. Across cohorts, NSCLC (78%) made up the majority of cancer diagnoses, followed by SCCHN (12%) and melanoma (10%). There were no differences in baseline demographics when patients were separated by cancer type (

Utilization Patterns of Immunotherapy Agents

Among the 3135 matched patients, nivolumab was the most common I-O agent (CC cohort: 89.1%; HC cohort: 89.1%); 5.5% of patients from both cohorts received pembrolizumab and 4% received ipilimumab. Only 1% received a combination of nivolumab and ipilimumab. The mean (SD) duration of therapy in each cohort was similar (CC cohort: 88 [59] days; HC cohort: 89 [61] days). When categorized by cancer type, nivolumab was the most commonly used agent in those with NSCLC (99%) and SCCHN (100%), and pembrolizumab and ipilimumab were the most commonly utilized agents in melanoma (45% and 41%, respectively) (

Across all tumor types, the mean (SD) total cost (ie, medical plus pharmacy costs) PPPM during the postindex period was $23,904 ($18,753). The mean (SD) total cost PPPM was significantly lower in patients in the CC cohort compared with those in the HC cohort ($22,685 [$16,205] vs $26,343 [$22,832], respectively; 

<.001). This trend remained the same for the subgroups of patients with NSCLC and melanoma (NSCLC: $20,697 [$14,781] vs $23,153 [$19,044]; melanoma: $34,586 [$23,077] vs $49,017 [$37,244]; 

). Within the subgroup of patients with SCCHN, although the mean cost was lower in the CC cohort, the difference between the cohorts was not statistically significant.

Overall, the major driver of the cost differential between the CC and HC cohorts was lower mean (SD) PPPM medical costs in the CC cohort compared with the HC cohort ($21,382 [$15,667] vs $24,831 [$22,102], respectively; 

<.001), although the mean (SD) pharmacy PPPM costs were also slightly lower in the CC cohort versus the HC cohort ($1303 [$4142] vs $1512 [$4403]; 

The costs were also compared by the I-O therapy that was received on the index date. For patients who received ipilimumab, the mean (SD) total cost PPPM was significantly lower in the CC cohort compared with the HC cohort ($45,038 [$25,940] vs $58,360 [$41,873]; 

= .043). Similar trends were observed for patients who received the other I-O therapies: nivolumab ($21,328 [$14,687] vs $23,761 [$18,978]; 

<.001); nivolumab plus ipilimumab ($43,378 [$15,943] vs $66,152 [$36,691]; 

 = .013); and pembrolizumab ($22,899 [$14,778] vs $34,587 [$27,326]; 

Our study results suggest that the cost of cancer care for patients treated with I-O therapy in the CC setting is significantly lower than that for patients treated in the HC setting and that this is irrespective of I-O agent utilized. Further, costs were lower regardless of evaluated tumor type.

Our data are consistent with previous reports of site of care being significantly associated with cost of care delivery. For example, a commercial claims database analysis demonstrated a 20% to 39% higher mean cost per member per month for patients treated at a hospital-based practice, which was irrespective of cancer type, geographic location, patient age, and number of chemotherapy sessions.

 Further, a systematic literature review (n = 10 studies of Medicare or commercial claims) revealed that the average cost of cancer care was 38% higher for patients treated in hospital-based practices versus those treated at community-based practices.

 A previous matched cohort analysis by Gordan et al revealed that the cost of cancer care for patients with breast, lung, or colorectal cancer treated in the CC setting was approximately $8000 less PPPM than for patients treated in the hospital-based outpatient setting, and this cost differential was irrespective of chemotherapy regimen, branded versus generic agents used, or tumor type.

 Our analysis expands on this previous work by evaluating the newer and costlier I-O agents and including Medicare enrollees, while still matching patients on specific tumor types, treatments, and other possible confounders, such as presence of metastatic disease, surgery, radiation, and geographic region.

It has been proposed that healthcare systems are shaped by their reimbursement design.

 Until very recently in the United States, this has meant delivery of healthcare services defined by transactional payments (ie, a given service is identified by a Current Procedural Terminology code, which has an assigned value relative to a standard reference service, and a fee is paid for each service delivered).

 This volume-based fee-for-service (FFS) system stimulated a wide array of sites of service in which oncology patients receive their care.

 Services that are provided in an oncology physician’s office have been repeatedly shown to be less costly than those delivered in a hospital setting.

 However, the FFS system has not recognized many of the services that oncology practices provide, and historically, these services were covered through the margins on chemotherapy drugs.

 In 2003, the marginal revenues from these agents were substantially reduced with the implementation of reimbursement based on average sales price, and there began a consistent trend in community oncology practice closures.

 Notably, since 2008, community-based practice clinic closures have increased by 121%, and acquisition of community practices by hospitals has increased by 172%.

The FFS system can no longer be sustained in an era of rising costs, specifically in oncology care, and in this time of healthcare reform, value-based payment systems have been aimed toward models that incentivize provision of care delivered more efficiently, at a higher quality, and for less cost to the healthcare system. It is imperative that these new payment models support the provision of care in lower-cost sites of service, such as community oncology practices, and promote innovation in practice structure and care delivery.

In our analysis, cost was captured at the point of first I-O therapy administration, and the cost differential was noted despite the fact that the durations of therapy with the I-O agents were similar between the matched cohorts. This indicates that the difference in cost associated with I-O therapy treatment is not due to disproportionately shorter treatment in the CC cohort. In other words, for the same therapy, given for the same length of time and for the same indication, the reimbursement received was different (lower for the CC cohort) based on the site of care delivery. Further, although the cost differential is not as high as that reported in previous studies, it should be noted that further evaluation may be needed as these are relatively new agents with unique adverse effect profiles. As such, as comfort builds and indications expand with these I-O agents, further evaluation of contributors to increased cost with these already costly agents should be explored.

Limitations of this study include those inherent in any retrospective study. Despite the frequent use of 

 coding similar to our analyses to identify cancer and metastases in claims-based studies, the sensitivity and specificity associated with these methods

 may have led to misclassification of patients; however, we would anticipate that this would affect the CC and HC cohorts equally. Further, in spite of robust matching for anticipated confounding factors, other potential confounders, such as socioeconomic data, were not available for any patient. In addition, there are certain aspects within general oncology care that are specific to the use of these agents (ie, biomarker testing, genetic testing/counseling, pain management consult services) that cannot be evaluated using these types of data. Also, indirect costs, such as inability to work or cost of travel, could not be captured from this database.

This study indicates that treatment with immunotherapies for cancer in the community practice setting is associated with a lower total cost of care compared with similar treatment in the hospital-based outpatient practice setting. These data provide real-world insight to payers, the oncology workforce, policy makers, and other health-system stakeholders to examine contributors to total cost of cancer care in this turbulent time of innovative therapies that both improve outcomes and add to an increasing cost trajectory. Due to the time frame of these data and the expanding indications of these agents, future research is needed.

Florida Cancer Specialists & Research Institute (LG), Gainesville, FL; Xcenda (MB, VS, DK, ME), Palm Harbor, FL; IntrinsiQ (SW), Frisco, TX.

 This study was supported by the Community Oncology Alliance (COA).

 Dr Gordan is a board member of Florida Cancer Specialists, COA, and American Oncology Network. Dr Blazer, Mr Saundankar, Ms Kazzaz, and Dr Eaddy are employees of Xcenda, a consulting firm, which received funding for conducting this analysis and preparing the manuscript. Ms Weidner is employed by a drug wholesaler distributer, has attended meetings of COA, and owns stock via mutual funds.

 Concept and design (LG, MB, VS, DK, SW, ME); acquisition of data (LG); analysis and interpretation of data (LG, MB, VS, DK, SW, ME); drafting of the manuscript (LG, MB, VS, DK, SW, ME); critical revision of the manuscript for important intellectual content (LG, MB, VS, DK, SW, ME); statistical analysis (LG, VS); and supervision (LG).

 Lucio Gordan, MD, Division of Quality and Informatics, Florida Cancer Specialists & Research Institute, 6420 W Newberry Rd, Ste 100, Gainesville, FL 32605. Email: LGordan@flcancer.com.

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Administration of immuno-oncology therapy for cancer diagnoses in the community clinic setting is associated with lower costs compared with administration in a hospital-based clinic setting.

Susan Weidner, MS

Articles

Impact of the COVID-19 Pandemic on Specialty Community Practices: An Oncology Perspective

Cost Differential of Immuno-Oncology Therapy Delivered at Community Versus Hospital Clinics