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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Posted Content•
TL;DR: In this paper, relative Medicare reimbursement rates for surgical vs. non-surgical treatments and the availability of both primary care physicians and relevant specialists were associated with the likelihood of surgery and cost per episode.
Abstract: 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
TL;DR: The findings suggest promising improvement in resource utilization and cost control after transition to prospective payment models, but, further primary research is needed to apply robust measures of performance and quality to better ensure that providers are delivering high-value care to their patients, while reducing the cost of care.
Abstract: Objectives
To investigate the impact of provider payment reforms and associated care delivery models on cost and quality in cancer care.
Methods
Data sources/study setting: Review of English-language literature published in PubMed, Embase and Cochrane library (2007–2019).
Study design: We performed a systematic literature review (SLR) to identify the impact of cancer care reforms. Primary endpoints were resource use, cost, quality of care, and clinical outcomes.
Data collection/extraction methods: For each study, we extracted and categorized comparative data on the impact of policy reforms. Given the heterogeneity in patients, interventions and outcome measures, we did a qualitative synthesis rather than a meta-analysis.
Results
Of the 26 included studies, seven evaluations were in fact qualified as quasi experimental designs in retrospect. Alternative payment models were significantly associated with reduction in resource use and cost in cancer care. Across the seventeen studies reporting data on the implicit payment reforms through care coordination, the adoption of clinical pathways was found effective in reduction of unnecessary use of low value services and associated costs. The estimates of all measures in ACO models varied considerably across participating providers, and our review found a rather mixed impact on cancer care outcomes.
Conclusion
The findings suggest promising improvement in resource utilization and cost control after transition to prospective payment models, but, further primary research is needed to apply robust measures of performance and quality to better ensure that providers are delivering high-value care to their patients, while reducing the cost of care.
9 citations
TL;DR: Few oncologic entities are more deserving of national scrutiny than low-risk prostate cancer and Intensity modulated radiation therapy (IMRT) and proton therapy, and payors are taking notice.
Abstract: Few oncologic entities are more deserving of national scrutiny than low-risk prostate cancer. Prostate cancer is among the top 5 most costly cancers, with $11.9 billion spent annually in the United States (1). Recent publications have drawn attention to financially driven practices and questionable referral patterns (2, 3). The Congressional Budget Office estimates that half the increase in health care expenditures over the past decades has been driven by expanded capabilities associated with new technologies (4). Intensity modulated radiation therapy (IMRT) and proton therapy come to mind. IMRT now accounts for more than 80% of radiation therapy treatments (5). Brachytherapy, by contrast, has been steadily declining in the United States (6). Payors are taking notice. Blue Shield of California and Aetna have stopped covering proton therapy for prostate cancer. Government and privately administered health insurers cut costs by reimbursing IMRT at a fraction of the billable rate. Treating institutions respond by inflating rates to compensate for aggressive cuts.
9 citations
Cites background from "Reduction in Physician Reimbursemen..."
...Recent publications have drawn attention to financially driven practices and questionable referral patterns (2, 3)....
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TL;DR: Patients treated by non-medical school-affiliated or non-US-trained urologists or both are significantly more likely to receive non-evidence-based ADT before and after the passage of the Medicare Modernization Act.
Abstract: Objectives Physician characteristics and changes in drug reimbursement rates have been shown to influence practice patterns regardless of clinical guidelines, patient, clinical, or sociodemographic factors. We concurrently examined the association between urologists׳ characteristics and non–evidence-based use of primary medical androgen deprivation therapy (ADT) for clinically localized patients with prostate cancer, before and after the 2003 Medicare Modernization Act׳s reductions in ADT reimbursement rates. Methods and materials The Surveillance, Epidemiology, and End Results-Medicare–linked database and the American Medical Association Physician Masterfile are used in a retrospective analysis of 12,255 patients diagnosed between 2001 and 2007 with clinical stage T1-T2, low- to intermediate-grade prostate cancer, and the 1,863 urologists who treated them. Logistic multilevel regression analyses are used to evaluate the association of urologists׳ characteristics on ADT use among patients within 6 months of diagnosis. Results Overall, 3,866 (32%) patients received non–evidence-based ADT. After adjusting for patient and urologist characteristics, patients treated by urologists with no medical school affiliations, compared with those treated by urologists with major medical school affiliations, are significantly more likely to receive non–evidence-based medical ADT (odds ratio = 2.35; 95% CI: 1.71–3.23; P P Conclusions Patients treated by non–medical school–affiliated or non–US-trained urologists or both are significantly more likely to receive non–evidence-based ADT before and after the passage of the Medicare Modernization Act. Better strategies to encourage evidence-based ADT use on clinically localized patients with prostate cancer may be of benefit especially among non–medical school–affiliated or non–US-trained urologists or both.
8 citations
Cites background or result from "Reduction in Physician Reimbursemen..."
...Other significant associations found between ADT and other patients' and urologists' characteristics complement previous findings [7,8,13]....
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...Patients who received radiation therapy or radical prostatectomy (or both) [7] 12 months post-diagnosis were excluded [8]....
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...Growth in ADT use may also be the result of Medicare reimbursement policy that made prescribing LHRH agonists profitable for urologists [1,7,8]....
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...Reimbursement changes consequently affected practice patterns and incomes of urologists depending on practice setting [1,7,8,10]....
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...Although, grade migration trends in recent years could have led to lower ADT use [1,8], as pointed out in a previous study, such migration is expected to have a gradual effect on ADT utilization rates [8] and therefore is unlikely to fully account for the 25% overall reduction in non– evidence-based ADT use observed throughout the study period....
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TL;DR: Using neoadjuvant AST as the model for the nonindicated use of AST, physicians reduced AST use in response to high-level evidence showing a lack of benefit, despite the high reimbursement, suggests that physicians adapt to emerging evidence and use evidence-based practice.
8 citations
Cites methods or result from "Reduction in Physician Reimbursemen..."
...In contrast, we have previously shown that discretionary AST use (which was sensitive to financial incentives) decreased by 40% from 2003 to 2005 after reimbursement changes.(2) It was not possible to completely discount the possibility that the reimbursement changes for AST use contributed to the decreased use of neoadjuvant AST from 2003 to 2005....
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...The tumor grade was reported in SEER according to the World Health Organization grade, as we have previously described.(2)...
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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.
39,961 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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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.
3,500 citations
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.
1,692 citations
"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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