Reimbursement and Managed Care News

By Stanton R. Mehr
Published: Thursday, Jun 17, 2010
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Cost Effectiveness of Extended Letrozole Treatment After Discontinuation of Tamoxifen

The MA-17 trial assessed whether patients with early-stage breast cancer taking letrozole for five years after having received adjuvant tamoxifen experienced improved survival compared with those receiving placebo for the second five-year stage. The original study was discontinued when it was half completed, as the survival benefit was significant over placebo. As participants who were in the placebo arm were offered to continue with letrozole, the study was unblended, and the investigators decided to analyze whether those taking letrozole treatment compared with those from the placebo group who elected to continue with letrozole treatment, after what was a essentially a 2.5-year break in therapy, and if any health economic benefit was revealed.

A total of 1,655 patients in the placebo group decided to initiate letrozole therapy after unblinding. Six hundred thirteen elected to forego any therapy. The patients were followed up for two more years, and the cost-effectiveness analysis was performed based on the resulting improvement in survival. A Markov decision-analysis model was used to map the likelihood that patients would proceed to recurrence, maintain remission, or experience other health outcomes associated with therapy, based on the MA-17 clinical trial results.

Taken from the United Kingdom’s National Health Service perspective and using U.K. costs for treatment pathways, the researchers found that patients in the letrozole group gained 14.14 quality-adjusted life-years (QALYs) at a cost of £8,477 ($12,370) over the expected lifetime. Patients who did not elect to use letrozole after the placebo arm was discontinued gained 13.84 QALYs at a lifetime cost of £4,524 ($6,601). For patients receiving letrozole, the mean cost per QALY was £13,154 ($19,195), which is well beneath the threshold of what is expected to be cost effective.

The researchers conclude that compared with five years of tamoxifen therapy and no further active treatment, continuing five years of letrozole therapy is a cost-effective intervention.


Karnon J, DiTrapani F, Kaura S: Cost effectiveness of late extended adjuvant letrozole following a prolonged therapy break from tamoxifen. Presented at the American Society of Community Oncology’s San Antonio Breast Cancer Symposium, San Antonio, December 14, 2007.





The Effect of Consumer Cost Sharing on Mammography Rates

It has long been known that patients do not comply as well with pharmaceutical regimens when they are asked to shoulder more of the cost in terms of copayments (a fixed payment per prescription) or coinsurance (a percentage of the total cost of the prescription). Does this also apply to preventive interventions? According to researchers from Brown University, Providence, Rhode Island, the answer is yes.

In a retrospective study of members of 174 Medicare managed care plans conducted from 2001 to 2004, the investigators evaluated mammography testing frequencies for more than 366,000 women between the ages of 65 and 69 years. Over time, 18 of the health plans changed their benefit design, requiring cost sharing by the member (considered to be more than $10 per mammogram or a coinsurance of more than 10%), when none of the plans had required cost sharing earlier. This change affected 11.4% of the women whose claims records had been studied.

Mammography performed every two years in those plans after the cost share was introduced or increased was eight percentage points lower than in those with full coverage (P < .001). In fact, in plans that retained full coverage, mammography rates increased by 3.4 percentage points. Unsurprisingly, the difference in mammography rates increased further in low socioeconomic groups.

As in prescription drug coverage, small increases in consumer cost sharing had a significant effect on the use of preventive mammography screening in this Medicare population. The investigators suggested that removing cost shares for this specific population may help improve mammography rates.


Trivedi AN, Rakowski W, Ayanian JZ: Effect of cost sharing on screening mammography in Medicare health plans. N Engl J Med 2008;358:375-383.





National Poll: Government Coverage Decision on Anemia Drugs Hurt Patient Outcomes

A poll sponsored by US Oncology, a large oncology provider network, revealed that the vast majority of physicians surveyed believe that the issuance of the National Coverage Decision by the Centers for Medicare and Medicaid Services regarding erythropoeisis-stimulating agents (ESAs) has resulted in preventable adverse patient events.

The national coverage decision set specific guidelines for reimbursement of ESAs based on hematocrit/hemoglobin levels in patients with cancer being treated for anemia. The guideline levels were set in reaction to studies showing that patients given ESAs above these levels were at risk for increased mortality.


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