Reduced physician reimbursements for hormone therapy resulted in less overtreatment for prostate cancer

Elliott SP. J Natl Cancer Inst. 2010;102:1826-1834.

Physician reimbursements for androgen suppression therapy were reduced by 64% between 2004 and 2005 as a result of the 2003 Medicare Modernization Act. According to recent data, this deduction in reimbursements resulted in a reduced rate of men overtreated for low-risk prostate cancer without reducing the number of needed treatments.

“A major reduction in physician reimbursement for [androgen suppression therapy] was associated with a 39% decrease in the odds of receiving non-indicated [androgen suppression therapy] but not indicated [androgen suppression therapy],” the researchers wrote. “These findings may help inform how payment changes will affect health care utilization in other disease models.”

Using the SEER database, researchers identified 72,818 men who were diagnosed with prostate cancer between 1992 and 2005. According to Medicare claims data, indicated treatment was defined as 3 or more months of androgen suppression therapy in the first year among men with metastatic disease (n=8,030); non-indicated treatment was defined as androgen suppression therapy alone, with no radical prostatectomy or radiation, in those with low-risk disease (n=64,788).

According to the researchers, the unadjusted annual proportion of men receiving therapy was plotted against the median Medicare androgen suppression therapy reimbursement. In addition, logistic regression models for metastatic and low-risk cohorts were developed; the models included three different definitions of androgen suppression therapy use: at least 1 month, at least 3 months and at least 6 months. Calendar year of payment change was the predictor of interest; additional covariates included age in 5-year categories, clinical tumor stage, WHO grade, Charlson comorbidity, race, education, income and tumor registry site.

In 2003, androgen suppression therapy among patients in the metastatic group peaked at 64% and decreased to 58.5% in 2005. In the low-risk group, between 1999 and 2003, therapy use was stable, then peaked at 10.2% in 2003; use declined to 7.1% in 2004 and 6.1% in 2005. Compared with 2003, the odds of receiving non-indicated therapy in 2004 and 2005 decreased significantly after adjusting for tumor and demographic covariates (OR=0.70; 95% CI, 0.61-0.80 in 2004 and OR=0.61; 95% CI, 0.53-0.71 in 2005). According to the researchers, therapy use was stable at 60% during the payment change in the metastatic group. Between 2004 and 2005, the OR for receiving therapy was unchanged among this group.

In an accompanying editorial, Nancy L. Keating, MD, MPH, Brigham and Women’s Hospital and Harvard Medical School, Health Care Policy, wrote: “This work adds to findings from a prior study demonstrating that actual Medicare payments to physicians for [gonadotropin-releasing hormone] agonists decreased by 65% between 2003 and 2005. The nice contribution by Elliot et al was in demonstrating that the decreased reimbursement for [gonadotropin-releasing hormone] agonists was associated with a substantial decrease in their use for an indication that very likely reflected overuse (primary therapy for very low-risk tumors) but no change in use for an indication that reflected appropriate use of this therapy.”

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