University of Florida urologist Dr. Scott Gilbert and colleagues at the University of Michigan and the University of Texas Medical Branch evaluated national patterns of how doctors prescribed a hormone treatment called androgen deprivation therapy before and after the federal Centers for Medicare and Medicaid Services lowered the associated reimbursement rates.
Among people for whom the treatment was considered necessary, there was no decline in use when payments were lowered. In contrast, use of the therapy fell more than 30 percent among patients for whom there is no medical evidence that it is beneficial.
“Even modest changes in how services are reimbursed can have a profound effect both in terms of clinical benefit and how health care dollars are spent,” said Gilbert, an assistant professor of urology and director of the Urologic Cancer Center in the UF College of Medicine.
“The findings demonstrate a lesson that is relevant in the current climate of health care reform,” added Dr. Vahakn Shahinian, an assistant professor of internal medicine at the University of Michigan and first author of the paper. “Reducing reimbursement can produce positive changes in how care is delivered, in that potentially unnecessary care is reduced without affecting care that is necessary.”
Androgen deprivation therapy has become a mainstay for reducing the severity of prostate cancer symptoms, but it does not cure the disease. In previous years, it was mainly achieved through removal of the testicles, but over the last two decades that practice has been all but replaced by the administering of a synthetic hormone.
Overall use of the hormone therapy doubled during the 1990s, and by 1999, nearly half of all patients with prostate cancer were receiving it within a year of diagnosis. The use was prevalent even among men who were 80 years or older and who had low-risk localized tumors, and for whom there is no clear evidence that the therapy improves chances of survival.
Because Medicare reimbursed physicians at high rates for use of the therapy, for some clinics it provided a significant portion — up to 40 percent — of their income, according to the General Accounting Office. In 2003, Medicare paid out almost $1 billion for the therapy.
But in 2004 and 2005, policy changes resulted in a 50 percent cut in reimbursement. That corresponded with a sharp drop in the rate of potentially inappropriate use — from 38.7 percent in 2003 to 25.7 percent in 2005, the researchers discovered in their evaluation of Medicare data for almost 55,000 patients.
“The findings show how reimbursement drives patterns of care,” said Dr. David Penson, a professor of urologic surgery and director of the Vanderbilt Center for Surgical Quality and Outcomes Research at Vanderbilt University, who was not involved in the study. “I don’t believe reimbursement is 100 percent responsible for the changes we see, but it’s clear that it must play a role.”
Still, there are nonfinancial reasons that physicians would administer the therapy even in cases for which there wasn’t a survival benefit, urologists say. It might contribute to peace of mind and improve quality of life for patients whose tumors are low-risk, but who are not satisfied simply to have their physicians monitor their tumor and want to feel that their cancer is being treated.
“In some respects it may not be about the evidence, but about helping a patient deal with his diagnosis,” Penson said. “I think providers really felt that this was truly harmless treatment that has some psychological benefit for patients.”
But doctors have slowly learned that the therapy is not as benign as previously thought. That new knowledge might also have played a role in the decline in use, the researchers said. In recent years urologists have become more aware of negative side effects including increased risk of cardiovascular disease, diabetes, bone disease and fractures — consequences not yet known when the therapy first came into use.
“So if we can limit exposure to these drugs to patients who absolutely need them, there’s a clinical benefit as well as a financial one,” Gilbert said.
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