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The American Journal of Managed Care March 2019
Fragmented Ambulatory Care and Subsequent Emergency Department Visits and Hospital Admissions Among Medicaid Beneficiaries
Lisa M. Kern, MD, MPH; Joanna K. Seirup, MPH; Mangala Rajan, MBA; Rachel Jawahar, PhD, MPH; and Susan S. Stuard, MBA
Incorrect and Missing Author Initials in Affiliations and Authorship Information
From the Editorial Board: Austin Frakt, PhD
Austin Frakt, PhD
Implications of Eligibility Category Churn for Pediatric Payment in Medicaid
Deena J. Chisolm, PhD; Sean P. Gleeson, MD, MBA; Kelly J. Kelleher, MD, MPH; Marisa E. Domino, PhD; Emily Alexy, MPH; Wendy Yi Xu, PhD; and Paula H. Song, PhD
Factors Influencing Primary Care Providers’ Decisions to Accept New Medicaid Patients Under Michigan’s Medicaid Expansion
Renuka Tipirneni, MD, MSc; Edith C. Kieffer, PhD, MPH; John Z. Ayanian, MD, MPP; Eric G. Campbell, PhD; Cengiz Salman, MA; Sarah J. Clark, MPH; Tammy Chang, MD, MPH, MS; Adrianne N. Haggins, MD, MSc; Erica Solway, PhD, MPH, MSW; Matthias A. Kirch, MS; and Susan D. Goold, MD, MHSA, MA
Did Medicaid Expansion Matter in States With Generous Medicaid?
Alina Denham, MS; and Peter J. Veazie, PhD
Access to Primary and Dental Care Among Adults Newly Enrolled in Medicaid
Krisda H. Chaiyachati, MD, MPH, MSHP; Jeffrey K. Hom, MD, MSHP; Charlene Wong, MD, MSHP; Kamyar Nasseh, PhD; Xinwei Chen, MS; Ashley Beggin, BS; Elisa Zygmunt, MSW; Marko Vujicic, PhD; and David Grande, MD, MPA
Medicare Annual Wellness Visit Association With Healthcare Quality and Costs
Adam L. Beckman, BS; Adan Z. Becerra, PhD; Anna Marcus, BS; C. Annette DuBard, MD, MPH; Kimberly Lynch, MPH; Emily Maxson, MD; Farzad Mostashari, MD, ScM; and Jennifer King, PhD
Common Elements in Opioid Use Disorder Guidelines for Buprenorphine Prescribing
Timothy J. Atkinson, PharmD, BCPS, CPE; Andrew J.B. Pisansky, MD, MS; Katie L. Miller, PharmD, BCPS; and R. Jason Yong, MD, MBA
Specialty Care Access for Medicaid Enrollees in Expansion States
Justin W. Timbie, PhD; Ashley M. Kranz, PhD; Ammarah Mahmud, MPH; and Cheryl L. Damberg, PhD
Gender Differences in Prescribing of Zolpidem in the Veterans Health Administration
Guneet K. Jasuja, PhD; Joel I. Reisman, AB; Renda Soylemez Wiener, MD, MPH; Melissa L. Christopher, PharmD; and Adam J. Rose, MD, MSc
Currently Reading
Cost Differential of Immuno-Oncology Therapy Delivered at Community Versus Hospital Clinics
Lucio Gordan, MD; Marlo Blazer, PharmD, BCOP; Vishal Saundankar, MS; Denise Kazzaz; Susan Weidner, MS; and Michael Eaddy, PharmD, PhD

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

Lucio Gordan, MD; Marlo Blazer, PharmD, BCOP; Vishal Saundankar, MS; Denise Kazzaz; Susan Weidner, MS; and Michael Eaddy, PharmD, PhD
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.

Objectives: 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.

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

Methods: 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.

Results: 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]; P <.001). Lower PPPM medical cost in the community versus hospital setting ($21,382 [$15,667] vs $24,831 [$22,102]; P <.001) was the major driver of this cost differential. Lower total cost was seen regardless of cancer type or I-O therapy administered.

Conclusions: 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.

Am J Manag Care. 2019;25(3):e66-e70
Takeaway Points
  • 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]; P <.001).
  • 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 2025.1 Comparing PD-1/PD-L1 agents with conventional chemotherapy, significant improvements in overall survival have been shown in several types of malignancies.2 However, these advances are coupled with considerable treatment costs, which can reach more than $100,000 per patient per year.3 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.4

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.5 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.6 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.


Data Source

The Truven MarketScan Commercial and Supplemental Medicare claims databases were used to conduct this analysis (see eAppendix [available at]).

Sample Selection

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, and Tenth Revision, Clinical Modification (ICD-9-CM/ICD-10-CM), 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.

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