Pointless prostate cancer hormonal treatment dropped after medicare reimbursement change

Pointless prostate cancer hormonal treatment dropped after medicare reimbursement change

There was a sharp drop in the number of unnecessary prostate cancer hormonal treatments after Medical policy changes reduced reimbursements. However, hormonal therapy for prostate cancer patients who clearly benefited from such therapy continued unaffected, researchers wrote in an article published in the NEJM (New England Journal of Medicine). The authors believe their findings suggest that the health care reforms can reduce waste without affecting effective treatment rates.

Lead author, Vahakn B. Shahinian, M.D., M.S., said:

We found that physicians respond to reimbursement, but they respond in a way that appears to be beneficial to the patient. They don't tend to cut out necessary care, but they tend to cut out unnecessary or inappropriate care. This suggests cutting reimbursements in the right context can help reduce unnecessary care.

The authors aimed to examine what impact Medicare policy changes might have had on androgen deprivation therapy, a common type of hormonal therapy for prostate cancer patients which uses regular injections to block testosterone, a male hormone.

Androgen deprivation therapy in combination with radiation therapy has been demonstrated to be effective in human trials for patients with high risk tumors. However, when used on its own for individuals with lower risk tumors, the evidence demonstrating its efficacy is much less compelling.

Medicare reimbursement for this type of treatment was 95% of the drug's wholesale price throughout the 1990s. Most practices were able to make hefty profits because they got the medication at 82% of wholesale price. Eventually half-a-million American men were receiving androgen deprivation therapy - which cost Medicare over $1 billion.

Policies for injected medication reimbursements changed after the Medicare Modernization Act, 2003. By 2005 it was set at 106%. This left less room for profit because it was based on sales transactions reported by pharma companies - it was more precise than the wholesale price.

Shahinian and team gathered data on 54,925 patients who had received prostate cancer treatment between 2003 and 2005 from the Surveillance, Epidemiology and End Results-Medicare (SEER-Medicare) database.

Author Yong-Fang Kuo, said:

SEER-Medicare has all the detailed cancer and treatment data we needed to categorize these patients, and it gave us a very good picture of the response to this change in Medicare reimbursement.

The patients were split into three groups for hormonal therapy - appropriate use, potentially inappropriate use, and discretionary - based on their tumor types and other treatments received.

During the course of the Medicare reimbursement cuts, the authors found that:

  • The numbers in the appropriate use category remained the same
  • The numbers in the inappropriate use category fell by 39% by the end of 2003 and 22% at the end of 2005
  • The numbers in the discretionary group fell slightly.
Androgen deprivation therapy reimbursements dropped from $356 per dose in 2003 to $176 in 2005 (after the new reimbursement policy).

Shahinian said:

There's a growing realization that these treatments might have more side effects than we first realized. Some of the patients who had been receiving androgen deprivation therapy would tend to do well without any treatment, and a lot of older patients die of causes other than their prostate cancer. It's inappropriate to treat these men when there is limited likelihood of benefit, no positive proof of benefit and increasing threat of side effects.

The authors point out that side effects were being uncovered during the same period, a factor which could also have an impact on hormone therapy usage for prostate cancer patients.

Androgen deprivation therapy remains a life-saving treatment for a certain subset of patients, and in our study, those patients continued to be prescribed this treatment. Financial incentives are most likely to impact physician behavior when there's a gray zone in terms of benefit, not when there's clear evidence of life-saving benefit.

"Reimbursement Policy and Androgen-Deprivation Therapy for Prostate Cancer"

Vahakn B. Shahinian, M.D., Yong-Fang Kuo, Ph.D., and Scott M. Gilbert, M.D.

N Engl J Med 2010; 363:1822-1832November 4, 2010

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