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: Barriers to urologists’ recommendation of active surveillance in low-risk prostate cancer are described and variation of barriers by setting is explored to identify potential opportunities for intervention.
Abstract: Clinical practice guidelines recommend active surveillance as the preferred treatment option for low-risk prostate cancer, but only a minority of eligible men receive active surveillance, and practice variation is substantial. The aim of this study is to describe barriers to urologists’ recommendation of active surveillance in low-risk prostate cancer and explore variation of barriers by setting. We conducted semi-structured interviews among 22 practicing urologists, evenly distributed between academic and community practice. We coded barriers to active surveillance according to a conceptual model of determinants of treatment quality to identify potential opportunities for intervention. Community and academic urologists were generally in agreement on factors influencing active surveillance. Urologists perceived patient-level factors to have the greatest influence on recommendations, particularly tumor pathology, patient age, and judgements about the patient’s ability to adhere to follow-up protocols. They also noted cross-cutting clinical barriers, including concerns about the adequacy of biopsy samples, inconsistent protocols to guide active surveillance, and side effects of biopsy procedures. Urologists had differing opinions on the impact of environmental factors, such as financial disincentives and fear of litigation. Despite national and international recommendations, both academic and community urologists note a variety of barriers to implementing active surveillance in low risk prostate cancer. These barriers will need to be specifically addressed in efforts to help urologists offer active surveillance more consistently.
4 citations
15 Jul 2015
TL;DR: The results of a simulation analysis of a payment model for specialty oncology services that is being developed for possible testing by the Center for Medicare and Medicaid Innovation at the Centers for Medicare & Medicaid Services are described.
Abstract: This article describes the results of a simulation analysis of a payment model for specialty oncology services that is being developed for possible testing by the Center for Medicare and Medicaid Innovation at the Centers for Medicare & Medicaid Services (CMS). CMS asked MITRE and RAND to conduct simulation analyses to preview some of the possible impacts of the payment model and to inform design decisions related to the model. The simulation analysis used an episode-level dataset based on Medicare fee-for-service (FFS) claims for historical oncology episodes provided to Medicare FFS beneficiaries in 2010. Under the proposed model, participating practices would continue to receive FFS payments, would also receive per-beneficiary per-month care management payments for episodes lasting up to six months, and would be eligible for performance-based payments based on per-episode spending for attributed episodes relative to a per-episode spending target. The simulation offers several insights into the proposed payment model for oncology: (1) The care management payments used in the simulation analysis-$960 total per six-month episode-represent only 4 percent of projected average total spending per episode (around $27,000 in 2016), but they are large relative to the FFS revenues of participating oncology practices, which are projected to be around $2,000 per oncology episode. By themselves, the care management payments would increase physician practices' Medicare revenues by roughly 50 percent on average. This represents a substantial new outlay for the Medicare program and a substantial new source of revenues for oncology practices. (2) For the Medicare program to break even, participating oncology practices would have to reduce utilization and intensity by roughly 4 percent. (3) The break-even point can be reduced if the care management payments are reduced or if the performance-based payments are reduced.
3 citations
01 Dec 2014
TL;DR: It is imperative to recognize this reality and individualize care to each particular man with age and comorbidities in mind to try to minimize both overtreatment and undertreatment of geriatric patients with prostate cancer.
Abstract: The definition of the “geriatric” population is somewhat variable. For the purposes of this chapter, we will define it as those aged 70 years and older. Management of prostate cancer in this population can be particularly challenging due to two inherent yet seemingly contradictory truths. Age is a risk factor for the diagnosis of prostate cancer and also for the presence of higher risk disease. However, older men with prostate cancer are at higher risk of dying from competing causes than younger men with comparable disease. Therefore, it is imperative to recognize this reality and individualize care to each particular man with age and comorbidities in mind to try to minimize both overtreatment and undertreatment of geriatric patients with prostate cancer.
2 citations
01 May 2012
TL;DR: After propensity score matching, overall three-year survival rate following radical prostatectomy among patients with localized prostate cancer was significantly higher than that after primary androgen deprivation therapy.
Abstract: Correspondence: Jinan Liu Tulane University, School of Public Health and Tropical Medicine, Tulane University, 1440 Canal Street, Suite 1900, New Orleans, LA 70112, USA Tel +1 504 810 7282 Fax +1 504 988 3783 Email jliu4@tulane.edu Background: This retrospective cohort study aimed to examine the comparative effectiveness of monotherapy of primary androgen deprivation therapy or radical prostatectomy. Methods: Male patients with localized prostate cancer (T1-T2, N0, M0) were identified in the Veterans Affairs Veterans Integrated Service Network 16 data warehouse (January 2003 to June 2006), with one-year baseline and at least three-year follow-up data (until June 2009). Patients were required to be 18–75 years old and without other recorded cancer history. The initiation of primary androgen deprivation therapy or monotherapy of radical prostatectomy within six months after the first diagnosis of prostate cancer was used as the index date. Primary androgen deprivation therapy patients were matched to the radical prostatectomy patients via propensity score, which was predicted from a logistic regression of treatment selection (primary androgen deprivation therapy versus radical prostatectomy) on age, race, marital status, insurance type, cancer stage, Charlson comorbidity index, and alcohol and tobacco use. The overall survival from initiation of index treatment was then analyzed using the Kaplan–Meier and Cox proportional hazards model. Results: The two cohorts were well matched at baseline (all P . 0.05). During a median follow-up of 4.3 years, the cumulative incidence of death was 13 (10.57%) among 123 primary androgen deprivation therapy patients and four (3.25%) among 123 radical prostatectomy patients (P , 0.05). The overall three-year survival rate was 92.68% for primary androgen deprivation therapy and 98.37% for radical prostatectomy (P , 0.05). Patients who received primary androgen deprivation therapy had almost three times as high a mortality risk as those using radical prostatectomy (hazards ratio 3.388, 95% confidence interval 1.094–10.492, P = 0.034). Conclusion: After propensity score matching, overall three-year survival rate following radical prostatectomy among patients with localized prostate cancer was significantly higher than that after primary androgen deprivation therapy.
2 citations
Cites background from "Reduction in Physician Reimbursemen..."
...1% in 2005 among low-risk prostate cancer patients.(24) In contrast with private practice, the Veterans Affairs system does not link drug usage to physician reimbursement incentives....
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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.
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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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