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In recent years many policy makers have recommended alternative payment models in medical oncology in order to reduce costs and improve patient outcomes. Yet information on how oncology practices differ in their use of key service categories is limited. We measured annual payments for key service categories delivered to fee-forservice Medicare beneficiaries receiving care from 1,534 medical oncology practices in 2011-12. In 2012, differences in payments per beneficiary at the seventy-fifth-percentile practice compared to the twenty-fifthpercentile practice were $3,866 for chemotherapy (including administration and supportive care drugs), $1,872 for acute medical hospitalizations, and $439 for advanced imaging. Supportive care drugs, bevacizumab, and positron-emission tomography accounted for the greatest percentage of variation. Average practice payments for service categories were highly correlated across years but not correlated with each other, which suggests that service categories may be affected by different physician practice characteristics. These differences, even when clinical guidelines exist, demonstrate the potential for quality improvement that could be accelerated through alternative payment models. [ABSTRACT FROM AUTHOR]

In this article, the author examines the Medicare Access and CHIP Reauthorization Act (MACRA) in the U.S. Particular focus is given to how MACRA will overhaul Medicare's physician payment system starting in 2019. Additional topics discussed include payment adjustments in the Merit-Based Incentive Payment System (MIPS), Advanced Alternative Payment Models and how physicians should prepare for these changes.

Introduction: The 2013 American College of Cardiology/American Heart Association Cholesterol Treatment Guideline increased the number of primary prevention patients eligible for statin therapy, yet uptake of these guidelines has been modest. Hypothesis: We hypothesized that primary care providers' (PCPs) reported beliefs and approaches to discussing statins for primary prevention vary and are associated with statin prescription. Methods: We surveyed 164 PCPs from a community-based practice network in North Carolina in 2017. Reported beliefs and approaches were examined, along with statin prescription rates during 2014-2015 in primary prevention patients with no prior statin prescription. Results: Seventy-two PCPs (43.9%) completed the survey. The median estimate of the relative risk reduction for high-intensity statins was 45% (IQR 25%-50%). A minority of providers (27.8%) believed statins caused diabetes, and only 16.7% reported always/very often discussing it with their patients. Most (97.2%) PCPs believed that statins cause myopathy and 72.3% reported always/very often discussing this with patients. Most (77.7%) reported always/very often using the 10-year ASCVD risk calculator to guide decisions, 59.8% reported that in the majority of cases prescriptions were influenced by other clinical risk factors and 43.1% that patient preferences altered prescribing. Of 6,172 eligible patients of survey respondents, 22.3% received a prescription for a moderate- or high-intensity statin. After adjustment for patient/provider characteristics, only lower reliance on risk factors beyond estimated ASCVD risk was associated with a modest increased likelihood of statin prescription (odds ratio 1.12, 95% confidence interval 1.03-1.23). Conclusions: Although beliefs and approaches to statin discussions vary among community PCPs, prescription rates are low and minimally associated with those beliefs. These results highlight the complexity of increasing statin prescriptions for primary prevention and suggest that efforts are needed beyond influencing PCPs' beliefs and motivation, particularly given the frequency with which reported patient preferences conflict with PCP recommendations. [ABSTRACT FROM AUTHOR]

Objectives: Since 2019, the Medicare Shared Savings Program (MSSP) has allowed accountable care organizations (ACOs) to choose either retrospectively or prospectively attributed ACO populations. To understand how ACOs' choice of attribution method affects incentives for care among seriously ill Medicare beneficiaries, this study compares beneficiary characteristics and Medicare per capita expenditures between prospective and retrospective ACO populations., Study Design: This retrospective, cross-sectional analysis describes survival, patient characteristics, and Medicare spending for Medicare fee-for-service beneficiaries identified with serious illness (n = 1,600,629) using 100% Medicare Master Beneficiary Summary and MSSP beneficiary files (2014-2016)., Methods: We used generalized linear models with ACO and year fixed effects to estimate the average within-ACO difference between potential retrospective and prospective ACO populations., Results: Dying in the first 90 days of the performance year was associated with reduced odds of retrospective ACO attribution (odds ratio [OR], 0.24; 95% CI, 0.24-0.25) relative to beneficiaries surviving 270 days or longer. Similarly, hospice use was associated with reduced odds of retrospective assignment (OR, 0.80; 95% CI, 0.79-0.80). Among ACOs that did not achieve shared savings, average per capita Medicare expenditures (after truncation) were $2459 (95% CI, $2192-$2725) higher for prospective vs retrospective ACO populations. The difference was $834 (95% CI, $402-$1266) greater per capita among ACOs that achieved shared savings., Conclusions: The difference in survival and spending for ACO populations captured by prospective vs retrospective attribution methods means that ACOs may need to employ different care management strategies to improve performance depending on their attribution method.

Objectives: Hospitals have rapidly acquired medical oncology practices in recent years. Experts disagree as to whether these trends are related to oncology-specific market factors or reflect a general trend of hospital-physician integration. The objective of this study was to compare the prevalence, geographic variation, and trends in physicians billing from hospital outpatient departments in medical oncology with other specialties., Study Design: Retrospective analysis of Medicare claims data for 2012 and 2013., Methods: We calculated the proportion of physicians and practitioners in the 15 highest-volume specialties who billed the majority of evaluation and management visits from hospital outpatient departments in each year, nationally and by state., Results: We included 338,998 and 352,321 providers in 2012 and 2013, respectively, of whom 9715 and 9969 were medical oncologists. Among the 15 specialties examined, medical oncology had the highest proportion of hospital outpatient department billing in 2012 and 2013 (35.0% and 38.3%, respectively). Medical oncology also experienced the greatest absolute change (3.3%) between the years, followed by thoracic surgery (2.4%) and cardiology (2.0%). There was marked state-level variation, with the proportion of medical oncologists based in hospital outpatient departments ranging from 0% in Nevada to 100% in Idaho., Conclusions: Hospital-physician integration has been more pronounced in medical oncology than in other high-volume specialties and is increasing at a faster rate. Policy makers should take these findings into consideration, particularly with respect to recent proposals that may continue to fuel these trends.