Reimbusement and Managed Care News

By Stanton R. Mehr
Published: Thursday, Jun 10, 2010
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Did Reduced Reimbursement for Medical Castration Result in More Orchiectomies?

Most men prefer medical castration with luteinizing hormone-releasing hormone (LHRH) agonists as a treatment for prostate cancer over surgical castration, but the utilization data has bucked the expected trend. This may be the unintended result of a 2004 reduction in reimbursements by the Centers for Medicare & Medicaid Services (CMS) for LHRH agonists, according to authors from the Cleveland Clinic. However, if the reimbursement for LHRH agonist use in prostate cancer is reduced to the point that it results in financial loss for the practice, can physicians balance the ethical versus the financial implications for this change in payments?

The change from average wholesale price–based to average sales price methodology, resulting in an effective 65% reduction in reimbursements over the course of a couple of years, and a 7% increase in reimbursement for surgical orchiectomy has paralleled a change in practice, stated the authors. They evaluated Medicare part B records from 2001 to 2005 for claims regarding the use of LHRH agonists and orchiectomy.

Utilization of medical castration fell by 14%, the investigators found, while the number of orchiectomies rose by 4%. Their review of the literature since 2004 does not provide alternative explanations for these trends. Although medical castration is not superior to surgical castration in terms of efficacy and outcomes, according to previous studies, men consistently prefer the medical option. The authors conclude that the “most plausible explanation” for this trend is the reimbursement, which has implications for how physicians present options to their patients with prostate cancer.

Weight CJ, Klein EA, Jones JS: Androgen deprivation falls as orchiectomy rates rise after changes in reimbursement in the U.S. Medicare population. Cancer 2008;112:2195-2201.

Tidal Wave of Breast Cancer Cases Expected as Elderly Age

As the baby boomer “age wave” continues to leave a wake in health care service consumption, it is clear that this nation’s aging population will also create a tidal wave of patients with diseases of aging, including cancer. This will tax our health care resources, skill, and ability to pay for treatment. A task force report, announced recently at the annual meeting of the National Comprehensive Cancer Network, warns that we are woefully unprepared in the treatment realm of addressing the age wave’s effect on breast cancer cases.

By 2040, it is estimated that 80 million American women will be at least 65 years of age. Task force Chairman Robert W. Carlson, MD, worried that there are few studies of breast cancer treatment in women older than 70 years—they are poorly represented in clinical trials, and the medical community does not have sufficient published experience to make treatment recommendations. Clinical practice guidelines should have separate branches to detail preferred therapeutic options in these elderly women, stated Dr. Carlson, but data do not exist on which to form the guidelines.

The task force believes that these older women will require greater use (and more effective) supportive therapies to enable them to complete chemotherapeutic regimens. Dr. Carlson also cautioned, “The benefit of treatment has to be bigger in a relative sense to be worth it in an absolute sense in the older patient because of competing causes of death.”

The task force recommended the development of new testing methodologies that can determine a woman’s “physiologic age” and “functional reserve,” which may enable the clinician to choose more conservatively among the various chemotherapy, radiation, and surgical options. Furthermore, the task force believes more interest in a patients’ priorities will be an important focus when considering how to treat these elderly women.

Carlson RW: Report of the NCCN Task Force on Breast Cancer in the Older Adult. Presented at the 13th annual meeting of the National Comprehensive Cancer Network, Hollywood, Florida, March 27, 2008.

The Cost Effectiveness of Neutropenia Treatment

The use of granulocyte colony-stimulating factors (G-CSFs) is an important tool in fighting febrile neutropenia. Health economists from the University of Rochester School of Medicine and Dentistry, New York, sought to determine the cost effectiveness of G-CSF therapy.

The investigators used a cost-utility model to estimate the cost effectiveness of the conventional G-CSF (filgrastim), pegylated form (pegfilgrastim), and no therapy was calculated. If patients received filgrastim treatment, it was assumed that it was given daily for seven to 12 days after chemotherapy was administered. If patients received pegfilgrastim, it was assumed to be administered once per chemotherapy cycle. A societal point of view was assumed for all cost-effectiveness calculations.

View Conference Coverage
Online CME Activities
TitleExpiration DateCME Credits
Community Practice Connections™: 18th Annual International Lung Cancer Congress®Oct 31, 20181.5
Provider and Caregiver Connection™: Addressing Patient Concerns While Managing Chemotherapy Induced Nausea and VomitingOct 31, 20182.0
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