Reduction in Physician Reimbursement and Use of Hormone Therapy in Prostate Cancer

Department of Urologic Surgery, University of Minnesota, 420 Delaware St SE, MMC 394, Minneapolis, MN 55455, USA.
Journal of the National Cancer Institute (Impact Factor: 12.58). 12/2010; 102(24):1826-34. DOI: 10.1093/jnci/djq417
Source: PubMed


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.
A cohort of 72,818 men diagnosed with prostate cancer in 1992-2005 was identified from the Surveillance, Epidemiology, and End Results database. From Medicare claims data, indicated AST was defined as 3 months or more of AST in the first year in men with metastatic disease (n = 8030). Non-indicated AST was defined as AST given without other therapies such as radical prostatectomy or radiation in men with low-risk disease (n = 64,788). The unadjusted annual proportion of men receiving AST was plotted against the median Medicare AST reimbursement. A multivariable model was used to estimate the odds of AST use in men with low-risk and metastatic disease, with the predictor of interest being the calendar year of the payment change. Covariates in the model included age in 5-year categories, clinical tumor stage (T1-T4), World Health Organization grade (1-3, unknown), Charlson comorbidity (0, 1, 2, ≥ 3), race, education, income, and tumor registry site, all as categorical variables. The models included variations in the definition of AST use (≥ 1, ≥ 3, and ≥ 6 months of AST). All statistical tests were two-sided.
AST use in the low-risk group peaked at 10.2% in 2003, then declined to 7.1% in 2004 and 6.1% in 2005. After adjusting for tumor and demographic covariates, the odds of receiving non-indicated primary AST decreased statistically significantly in 2004 (odds ratio [OR] = 0.70, 95% confidence interval = 0.61 to 0.80) and 2005 (OR = 0.61, 95% confidence interval = 0.53 to 0.71) compared with 2003. AST use in the metastatic disease group was stable at 60% during the payment change, and the adjusted odds ratio of receiving AST in this group was unchanged in 2004-2005.
In this example of hormone therapy for prostate cancer, decreased physician reimbursement was associated with a reduction in overtreatment without a reduction in needed services.

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Available from: Sean P Elliott, Feb 12, 2014
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    • "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]. Nonetheless, close and continuous monitoring of the effects on quality of changes in reimbursement rates is clearly important. "
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    ABSTRACT: Objective 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. Methods 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). Results 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. Conclusion 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.
    05/2014; 4(1):8. DOI:10.1186/s13561-014-0008-4
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    • "As evidenced in Table 1, 72.8% of the studies identified in our review relied to some degree on claims data. Of the 294 articles selected for review, 21.8% (n ¼ 64) were claimsonly studies [7–70], 5.1% (n ¼ 15) were registry-only [71] [72] [73] [74] [75] [76] [77] [78] [79] [80] [81] [82] [83] [84] [85], 51% (n ¼ 150) used claims and registry data together without any other supplemental data set [6,24,151–298], and the remaining 22.1% (n ¼ 65) used other data sources, primarily chart-based systems or hospital discharge data sets, either alone or in combination with claims and/or registry data [86–150]. Chartbased systems included paper or electronic health records (EHRs) as well as electronic medical record (EMR) databases, programmatically generated subsets of EHRs. "
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    ABSTRACT: The ISPOR Oncology Special Interest Group formed a working group at the end of 2010 to develop standards for conducting oncology health services research using secondary data. The first mission of the group was to develop a checklist focused on issues specific to selection of a sample of oncology patients using a secondary data source. A systematic review of the published literature from 2006 to 2010 was conducted to characterize the use of secondary data sources in oncology and inform the leadership of the working group prior to the construction of the checklist. A draft checklist was subsequently presented to the ISPOR membership in 2011 with subsequent feedback from the larger Oncology Special Interest Group also incorporated into the final checklist. The checklist includes six elements: identification of the cancer to be studied, selection of an appropriate data source, evaluation of the applicability of published algorithms, development of custom algorithms (if needed), validation of the custom algorithm, and reporting and discussions of the ascertainment criteria. The checklist was intended to be applicable to various types of secondary data sources, including cancer registries, claims databases, electronic medical records, and others. This checklist makes two important contributions to oncology health services research. First, it can assist decision makers and reviewers in evaluating the quality of studies using secondary data. Second, it highlights methodological issues to be considered when researchers are constructing a study cohort from a secondary data source.
    Value in Health 06/2013; 16(4):655-669. DOI:10.1016/j.jval.2013.02.006 · 3.28 Impact Factor
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    ABSTRACT: 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, insur-ance 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 andro-gen 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.
    Value in Health 05/2011; 14(3). DOI:10.1016/j.jval.2011.02.005 · 3.28 Impact Factor
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