Reimbursement and Managed Care News: September 2007

By Stanton R. Mehr
Published: Monday, Jul 12, 2010
%u25BA Exemestane Is a Cost-Effective Alternative to Tamoxifen in Estrogen Receptor–Positive Breast Cancer

A popular approach to adjuvant breast cancer treatment is to switch after two to three years of tamoxifen to an aromatase inhibitor to maximize disease-free survival. This protocol has been proven in studies to be clinically effective. Canadian economists have now confirmed that this approach is cost effective as well.

Following patients over 7.5 years, health economists from the University of Toronto and Sunnybrook Health Sciences Centre, Toronto found that a protocol using the aromatase inhibitor exemestane (Aromasin) in patients with estrogen receptor–positive breast cancer improved not only disease-free survival compared with patients not switching from tamoxifen resulted in greater diseasefree survival, but at a cost of CN$2,889 per patient (or $2,407 at 1.2 Canadian dollar to 1 U.S. dollar).

At an incremental cost-effectiveness ratio of CN$24,185 per quality-of-lifeyear gained, this would be considered by most health economists and health plans a cost-effective approach.

   Risebrough NA, Verma S, Trudeau M, et al: Cost effectiveness of switching to exemastane versus continued tamoxifen as adjuvant therapy for postmenopausal women with primary breast cancer. Cancer ,i>August 1, 2007.

%u25BA A More Accurate Way of Deciding Which Prostate Cancers to Treat?

For managed care plans, physicians, and patients alike, the diagnosis of prostate cancer is followed by the inevitable choices of watchful waiting, immediate surgical removal, and/or treatment with chemotherapy, depending on a number of issues, including anticipated tumor growth or spread. Scientists from London believe they may have found a genetic marker to better predict which prostate tumors are wolves in sheep’s clothing and require aggressive intervention.

Past research showed that the TMPRSS2 and ERG genes were typically fused in prostate tumors. However, new evidence from the Institute of Cancer Research of the United Kingdom indicates that patients with a double fusion of these genes, which appears in 7% of patients with prostate cancer, may portend far worse prognoses than for patients with single fusions of the genes.

The investigators found that the alteration, known as 2 Edel, is associated with 25% survival after eight years, compared with 90% survival in patients without the double fusion. The hazard rate for prostate-cancer related death was six times higher for patients with the double fusion than for those without it.

The authors of the study believe that this finding will enable physicians to go beyond the Gleason score, which is currently used to classify tumors. Physicians using the Gleason score may grade tumors differently, which may influence physician and patient decision making.

The use of the genetic test may lead to health plans and physicians more efficiently using resources and improve quality of life, by avoiding prostate surgery or other expensive intervention for those without the double fusion and in whom tumors are not aggressive.

   Attard G, Clark J, Ambroisine L, et al: Duplication of the fusion of TMPRSS2 to ERG sequences identifies fatal human prostate cancer. Oncogene July 16, 2007; (E-pub, ahead of print).

%u25BA Senate Proposal Would Increase Payments to Oncologists…

Senate Bill S.1750 was introduced in July by Pennsylvania Senators Robert Casey, Jr. (D) and Arlen Specter (R) that would significantly affect reimbursement for oncology services and medications. It is similar to a House bill sponsored by Congressmen Artur Davis (D-AL) and Jim Ramstad (R-MN).

The bill includes provisions to eliminate prompt payment discounts from the calculation of the average sales price, which would raise payments to oncologists for office-administered cancer agents. It also includes payment codes for planning of treatment and the use of pharmacy facilities, which are not currently reimbursed by Medicare. Also, this proposal, called the Community Cancer Care Preservation Act of 2007, would reinstate reasonable payments for the initiation of cancer medications.

More details on Senate Bill S.1750 are available through the website of the Community Oncology Alliance (www.communityoncolo, including the text of the bill and contact information for Senators in all 50 states.

  …But Medicare Seeks to Cut Physician Payments Across the Board

The physician fee schedule for 2008, released under a proposed rule, would drop payment rates under the Medicare Physician Fee Schedule by 9.9%. The size of the proposed reduction is a result of Congressional overruling cuts in the past, calculated through the use of a formula mandated by the Balanced Budget Act of 1997.

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