Dispersion in total cost of care for Medicare fee-for-service (FFS) patients with metastatic pancreatic cancer receiving FDA-approved/NCCN Category 1 regimens at teaching versus non-teaching institutions.
Authors: Helen Latimer, Samantha Tomicki, Gabriela Dieguez, Paul Cockrum, George P. Kim
Journal: Journal of Clinical Oncology (2021)

e16244 Background: Teaching institutions receive additional funding from Medicare &amp; Medicaid Services (CMS) to provide specialized, quality care. Objectives: To analyze the dispersion in total cost of care (TCOC) for Medicare FFS patients (pts) with metastatic pancreatic cancer (m-PANC) treated at teaching (teach) or non-teaching (non-teach) institutions. Methods: We identified pts with m-PANC using ICD-9/10 diagnosis codes in the 2016-18 Medicare Parts A/B/D 100% Research Identifiable Files. Study pts had 2+ claims with a pancreatic cancer diagnosis and Medicare FFS coverage for 6 months pre- and 3 months post-metastasis diagnosis. Study pts were treated with NCCN Category 1 regimens: 1L gemcitabine monotherapy (gem-mono), 1L gemcitabine/nab-paclitaxel (gem-nab), 1L FOLFIRINOX (FFX), and 2L liposomal irinotecan-based regimen (nal-IRI). Pts were attributed to teach or non-teach institutions based on plurality of chemotherapy claims. TCOC reflects insurer-paid services per line of therapy (LOT) for 3 categories: chemotherapy/supportive drugs (chemo/Rx), inpatient care (IP), and other outpatient care (OP). We grouped pts by quartile (qrt), evaluated drivers of TCOC, and mean rates of admissions (admits/pt). Results: We identified 3,908 (teach) and 2,632 (non-teach) pts taking NCCN Category 1 regimens. There was a similar mix of patients in both cohorts, with gem-mono pts making up only 3% of the sample. Gem-nab accounted for 73% and 70% of pts in teach and non-teach institutions, respectively. For gem-nab, FFX, and nal-IRI pts, median TCOC was similar in both cohorts. However, median TCOC for the two non-generic drugs in our study, gem-nab (teach: $36,332; non-teach: $40,135) and nal-IRI (teach: $31,526; non-teach: $39,360), were lower at teach institutions than non-teach institutions. The components of TCOC are similar between teach and non-teach institutions in all qrts. In both cohorts, % IP costs for all regimens increased between the first and fourth qrt (teach:14% to 23%, non-teach:14% to 26%). In the teach cohort, nal-IRI pts had the lowest admits/pt in all qrts. In the non-teach cohort, there was no discernable pattern, although nal-IRI pts had the lowest admits/pt in the second and fourth qrt. Conclusions: For non-generic regimens like nal-IRI and gem-nab, median TCOC was lower at teach institutions than non-teach institutions. There were no consistent differences in TCOC dispersion or admissions between cohorts. Across qrts, chemotherapy accounted for approximately half the TCOC. However, IP costs were proportionally higher in the fourth qrt, especially for non-teach institutions. Despite nal-IRI pts being on the second LOT, both median TCOC and admits/pt across qrts were lower than gem-nab and FFX in teach institutions. In the non-teach cohort, median TCOC were similar among nal-IRI, gem-nab, and FFX.