Reduction in Physician Reimbursement and Use of Hormone Therapy in Prostate Cancer
15 Dec 2010-Journal of the National Cancer Institute (Oxford University Press)-Vol. 102, Iss: 24, pp 1826-1834
TL;DR: The 2003 Medicare Modernization Act reduced reimbursements for AST by 64% between 2004 and 2005, but the effect of this large reduction on use of AST in prostate cancer is unknown.
Abstract: Background
Use of androgen suppression therapy (AST) in prostate cancer increased more than threefold from 1991 to 1999. The 2003 Medicare Modernization Act reduced reimbursements for AST by 64% between 2004 and 2005, but the effect of this large reduction on use of AST is unknown.
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TL;DR: Increasing the use of high‐value hysterectomy approaches can be achieved by adopting multimodal strategies, with changes in the payment models being the most important.
14 citations
TL;DR: Although the reason for the lower prevalence of prostate cancer among diabetic men remains unknown, the lower serum testosterone and PSA levels in them can account for the increased risk of advanced disease at diagnosis.
Abstract: Prostate cancer and the androgen deprivation therapy (ADT) thereof are involved in diabetes in terms of diabetes-associated carcinogenesis and ADT-related metabolic disorder, respectively. The aim of this study is to systematically review relevant literature. About 218,000 men are estimated to be newly diagnosed with prostate cancer every year in the United States. Approximately 10% of them are still found with metastasis, and in addition to them, about 30% of patients with nonmetastatic prostate cancer recently experience ADT. Population-based studies have shown that dissimilar to other malignancies, type 2 diabetes is associated with a lower incidence of prostate cancer, whereas recent large cohort studies have reported the association of diabetes with advanced high-grade prostate cancer. Although the reason for the lower prevalence of prostate cancer among diabetic men remains unknown, the lower serum testosterone and PSA levels in them can account for the increased risk of advanced disease at diagnosis. Meanwhile, insulin resistance already appears in 25–60% of the patients 3 months after the introduction of ADT, and long-term ADT leads to a higher incidence of diabetes (reported hazard ratio of 1.28–1.44). Although the possible relevance of cytokines such as Il-6 and TNF-α to ADT-related diabetes has been suggested, its mechanism is poorly understood.
13 citations
Cites background from "Reduction in Physician Reimbursemen..."
...Although the prostate-specific antigen (PSA) test has led to a stage migration with increased low- to intermediate-risk localized disease, about 10% of the patients are still found with metastatic disease at diagnosis [4]....
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TL;DR: GnRH agonist overuse remains high among some urologists who may be professionally isolated and difficult to reach and these findings provide guidance to develop interventions to address overuse in prostate cancer.
Abstract: Medicare reimbursement cuts have been associated with declining gonadotropin-releasing hormone (GnRH) agonist overuse in localized prostate cancer. Medical school affiliation and foreign training have been associated with persistent overuse. However, physician-level prescribing changes and the practice type of persistent overusers have not been examined. We sought to describe physician-level changes in GnRH agonist overuse and test the association of time in practice and solo practice type with GnRH agonist overuse. We matched American Medical Association physician data for 2138 urologists to Surveillance, Epidemiology and End Result-Medicare data for 12 943 men diagnosed with early-stage and lower-grade adenocarcinoma of the prostate between 2000 and 2007. We conducted a population-based, retrospective study using multilevel modeling to control for patient and provider characteristics. Three distinct patterns of GnRH agonist overuse were observed. Urologists’ time in practice was not associated with GnRH agonist overuse (odds ratio (OR) 0.89; 95% confidence interval (CI): 0.75–1.05). However, solo practice type (OR 1.65; 95% CI: 1.34–2.02), medical school affiliation (OR 0.65; 95% CI: 0.55–0.77) and patient race were. Compared with non-Hispanic whites, non-Hispanic blacks (OR 1.76; 95% CI: 1.37–2.27), Hispanics (OR 1.41; 95% CI: 1.12–1.79) and men of ‘other’ race (OR 1.44; 95% CI: 1.04–1.99) had greater odds of receiving unnecessary GnRH agonists. GnRH agonist overuse remains high among some urologists who may be professionally isolated and difficult to reach. These urologists treat more vulnerable populations, which may contribute to health disparities in prostate cancer treatment quality. Nonetheless, these findings provide guidance to develop interventions to address overuse in prostate cancer.
11 citations
Cites background or methods or result from "Reduction in Physician Reimbursemen..."
...Consistent with other studies, we found that GnRH agonist overuse declined precipitously over the 2000s, coincident with reimbursement policy changes (8, 13)....
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...Whereas oncologists’ response to MMA cuts was to increase the use of recommended chemotherapies (11, 12), urologists maintained GnRH agonist use in patients for whom it was recommended but decreased overuse in patients for whom it was non-recommended (8)....
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...Rates of overuse found in this study were between other published estimates and reflected a blending of two previously published sampling strategies and outcome definitions (8, 13)....
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...Because of changes in staging over the study period, the cohort excluded men diagnosed with 1) T1 or T2 cancers with Gleason scores 8–10; 2) T2b tumors before 2002 when the staging definition changed; 3) T2c tumors after 2002 when the category was added; or, 4) T3a tumors(8)....
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...Despite scant data supporting clinical effectiveness, GnRH agonist use in localized disease grew steadily from the 1990s, peaking in 2003 (8)....
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TL;DR: Relative Medicare reimbursement rates for surgical vs. non-surgical treatments and the availability of both primary care physicians and relevant specialists are associated with the likelihood of surgery and cost per episode.
Abstract: To identify associations between market factors, especially relative reimbursement rates, and the probability of surgery and cost per episode for three medical conditions (cataract, benign prostatic neoplasm, and knee degeneration) with multiple treatment options. We use 2004– 2006 Medicare claims data for elderly beneficiaries from sixty nationally representative communities to estimate multivariate models for the probability of surgery and cost per episode of care as a function local market factors, including Medicare physician reimbursement for surgical versus non-surgical treatment and the availability of primary care and specialty physicians. We used Symmetry’s Episode Treatment Groups (ETG) software to group claims into episodes for the three conditions (n = 540,874 episodes). Higher Medicare reimbursement for surgical episodes and greater availability of the relevant specialists are significantly associated with more surgery and higher cost per episode for all three conditions, while greater availability of primary care physicians is significantly associated with less frequent surgery and lower cost per episode. Relative Medicare reimbursement rates for surgical vs. non-surgical treatments and the availability of both primary care physicians and relevant specialists are associated with the likelihood of surgery and cost per episode.
10 citations
Cites background from "Reduction in Physician Reimbursemen..."
...Although evidence is limited on how such reimbursement policies would affect treatment decisions, two studies of physicians’ responses to reductions in Medicare payment rates for treatment of prostate cancer patients found that physicians maintained treatment for clinically appropriate cases and reduced it for less appropriate cases [35,36]....
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TL;DR: This narrative discusses financial pressures that have existed for cervical and prostate brachytherapy and how they may have influenced their declining usage, and considers other proposed influences to understand the scope of the issue.
10 citations
References
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TL;DR: The method of classifying comorbidity provides a simple, readily applicable and valid method of estimating risk of death fromComorbid disease for use in longitudinal studies and further work in larger populations is still required to refine the approach.
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"Reduction in Physician Reimbursemen..." refers methods in this paper
...Comorbidity was classified using a modification of the Charlson comorbidity index for use with Medicare data (19,20)....
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Journal Article•
TL;DR: In this article, the authors focus on the way in which the operation of the medical-care industry and the efficacy with which it satisfies the needs of society differ from a norm, and the most obvious distinguishing characteristics of an individual's demand for medical services is that it is not steady in origin as, for example, for food or clothing but is irregular and unpredictable.
Abstract: Publisher Summary This chapter focuses on the way in which the operation of the medical-care industry and the efficacy with which it satisfies the needs of society differ from a norm. The term norm that the economist usually uses for the purposes of such comparisons is the operation of a competitive model, that is, the flows of services that would be offered and purchased and the prices that would be paid for them. The interest in the competitive model stems partly from its presumed descriptive power and partly from its implications for economic efficiency. If a competitive equilibrium exists at all and if all commodities relevant to costs or utilities are in fact priced in the market, then the equilibrium is necessarily optimal. There is no other allocation of resources to services that will make all participants in the market better off. The most obvious distinguishing characteristics of an individual's demand for medical services is that it is not steady in origin as, for example, for food or clothing but is irregular and unpredictable. Medical services, apart from preventive services, afford satisfaction only in the event of illness, a departure from the normal state of affairs.
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TL;DR: Immediate androgen suppression with an LHRH analogue given during and for 3 years after external irradiation improves disease-free and overall survival of patients with locally advanced prostate cancer.
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"Reduction in Physician Reimbursemen..." refers background in this paper
...AST, delivered as a depot injection of luteinizing hormone– releasing hormone, is indicated for management of prostate cancer in two clinical situations, as palliative therapy in metastatic prostate cancer (6) or in combination with external beam radiotherapy in the treatment of locally advanced prostate cancer (7), for which it has been shown to improve survival....
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TL;DR: A comorbidity index that incorporates the diagnostic and procedure data contained in Medicare physician (Part B) claims and demonstrates the utility of a disease-specific index using an alternative method of construction employing study-specific weights.
1,602 citations
"Reduction in Physician Reimbursemen..." refers methods in this paper
...Comorbidity was classified using a modification of the Charlson comorbidity index for use with Medicare data (19,20)....
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01 Jan 2000
TL;DR: This article developed a comorbidity index that incorporates the diagnostic and procedure data contained in Medicare physician (Part B) claims, which significantly contributes to models of 2-year noncancer mortality and treatment received in both patient cohorts.
Abstract: Important comorbidities recorded on outpatient claims in administrative datasets may be missed in analyses when only inpatient care is considered. Using the comorbid conditions identified by Charlson and colleagues, we developed a comorbidity index that incorporates the diagnostic and procedure data contained in Medicare physician (Part B) claims. In the national cohorts of elderly prostate ( n 5 28,868) and breast cancer ( n 5 14,943) patients assessed in this study, less than 10% of patients had comorbid conditions identified when only Medicare hospital (Part A) claims were examined. By incorporating physician claims, the proportion of patients with comorbid conditions increased to 25%. The new physician claims comorbidity index significantly contributes to models of 2-year noncancer mortality and treatment received in both patient cohorts. We demonstrate the utility of a disease-specific index using an alternative method of construction employing study-specific weights. The physician claims index can be used in conjunction with a comorbidity index derived from
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