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: Lu-Yao et al. as discussed by the authors found that there is no significant difference between the two groups of men who did and did not receive ADT with regard to clinical stage and grade, among other attributes.
Abstract: In the late 1970s, investigators learned that androgendeprivation therapy (ADT) decreased serum testosterone levels and,more importantly, reducedbonepainamongmenwith prostate cancer. Whereas ADT demonstrated benefit in patients with metastatic disease and as an adjunct to radiation therapy in patients with locally advanced disease, its use at the organ-confined stage has never been supported by evidence or expert guidelines. Most importantly, randomized data have shown that immediate ADT for nonmetastatic prostate cancernotonly lacks a survival benefit but maycauseharm, suchasanexcess riskofbone fractures.1Nevertheless, the use of ADT for localized prostate cancer increased greatly between the 1990s and early 2000swith compelling evidence that favorable reimbursement contributed to this trend.2 In this issue of JAMA InternalMedicine, Lu-Yao et al3 have confirmed and extended their previous observational cohort studies of prostate cancer treatment outcomes in the Medicare population residing in a region encompassed by the National Cancer Institute’s Surveillance, Epidemiology, andEnd Results (SEER) registries. InaMedicare cohort spanningnearly 2 decades of 66 717 men aged 65 years and older with localized prostate cancerwho receivednodefinitive local therapy, they found that primary ADT confers neither overall nor disease-specific advantage. Moreover, Potosky et al4 have recently reported a similar observational cohort study of more than 15 000 men receiving non–curative intent treatment within integrated health care systems. This study leveraged longitudinalmedical recorddatawith richer clinicaldetail than is available in SEER-Medicare and, like the study of Lu-Yao et al,3 demonstrated neither a survival advantage nor disadvantage from ADT. The analysis of Lu-Yao et al3 highlights both the strengths andpitfalls of usingobservational cohorts, suchas those identified from SEER-Medicare linked data, tomeasure effectiveness. Inferences from observational studies aremost reliable when the groups being compared are similar in all respects other than the intervention under scrutiny. Of course in practice, this is often not the case. Indeed, in the study of Lu-Yao et al,3 baseline disease characteristics differ substantially between men who did and did not receive ADT with regard to clinical stage and grade, among other attributes. As it became clear that there is little or no role for primaryADT in the treatment of nonmetastatic prostate cancer, contemporary clinicians have becomemore selective in recommending primary ADT, for example, reserving it for patients with poor prognosis or the inability to tolerate radiation therapy. Conversely, “conservative management” of prostate cancer as a concept has shifted fromwatchfulwaiting, apassiveapproach forolder menwith limited life expectancy focused on palliation rather than treatment, to active surveillance, in which healthy patients are intensively monitored with repeated prostatespecific antigen tests, digital rectal examinations, and prostate biopsies at systematic intervals and in which definitive treatment is advocated at any signof disease progression.5 Finally, prostate-specific antigen testing at diagnosis, an important prognostic and predictive marker, is imperfectly captured by SEER and is only available for themost recent years. Both the missing data and the imbalance from this registrybased study impede the ability to make definitive comparisonsbetween these treatment strategies.The limitationsofobservational cohort studies using SEER-Medicare datamust be balanced against the recognition that there will not be additional randomized trials and that the assessment of effectiveness fromSEER-Medicare data canbedone expeditiously and at nominal cost. One strategy to circumvent the classic selection bias that plagues the ability to make valid inferences from treatment comparisons using observational data is to use an instrumental variable to account for confounding by unmeasured differences between treatment groups. To be considered valid, an instrumental variable must satisfy 2 quintessential conditions: thevariablemustbecorrelatedwith the treatmentwhile not being associated with the outcome of interest except through the effect of the treatment itself. This statistical method therefore reduces treatment selectionbias and“pseudorandomizes” patients. Lu-Yao et al3 used the proportion of patientswho receivedADTwithinahealth service areaas their instrument. Knowinghowwell an instrument performs is the key to interpreting how successfully it accomplished the goal of pseudorandomization. TheF-statistic is commonlyused to assess the strength of the instrument and thereby the ability tomitigate potential selection bias. A robust instrument typically has an F-statistic greater than 10. The attempt to identify an instrumental variable is a strength of the study of LuYao et al3; nonetheless, inclusion of an assessment of the instrument’s performance would have helped readers gain a better understanding of howwell it addressed potential confounding. Indeed, physicians needmore guidance on how to interpret the results of instrumental variable analyses as they Related article page 1460 Research Original Investigation Androgen-Deprivation Therapy for Prostate Cancer
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TL;DR: In this paper, the authors compared trends in the use of IMRT between patients treated in practices directly affected by fee reductions (for prostate cancer, men treated in urology practices that own IMRT equipment; for breast cancer, women treated in freestanding radiotherapy clinics).
Abstract: OBJECTIVE To estimate the impact of a large Medicare fee reduction for intensity-modulated radiation therapy (IMRT) on its use in prostate and breast cancer patients. DATA SOURCES/STUDY SETTING SEER-Medicare. STUDY DESIGN We compared trends in the use of IMRT between patients treated in practices directly affected by fee reductions (for prostate cancer, men treated in urology practices that own IMRT equipment; for breast cancer, women treated in freestanding radiotherapy clinics) and patients treated in other types of practices. DATA COLLECTION/EXTRACTION METHODS We identified breast and prostate cancer patients receiving IMRT using outpatient and physician office claims. We classified urology practices based on whether they billed for IMRT and radiotherapy clinics based on whether they were reimbursed under the Physician Fee Schedule. PRINCIPAL FINDINGS Between 2006 and 2015 the payment for IMRT delivered in freestanding clinics and physician offices declined by $367 (-54.7%). However, the use of IMRT increased in physician practices subject to payment cuts, both in absolute terms and relative to use in practices unaffected by the payment cut. Use of IMRT in prostate cancer patients treated at urology practices that own IMRT equipment increased by 9.1 (95% CI: 2.0-16.2) percentage points between 2005 and 2016 relative to use in patients treated at other urology practices. Use of IMRT in breast cancer patients treated at freestanding radiotherapy centers increased by 7.5 (95% CI: -5.1 to 20.1) percentage points relative to use in patients treated at hospital-based centers. CONCLUSIONS A steep decline in IMRT fees did not decrease IMRT use over the period from 2006 to 2015, though use has declined since 2010.
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TL;DR: The results indicate that providers responded to reimbursement changes after the MMA by increasing use of newly approved agents, but the magnitude of the response was small and limited to individuals diagnosed with Stage IV disease.
Abstract: Background The Medicare Modernization Act (MMA) reduced reimbursement for many antineoplastics delivered in outpatient settings, altering practice patterns for some cancers. To further evaluate the MMA’s effect, we focus on colon cancer, where longstanding fluorouracil-based regimens were augmented in 2004 with 3 newly-approved drugs (oxaliplatin, bevacizumab, and/or cetuximab). Staggered implementation of MMA reimbursement changes (physician offices implemented reimbursement changes in 2005 vs hospital outpatient departments(OPD) in 2006) provide a natural experiment to examine policy effects. Methods Using the 2000–2009 SEER-Medicare data, we examined antineoplastic use among 59,642 stage II–IV colon cancer patients. Using multivariate logistic regression models, we conducted difference-in-differences analyses to examine an interaction between time (pre-post MMA) and setting (physician offices versus OPDs) on antineoplastic receipt, adjusting for patient and cancer characteristics. A significant interaction indicates different practice patterns in physician offices versus OPD during the staggered implementation. Results After the reimbursement change in 2007–09 relative to 2000-03, use of fluorouracil-based therapy decreased slightly (Marginal Probability(MP): −0.07 stage II;−0.05 stage III;−0.05 stage IV; p Conclusions Our results indicate that providers responded to reimbursement changes after the MMA by increasing use of newly approved agents, but the magnitude of the response was small and limited to individuals diagnosed with Stage IV disease.
1 citations
01 Dec 2013
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Cites background or result from "Reduction in Physician Reimbursemen..."
...Previous studies clarify the clinical population for which ADT use declined (10, 39)....
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...Consistent with other studies, we found that ADT overuse declined precipitously over the 2000s, a drop that was coincident with reimbursement policy changes (10, 39)....
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...use in localized prostate cancer grew steadily from the 1990s, peaking in 2003 (10, 18, 40-42)....
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...incident localized prostate cancer (10, 39), active surveillance may have replaced ADT use....
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...provide a list of potential confounders to their observational study of declining ADT use in the full Medicare population (42), most of which are addressed by later studies that show persistent declines in the cohort for which ADT was not indicated (10, 39)....
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TL;DR: Promotional payments to urologists at the market level are strongly associated with the specialty of the physician prescribing abiraterone or enzalutamide for the first time, and the effects of the shift in prescribing patterns on quality of care and financial hardship for men with advanced prostate cancer are elucidated.
1 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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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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