Out of system (OOS) costs for oncology clinics treating patients with breast, colorectal, and non-small cell lung cancer in Washington state.

5 Background: As payers move from fee-for-service to episode-based reimbursement, there is a need for oncology providers to accurately measure in- and out-of-system resource use and cost for patients under their care. Medicare assigns management of a patient to only one provider, yet delivery systems may assume contractual responsibility for a patient with cancer’s entire episode costs, including care received outside of their system. Accordingly, the goal of this study was to estimate OOS care for patients with breast, colorectal (CRC), and non-small cell lung cancer (NSCLC). Methods: Cancer registry records for patients with breast, CRC, or NSCLC diagnosed in Western Washington State from January 2007 to June 2016 were linked with claims from two regional commercial insurers. The analysis focused on initial treatment phase: first day of treatment (surgery, radiation, chemotherapy) through the first 4-month gap in treatment. Patients were assigned an oncology provider group by identifying the clinic Tax ID Number (TIN) with the most Evaluation & Management (E&M) claims with a cancer diagnosis. Claims were considered in system if the TIN matched the assigned clinic. Costs included claims paid to all providers (adjusted to 2016 dollars). Results: The study included 7,686 newly diagnosed patients with breast, CRC, or NSCLC. The average cost for the initial treatment phase was $61,147/patient (SD $75,432, median $35,750). Nearly 31% of claims paid (mean $18,684, SD $32,649) were out of system. Among OOS costs, 24% were for inpatient care, 68% were for outpatient care, and 8% were for outpatient pharmacy. Conclusions: Among newly diagnosed patients with breast, CRC, or NSCLC, approximately 1/3 of costs for the initial treatment period stemmed from OOS care. Developing best practices for the reporting and management of OOS will be critical for organizations to succeed under episode-based reimbursement plans.[Table: see text]

Duke Scholars

Author Gary Herbert Lyman Medicine, Medical Oncology