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Eaglehouse YL, Georg MW, Richard P, Shriver CD, Zhu K. Cost-Efficiency of Breast Cancer Care in the US Military Health System: An Economic Evaluation in Direct and Purchased Care. Mil Med 2020; 184:e494-e501. [PMID: 30839064 DOI: 10.1093/milmed/usz025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2018] [Revised: 11/07/2018] [Indexed: 11/14/2022] Open
Abstract
INTRODUCTION With the rising costs of cancer care, it is critical to evaluate the overall cost-efficiency of care in real-world settings. In the United States, breast cancer accounts for the largest portion of cancer care spending due to high incidence and prevalence. The purpose of this study is to assess the relationship between breast cancer costs in the first 6 months after diagnosis and clinical outcomes by care source (direct or purchased) in the universal-access US Military Health System (MHS). MATERIALS AND METHODS We conducted a retrospective analysis of data from the Department of Defense Central Cancer Registry and MHS Data Repository administrative records. The institutional review boards of the Walter Reed National Military Medical Center and the Defense Health Agency reviewed and approved the data linkage. We used the linked data to identify women aged 40-64 who were diagnosed with pathologically-confirmed breast cancer between 2003 and 2007 with at least 1 year of follow-up through December 31, 2008. We identified cancer treatment from administrative data using relevant medical procedure and billing codes and extracted costs paid by the MHS for each claim. Multivariable Cox proportional hazards models estimated hazards ratios (HR) and 95% confidence intervals (CI) for recurrence or all-cause death as a function of breast cancer cost in tertiles. RESULTS The median cost per patient (n = 2,490) for cancer care was $16,741 (interquartile range $9,268, $28,742) in the first 6 months after diagnosis. In direct care, women in the highest cost tertile had a lower risk for clinical outcomes compared to women in the lowest cost tertile (HR 0.58, 95% CI 0.35, 0.96). When outcomes were evaluated separately, there was a statistically significant inverse association between higher cost and risk of death (p-trend = 0.025) for women receiving direct care. These associations were not observed among women using purchased care or both care sources. CONCLUSIONS In the MHS, higher breast cancer costs in the first 6 months after diagnosis were associated with lower risk for clinical outcomes in direct care, but not in purchased care. Organizational, institutional, and provider-level factors may contribute to the observed differences by care source. Replication of our findings in breast and other tumor sites may have implications for informing cancer care financing and value-based reimbursement policy.
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Affiliation(s)
- Yvonne L Eaglehouse
- Murtha Cancer Center Research Program, Department of Surgery, Uniformed Services University of the Health Sciences, 11300 Rockville Pike, Suite 1120, Rockville, MD.,Department of Surgery, Uniformed Services University of the Health Sciences, 4301 Jones Bridge Road, Bethesda, MD
| | - Matthew W Georg
- Murtha Cancer Center Research Program, Department of Surgery, Uniformed Services University of the Health Sciences, 11300 Rockville Pike, Suite 1120, Rockville, MD
| | - Patrick Richard
- Department of Preventive Medicine and Biostatistics, Uniformed Services University of the Health Sciences, 4301 Jones Bridge Road, Bethesda, MD
| | - Craig D Shriver
- Murtha Cancer Center Research Program, Department of Surgery, Uniformed Services University of the Health Sciences, 11300 Rockville Pike, Suite 1120, Rockville, MD.,Department of Surgery, Uniformed Services University of the Health Sciences, 4301 Jones Bridge Road, Bethesda, MD
| | - Kangmin Zhu
- Murtha Cancer Center Research Program, Department of Surgery, Uniformed Services University of the Health Sciences, 11300 Rockville Pike, Suite 1120, Rockville, MD.,Department of Preventive Medicine and Biostatistics, Uniformed Services University of the Health Sciences, 4301 Jones Bridge Road, Bethesda, MD
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2
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Yashkin AP, Greenup RA, Gorbunova G, Akushevich I, Oeffinger KC, Hwang ES. Outcomes and Costs for Women After Breast Cancer: Preparing for Improved Survivorship of Medicare Beneficiaries. JCO Oncol Pract 2020; 17:e469-e478. [PMID: 32692618 DOI: 10.1200/op.20.00155] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE Increasing health care costs, longer life expectancy, improved breast cancer (BC) survival, and higher levels of complex comorbidities have important implications for future Medicare expenditures. METHODS Data from the SEER program linked to Medicare claims records were used. Women with BC (cases) were categorized into 3 groups on the basis of their year of diagnosis (1998, 2003, or 2008) and were propensity score matched to women without a BC diagnosis (controls). All stage and stage-specific longitudinal changes in survival, morbidity levels using the Elixhauser index, and Medicare expenditures in 2018 dollars were calculated and compared. RESULTS More than 15% of BC cases were diagnosed in patients over the age of 85 years. The prevalence of most comorbidities increased over time. Costs among cases increased between 1998 and 2008. Spending directly correlated with the stage of disease at diagnosis, with the lowest per-patient costs in the ductal carcinoma in situ (DCIS) subgroup ($14,792 in 1998 and $19,652 in 2008) and the highest in those with distant cancer ($37,667 in 1998 and $43,675 in 2008). Assuming no significant changes in the distribution of BC stage or age at diagnosis, the total annual costs of caring for patients with BC in women 65 years of age or older at diagnosis increased by at least $1.1 billion between 1998 and 2008. CONCLUSION Improvements in BC survivorship are associated with intensive use of health care resources and substantially higher downstream costs among Medicare beneficiaries. Appropriate planning, in both the fiscal and the oncology care infrastructure, is required to prepare the health system for these emerging health care trends.
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Affiliation(s)
- Arseniy P Yashkin
- Biodemography of Aging Research Unit, Duke Population Research Center, Duke University, Durham, NC
| | - Rachel A Greenup
- Department of Surgery, Duke University, Durham, NC.,Duke Cancer Institute, Duke University, Durham, NC.,Department of Population Health Sciences, Duke University, Durham, NC
| | - Galina Gorbunova
- Biodemography of Aging Research Unit, Duke Population Research Center, Duke University, Durham, NC
| | - Igor Akushevich
- Biodemography of Aging Research Unit, Duke Population Research Center, Duke University, Durham, NC
| | - Kevin C Oeffinger
- Duke Cancer Institute, Duke University, Durham, NC.,Department of Population Health Sciences, Duke University, Durham, NC.,Department of Medicine, Duke University, Durham, NC
| | - E Shelley Hwang
- Department of Surgery, Duke University, Durham, NC.,Duke Cancer Institute, Duke University, Durham, NC
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3
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Zang S, Zhan H, Zhou L, Wang X. Research on Current Curative Expenditure among Lung Cancer Patients Based on the "System of Health Accounts 2011": Insights into Influencing Factors. J Cancer 2019; 10:6491-6501. [PMID: 31777579 PMCID: PMC6856899 DOI: 10.7150/jca.34891] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2019] [Accepted: 09/22/2019] [Indexed: 01/02/2023] Open
Abstract
PURPOSE To investigate the total current curative expenditure (CCE) of lung cancer in Hunan Province, China under the framework of the System of Health Accounts 2011 (SHA 2011) and explore the effect of insurance status, surgery and length of stay on the hospitalization expenses of patients with lung cancer. METHODS Through multistage stratified cluster random sampling, a total of 46,214 patients with lung cancer were enrolled from 1,072 medical institutions in Hunan Province in 2016. Under the SHA 2011 framework, the lung cancer CCE was analyzed. The relationships between hospitalization expenditure and the following factors (surgery, type of hospital, insurance status, length of stay, institution level, age and sex) were analyzed using Spearman's correlation analyses, and how these factors influenced hospital expenditure was explored through multiple stepwise regression analysis and structural equation modelling. RESULTS The CCE for lung cancer patients was 8063.75 million CNY. In total, 96.03% of the CCE for lung cancer occurred in hospitals and 58.88% of the expenditure flowed to general hospitals. The highest expenditures were incurred in the group aged 55-74 y, which accounted for 61.58% of the CCE. Drugs accounted for the greatest share expenditure to lung cancer patients at 34.31% of the CCE. Surgery, insurance status, institution level, sex and hospital type explained 57.5% of the variance in hospital expenses. The hospitalization expenses were related to surgery, insurance status, institution level and sex (rs = 0.033-0.688, p < 0.001). Surgery, insurance status and length of stay had direct effects on hospitalization expenses. Length of stay mediated the relationship between surgery and hospitalization expenses for lung cancer patients. Surgery mediated the relationship between insurance status and hospitalization expenses. All of these variables can explain 45% of the variance in hospitalization expenses. CONCLUSIONS The CCE of lung cancer is extremely high. The problems related to treatment efficiency and equity are serious for lung cancer patients in China. It is essential to expand health insurance coverage and reduce the curative expenditure of lung cancer.
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Affiliation(s)
- Shuang Zang
- School of Nursing, China Medical University, Shenyang, Liaoning
| | - Huan Zhan
- School of Humanities and Management, Hunan University of Chinese Medicine, Changsha, Hunan
| | - Liangrong Zhou
- School of Humanities and Management, Hunan University of Chinese Medicine, Changsha, Hunan
| | - Xin Wang
- College of the Humanities and Social Sciences, China Medical University, Shenyang, Liaoning
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Eaglehouse YL, Aljehani M, Georg MW, Castellanos O, Lee JSH, Seabury SA, Shriver CD, Zhu K. Contribution Of Care Source To Cancer Treatment Cost Variation In The US Military Health System. Health Aff (Millwood) 2019; 38:1335-1342. [PMID: 31381409 DOI: 10.1377/hlthaff.2019.00283] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
The US Military Health System (MHS) provides universal access to health care for more than nine million eligible beneficiaries through direct care in military treatment facilities or purchased care in civilian facilities. Using information from linked cancer registry and administrative databases, we examined how care source contributed to cancer treatment cost variation in the MHS for patients ages 18-64 who were diagnosed with colon, female breast, or prostate cancer in the period 2003-14. After accounting for patient, tumor, and treatment characteristics, we found the independent contribution of care source to total variation in cost to be 8 percent, 12 percent, and 2 percent for colon, breast, and prostate cancer treatment, respectively. About 20-50 percent of the total cost variance remained unexplained and may be related to organizational and administrative factors.
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Affiliation(s)
- Yvonne L Eaglehouse
- Yvonne L. Eaglehouse is a health services researcher in the Murtha Cancer Center Research Program, Department of Surgery, Uniformed Services University of the Health Sciences (USUHS); is an assistant professor in the Department of Surgery at USUHS; and is employed by the Henry M. Jackson Foundation for the Advancement of Military Medicine, all in Bethesda, Maryland
| | - Mayada Aljehani
- Mayada Aljehani is a biostatistician in the Lawrence J. Ellison Institute for Transformative Medicine, University of Southern California (USC), in Los Angeles
| | - Matthew W Georg
- Matthew W. Georg is a research associate in the Murtha Cancer Center Research Program, Department of Surgery, USUHS; and is employed by the Henry M. Jackson Foundation for the Advancement of Military Medicine
| | - Olga Castellanos
- Olga Castellanos is a clinical research program manager in the Lawrence J. Ellison Institute for Transformative Medicine, USC
| | - Jerry S H Lee
- Jerry S. H. Lee is the chief science and innovation officer in the Lawrence J. Ellison Institute for Transformative Medicine, USC; is an associate professor in the Departments of Clinical Medicine and Chemical Engineering, both at USC; and is employed by the Henry M. Jackson Foundation for the Advancement of Military Medicine
| | - Seth A Seabury
- Seth A. Seabury is the director of the Keck-Schaeffer Initiative for Population Health Policy at the Leonard D. Schaeffer Center for Health Policy and Economics and an associate professor in the Department of Pharmaceutical and Health Economics at the School of Pharmacy, both at USC
| | - Craig D Shriver
- Craig D. Shriver is the director of the Murtha Cancer Center Research Program, Department of Surgery, USUHS; director of the Murtha Cancer Center at Walter Reed National Military Medical Center; and a professor in the Department of Surgery at USUHS
| | - Kangmin Zhu
- Kangmin Zhu ( ) is the director of Military Epidemiology and Population Science in the Murtha Cancer Center Research Program, Department of Surgery, USUHS; is a professor in the Department of Preventive Medicine and Biostatistics at USUHS; and is employed by the Henry M. Jackson Foundation for the Advancement of Military Medicine
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5
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Keating NL, Huskamp HA, Kouri E, Schrag D, Hornbrook MC, Haggstrom DA, Landrum MB. Factors Contributing To Geographic Variation In End-Of-Life Expenditures For Cancer Patients. Health Aff (Millwood) 2019; 37:1136-1143. [PMID: 29985699 DOI: 10.1377/hlthaff.2018.0015] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Health care spending in the months before death varies across geographic areas but is not associated with outcomes. Using data from the prospective multiregional Cancer Care Outcomes Research and Surveillance Consortium (CanCORS) study, we assessed the extent to which such variation is explained by differences in patients' sociodemographic factors, clinical factors, and beliefs; physicians' beliefs; and the availability of services. Among 1,132 patients ages sixty-five and older who were diagnosed with lung or colorectal cancer in 2003-05, had advanced-stage cancer, died before 2013, and were enrolled in fee-for-service Medicare, mean expenditures in the last month of life were $13,663. Physicians in higher-spending areas reported less knowledge about and comfort with treating dying patients and less positive attitudes about hospice, compared to those in lower-spending areas. Higher-spending areas also had more physicians and fewer primary care providers and hospices in proportion to their total population than lower-spending areas did. Availability of services and physicians' beliefs, but not patients' beliefs, were important in explaining geographic variations in end-of-life spending. Enhanced training to better equip physicians to care for patients at the end of life and strategic resource allocation may have potential for decreasing unwarranted variation in care.
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Affiliation(s)
- Nancy L Keating
- Nancy L. Keating ( ) is a professor of health care policy and medicine in the Department of Health Care Policy, Harvard Medical School and the Division of General Internal Medicine at Brigham and Women's Hospital, both in Boston, Massachusetts
| | - Haiden A Huskamp
- Haiden A. Huskamp is the 30th Anniversary Professor of Health Care Policy in the Department of Health Care Policy, Harvard Medical School
| | - Elena Kouri
- Elena Kouri is project director in the Department of Health Care Policy at Harvard Medical School
| | - Deborah Schrag
- Deborah Schrag is a professor of medicine at Harvard Medical School and a research scientist in medical oncology and population sciences at the Dana-Farber Cancer Institute, in Boston
| | - Mark C Hornbrook
- Mark C. Hornbrook is a senior investigator emeritus in the Center for Health Research, Kaiser Permanente Northwest, in Portland, Oregon
| | - David A Haggstrom
- David A. Haggstrom is an associate professor of medicine at Indiana University School of Medicine and core investigator at the Indianapolis Veterans Affairs Medical Center, in Indianapolis
| | - Mary Beth Landrum
- Mary Beth Landrum is a professor of health care policy in the Department of Health Care Policy, Harvard Medical School
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Sinaiko AD, Chien AT, Hassett MJ, Kakani P, Rodin D, Meyers DJ, Fraile B, Rosenthal MB, Landrum MB. What drives variation in spending for breast cancer patients within geographic regions? Health Serv Res 2018; 54:97-105. [PMID: 30318592 DOI: 10.1111/1475-6773.13068] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2017] [Revised: 08/09/2018] [Accepted: 08/30/2018] [Indexed: 01/15/2023] Open
Abstract
OBJECTIVE To estimate and describe factors driving variation in spending for breast cancer patients within geographic region. DATA SOURCE Surveillance, Epidemiology, and End Results (SEER)-Medicare database from 2009-2013. STUDY DESIGN The proportion of variation in monthly medical spending within geographic region attributed to patient and physician factors was estimated using multilevel regression models with individual patient and physician random effects. Using sequential models, we estimated the contribution of differences in patient and disease characteristics or use of cancer treatment modalities to patient-level and physician-level variance in spending. Services associated with high spending physicians were estimated using linear regression. DATA EXTRACTION METHOD A total of 20 818 women with a breast cancer diagnosis in 2010-2011. PRINCIPAL FINDINGS We observed substantial between-patient and between-provider variation in spending following diagnosis and at the end-of-life. Immediately following diagnosis, 48% of between-patient and 31% of between-physician variation were driven by differences in delivery of cancer treatment modalities to similar patients. At the end-of-life, patients of high spending physicians had twice as many inpatient days, double the chemotherapy spending, and slightly more hospice days. CONCLUSIONS Similar patients receive very different treatments, which yield significant differences in spending. Efforts to reduce unwanted variation may need to target treatment choices within patient-doctor discussions.
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Affiliation(s)
- Anna D Sinaiko
- Department of Health Policy and Management, Harvard T. H. Chan School of Public Health, Boston, Massachusetts
| | - Alyna T Chien
- Harvard Medical School, Boston, Massachusetts.,Boston Children's Hospital, Boston, Massachusetts
| | - Michael J Hassett
- Department of Medicine, Harvard Medical School, Boston, Massachusetts.,Department of Medical Oncology, Dana Farber Cancer Institute, Boston, Massachusetts
| | | | - Danielle Rodin
- Department of Radiation Oncology, University of Toronto, Toronto, Ontario, Canada
| | - David J Meyers
- Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, Rhode Island
| | - Belen Fraile
- Department of Finance, Value and Population Health Management, Dana Farber Cancer Institute, Boston, Massachusetts
| | - Meredith B Rosenthal
- Department of Health Policy and Management, Harvard T. H. Chan School of Public Health, Boston, Massachusetts
| | - Mary Beth Landrum
- Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts
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7
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The Accountable Care Organization for Surgical Care. Surg Oncol Clin N Am 2018; 27:717-725. [PMID: 30213415 DOI: 10.1016/j.soc.2018.05.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Rising health care costs superimposed on uncertainty surrounding the relationship between health care spending and quality have resulted in an urgent need to develop strategies to better align health care payment with value. Such approaches, at least in theory, work to achieve the dual aims of reducing growth in health care spending and improving population health. To date, surgery has not been prioritized in accountable care organizations (ACOs). Nonetheless, it is critically important to begin to consider strategic and impactful mechanisms through which surgery can be seamlessly woven into innovative population health models.
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8
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Eaglehouse YL, Manjelievskaia J, Shao S, Brown D, Hofmann K, Richard P, Shriver CD, Zhu K. Costs for Breast Cancer Care in the Military Health System: An Analysis by Benefit Type and Care Source. Mil Med 2018; 183:e500-e508. [DOI: 10.1093/milmed/usy052] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2017] [Indexed: 12/22/2022] Open
Affiliation(s)
- Yvonne L Eaglehouse
- John P. Murtha Cancer Center, Uniformed Services University of the Health Sciences and Walter Reed National Military Medical Center, 11300 Rockville Pike, Suite 1120, Rockville, MD
- Department of Surgery, Uniformed Services University of the Health Sciences, 4301 Jones Bridge Road, Bethesda, MD
| | - Janna Manjelievskaia
- John P. Murtha Cancer Center, Uniformed Services University of the Health Sciences and Walter Reed National Military Medical Center, 11300 Rockville Pike, Suite 1120, Rockville, MD
| | - Stephanie Shao
- John P. Murtha Cancer Center, Uniformed Services University of the Health Sciences and Walter Reed National Military Medical Center, 11300 Rockville Pike, Suite 1120, Rockville, MD
| | - Derek Brown
- John P. Murtha Cancer Center, Uniformed Services University of the Health Sciences and Walter Reed National Military Medical Center, 11300 Rockville Pike, Suite 1120, Rockville, MD
| | - Keith Hofmann
- Kennell and Associates, Inc., 3130 Fairview Park Drive, Suite 450, Falls Church, VA
| | - Patrick Richard
- Department of Preventive Medicine and Biostatistics, Uniformed Services University of the Health Sciences, 4301 Jones Bridge Road, Bethesda, MD
| | - Craig D Shriver
- John P. Murtha Cancer Center, Uniformed Services University of the Health Sciences and Walter Reed National Military Medical Center, 11300 Rockville Pike, Suite 1120, Rockville, MD
- Department of Surgery, Uniformed Services University of the Health Sciences, 4301 Jones Bridge Road, Bethesda, MD
| | - Kangmin Zhu
- John P. Murtha Cancer Center, Uniformed Services University of the Health Sciences and Walter Reed National Military Medical Center, 11300 Rockville Pike, Suite 1120, Rockville, MD
- Department of Preventive Medicine and Biostatistics, Uniformed Services University of the Health Sciences, 4301 Jones Bridge Road, Bethesda, MD
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9
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Kaye DR, Min HS, Herrel LA, Dupree JM, Ellimoottil C, Miller DC. Costs of Cancer Care Across the Disease Continuum. Oncologist 2018; 23:798-805. [PMID: 29567821 PMCID: PMC6058326 DOI: 10.1634/theoncologist.2017-0481] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2017] [Accepted: 12/18/2017] [Indexed: 12/27/2022] Open
Abstract
Using SEER‐Medicare data, this article demonstrates that considerable differences exist in expenditures across phases of care and varying patient characteristics. These findings can help to provide a better understanding of the drivers of payment variation across patient and tumor characteristics to inform efforts to decrease costs and increase quality of cancer care. Purpose. The aim of this study was to estimate Medicare payments for cancer care during the initial, continuing, and end‐of‐life phases of care for 10 malignancies and to examine variation in expenditures according to patient characteristics and cancer severity. Materials and Methods. We used linked Surveillance, Epidemiology and End Results‐Medicare data to identify patients aged 66–99 years who were diagnosed with one of the following 10 cancers: prostate, bladder, esophageal, pancreatic, lung, liver, kidney, colorectal, breast, or ovarian, from 2007 through 2012. We attributed payments for each patient to a phase of care (i.e., initial, continuing, or end of life), based on time from diagnosis until death or end of study interval. We summed payments for all claims attributable to the primary cancer diagnosis and analyzed the overall and phase‐based costs and then by differing demographics, cancer stage, geographic region, and year of diagnosis. Results. We identified 428,300 patients diagnosed with one of the 10 malignancies. Annual payments were generally highest during the initial phase. Mean expenditures across cancers were $14,381 during the initial phase, $2,471 for continuing, and $13,458 at end of life. Payments decreased with increasing age. Black patients had higher payments for four of five cancers with statistically significant differences. Stage III cancers posed the greatest annual cost burden for four cancer types. Overall payments were stable across geographic region and year. Conclusion. Considerable differences exist in expenditures across phases of cancer care. By understanding the drivers of such payment variations across patient and tumor characteristics, we can inform efforts to decrease payments and increase quality, thereby reducing the burden of cancer care. Implications for Practice. Considerable differences exist in expenditures across phases of cancer care. There are further differences by varying patient characteristics. Understanding the drivers of such payment variations across patient and tumor characteristics can inform efforts to decrease costs and increase quality, thereby reducing the burden of cancer care.
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Affiliation(s)
- Deborah R Kaye
- Dow Division of Health Services Research, Department of Urology, University of Michigan, Ann Arbor, Michigan, USA
| | - Hye Sung Min
- Dow Division of Health Services Research, Department of Urology, University of Michigan, Ann Arbor, Michigan, USA
| | - Lindsey A Herrel
- Dow Division of Health Services Research, Department of Urology, University of Michigan, Ann Arbor, Michigan, USA
| | - James M Dupree
- Dow Division of Health Services Research, Department of Urology, University of Michigan, Ann Arbor, Michigan, USA
| | - Chad Ellimoottil
- Dow Division of Health Services Research, Department of Urology, University of Michigan, Ann Arbor, Michigan, USA
| | - David C Miller
- Dow Division of Health Services Research, Department of Urology, University of Michigan, Ann Arbor, Michigan, USA
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10
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Tannenbaum S, Soulos PR, Herrin J, Mougalian S, Long JB, Wang R, Ma X, Gross CP, Xu X. Regional Medicare Expenditures and Survival Among Older Women With Localized Breast Cancer. Med Care 2017; 55:1030-1038. [PMID: 29068906 PMCID: PMC5863278 DOI: 10.1097/mlr.0000000000000822] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Despite evidence on large variation in breast cancer expenditures across geographic regions, there is little understanding about the association between expenditures and patient outcomes. OBJECTIVES To examine whether Medicare beneficiaries with nonmetastatic breast cancer living in regions with higher cancer-related expenditures had better survival. RESEARCH DESIGN A retrospective cohort study of women with localized breast cancer from the Surveillance, Epidemiology, and End Results-Medicare linked database. Hospital referral regions (HRR) were categorized into quintiles based on risk-standardized per patient Medicare expenditures on initial phase of breast cancer care. Hierarchical generalized linear models were estimated to examine the association between patients' HRR quintile and survival. SUBJECTS In total, 12,610 Medicare beneficiaries diagnosed with stage II-III breast cancer during 2005-2008 who underwent surgery. MEASURES Outcome measures for our analysis were 3- and 5-year overall survival. RESULTS Risk-standardized per patient Medicare expenditures on initial phase of breast cancer care ranged from $13,338 to $26,831 across the HRRs. Unadjusted 3- and 5-year survival varied from 66.7% to 92.2% and 50.0% to 84.0%, respectively, across the HRRs, but there was no significant association between HRR quintile and survival in bivariate analysis (P=0.08 and 0.28, respectively). After adjustment for sociodemographic and clinical characteristics, quintiles of regional cancer expenditures remained unassociated with patients' 3-year (P=0.35) and 5-year survival (P=0.20). Further analysis adjusting for treatment factors (surgery type and receipt of radiation and systemic therapy) and stratifying by cancer stage showed similar results. CONCLUSIONS For Medicare beneficiaries with nonmetastatic breast cancer, residence in regions with higher breast cancer-related expenditures was not associated with better survival. More attention to value in breast cancer care is warranted.
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Affiliation(s)
| | - Pamela R. Soulos
- Section of General Internal Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, CT
- Yale University Cancer Outcomes, Public Policy and Effectiveness Research (COPPER) Center, New Haven, CT
| | - Jeph Herrin
- Yale University Cancer Outcomes, Public Policy and Effectiveness Research (COPPER) Center, New Haven, CT
- Division of Cardiology, Department of Internal Medicine, Yale School of Medicine, New Haven, CT
- Health Research & Educational Trust, Chicago, IL
| | - Sarah Mougalian
- Yale University Cancer Outcomes, Public Policy and Effectiveness Research (COPPER) Center, New Haven, CT
- Section of Medical Oncology, Department of Internal Medicine, Yale School of Medicine, New Haven, CT
| | - Jessica B. Long
- Section of General Internal Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, CT
- Yale University Cancer Outcomes, Public Policy and Effectiveness Research (COPPER) Center, New Haven, CT
| | - Rong Wang
- Yale University Cancer Outcomes, Public Policy and Effectiveness Research (COPPER) Center, New Haven, CT
- Department of Chronic Disease Epidemiology, Yale School of Public Health, New Haven, CT
| | - Xiaomei Ma
- Yale University Cancer Outcomes, Public Policy and Effectiveness Research (COPPER) Center, New Haven, CT
- Department of Chronic Disease Epidemiology, Yale School of Public Health, New Haven, CT
| | - Cary P. Gross
- Section of General Internal Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, CT
- Yale University Cancer Outcomes, Public Policy and Effectiveness Research (COPPER) Center, New Haven, CT
| | - Xiao Xu
- Yale University Cancer Outcomes, Public Policy and Effectiveness Research (COPPER) Center, New Haven, CT
- Department of Obstetrics, Gynecology and Reproductive Sciences, Yale School of Medicine, New Haven, CT
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11
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Chen CT, Li L, Brooks G, Hassett M, Schrag D. Medicare Spending for Breast, Prostate, Lung, and Colorectal Cancer Patients in the Year of Diagnosis and Year of Death. Health Serv Res 2017; 53:2118-2132. [PMID: 28748564 DOI: 10.1111/1475-6773.12745] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
OBJECTIVE To characterize spending patterns for Medicare patients with incident breast, prostate, lung, and colorectal cancer. DATA SOURCES/STUDY SETTING/STUDY DESIGN 2007-2012 data from the Surveillance, Epidemiology, and End Results Program linked with Medicare fee-for-service claims. DATA COLLECTION/EXTRACTION METHODS We calculate per-patient monthly and yearly mean and median expenditures, by cancer type, stage at diagnosis, and spending category, over the years of diagnosis and death. PRINCIPAL FINDINGS Over the year of diagnosis, mean spending was $35,849, $26,295, $55,597, and $63,063 for breast, prostate, lung, and colorectal cancer, respectively. Over the year of death, spending was similar across different cancer types and stage at diagnosis. CONCLUSIONS Characterization of Medicare spending according to clinically meaningful categories may assist development of oncology alternative payment models and cost-effectiveness models.
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Affiliation(s)
| | - Ling Li
- Division of Population Sciences, Dana Farber Cancer Institute, Boston, MA
| | - Gabriel Brooks
- Division of Population Sciences, Dana Farber Cancer Institute, Boston, MA
| | - Michael Hassett
- Division of Population Sciences, Dana Farber Cancer Institute, Boston, MA
| | - Deborah Schrag
- Division of Population Sciences, Dana Farber Cancer Institute, Boston, MA
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Vyas A, Madhavan SS, Sambamoorthi U. Differences in Medicare Expenditures Between Appalachian and Nationally Representative Cohorts of Elderly Women With Breast Cancer: An Application of Decomposition Technique. J Natl Compr Canc Netw 2017; 15:578-587. [PMID: 28476737 PMCID: PMC5576717 DOI: 10.6004/jnccn.2017.0060] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2016] [Accepted: 01/10/2017] [Indexed: 11/17/2022]
Abstract
Background: Differences in Medicare expenditures during the initial phase of cancer care among rural and medically underserved elderly women with breast cancer (BC) and those from a nationally representative cohort have not been reported. The objective of this study was to determine Medicare expenditures during the initial phase of care among women in West Virginia (WV) who were Medicare beneficiaries with BC and compare them with national estimates. The magnitude of differences in these expenditures was also determined by using a linear decomposition technique. Methods: A retrospective observational study was conducted using the WV Cancer Registry-Medicare database and the SEER-Medicare database. Our study cohorts consisted of elderly women aged ≥66 years diagnosed with incident BC in 2003 to 2006. Medicare expenditures during the initial year after BC diagnosis were derived from all of the Medicare files. Generalized linear regressions were performed to model expenditures, after controlling for predisposing factors, enabling resources, need, healthcare use, and external healthcare environmental factors. Blinder-Oaxaca decomposition was conducted to examine the proportion of the differences in the average expenditures explained by independent variables included in the model. Results: Average Medicare expenditures for the WV Medicare cohort during the initial phase of BC care were $25,626 compared with $29,502 for the SEER-Medicare cohort; a difference of $3,876. In the multivariate regression, this difference decreased to $708 and remained significant. Only 16% of the differences in the average expenditures between the cohorts were explained by the independent variables included in the model. Enabling resources (6.86%), healthcare use (7.55%), and external healthcare environmental factors (3.33%) constituted most of the explained portion of the differences in the average expenditures. Conclusions: The difference in average Medicare expenditures between the elderly beneficiaries with BC from a rural state (WV) and their national counterparts narrowed but remained significantly lower after multivariate adjustment. The explained portion of this difference was mainly driven by enabling and healthcare use factors, whereas 84% of this difference remained unexplained.
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Affiliation(s)
- Ami Vyas
- Department of Pharmacy Practice, College of Pharmacy, University of Rhode Island, Kingston, Rhode Island
| | - S. Suresh Madhavan
- Department of Pharmaceutical Systems and Policy, School of Pharmacy, West Virginia University, Morgantown, West Virginia
| | - Usha Sambamoorthi
- Department of Pharmaceutical Systems and Policy, School of Pharmacy, West Virginia University, Morgantown, West Virginia
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Pataky RE, Baliski CR. Reoperation costs in attempted breast-conserving surgery: a decision analysis. ACTA ACUST UNITED AC 2016; 23:314-321. [PMID: 27803595 DOI: 10.3747/co.23.2989] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
BACKGROUND Breast-conserving surgery (bcs) is the preferred surgical approach for most patients with early-stage breast cancer. Frequently, concerns arise about the pathologic margin status, resulting in an average reoperation rate of 23% in Canada. No consensus has been reached about the ideal reoperation rate, although 10% has been suggested as a target. Upon undergoing reoperation, many patients choose mastectomy and breast reconstruction, which add to the morbidity and cost of patient care. We attempted to identify the cost of reoperation after bcs, and the effect that a reduction in the reoperation rate could have on the B.C. health care system. METHODS A decision tree was constructed to estimate the average cost per patient undergoing initial bcs with two reoperation frequency scenarios: 23% and 10%. The model included the direct medical costs from the perspective of the B.C. health care system for the most common surgical treatment options, including breast reconstruction and postoperative radiation therapy. RESULTS Costs ranged from a low of $8,225 per patient with definitive bcs [95% confidence interval (ci): $8,061 to $8,383] to a high of $26,026 for reoperation with mastectomy and delayed reconstruction (95% ci: $23,991 to $28,122). If the reoperation rate could be reduced to 10%, the average saving would be $1,055 per patient undergoing attempted bcs (95% ci: $959 to $1,156). If the lower rate were to be achieved in British Columbia, it would translate into a savings of $1.9 million annually. SUMMARY The implementation of initiatives to reduce reoperation after bcs could result in significant savings to the health care system, while potentially improving the quality of patient care.
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Affiliation(s)
- R E Pataky
- Canadian Centre for Applied Research in Cancer Control, BC Cancer Agency, Vancouver
| | - C R Baliski
- Surgical Oncology, Sindi Ahluwalia Hawkins Centre for the Southern Interior, BC Cancer Agency, Kelowna, University of British Columbia, Vancouver, BC; Department of Surgery, University of British Columbia, Vancouver, BC
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Regional differences in recommended cancer treatment for the elderly. BMC Health Serv Res 2016; 16:262. [PMID: 27417075 PMCID: PMC4946160 DOI: 10.1186/s12913-016-1534-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2015] [Accepted: 07/06/2016] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Little is known about regional variation in cancer treatment and its determinants. We compare rates of adherence to treatment guidelines for elderly patients across Texas and whether local specialist supply is an important determinant of treatment variation. METHODS Previous literature reviewed indicated 7 recommended courses of treatment for colorectal, pancreatic, and prostate cancer. We analyzed Texas Cancer Registry data linked with Medicare claims for the years 2004 to 2007 to study patients with these cancers. We tested for unadjusted and adjusted differences in treatment rates across 22 hospital referral regions (HRR). We tested whether variation in the local supply of specialists treating each cancer was an important determinant of treatment. RESULTS We found significant differences in adjusted treatment rates across regions. For removal and examination of 12+ lymph nodes with colon cancer resection, 13 of 22 HRRs had rates significantly different from the median region. For adjuvant chemotherapy for regional colon cancer, five HRRs significantly differed from the median. For prostate cancer treatment with a favorable diagnosis, nine HRRs differed from the median HRR. Of the 7 treatments, only the local availability of surgeons was an important determinant for excision of lymph nodes for colon cancer patients. CONCLUSIONS There are significant variations across Texas for seven recommended cancer treatments. No one region has consistently higher or lower treatments than other regions, and local specialist supply is not an important predictor of treatment. Different factors may be determining regional variation in treatment rates across cancer types and treatment options.
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Zeidan AM, Wang R, Davidoff AJ, Ma S, Zhao Y, Gore SD, Gross CP, Ma X. Disease-related costs of care and survival among Medicare-enrolled patients with myelodysplastic syndromes. Cancer 2016; 122:1598-607. [PMID: 26970288 DOI: 10.1002/cncr.29945] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2015] [Revised: 01/21/2016] [Accepted: 01/28/2016] [Indexed: 11/10/2022]
Abstract
BACKGROUND Although newer treatments for myelodysplastic syndromes (MDS), particularly hypomethylating agents (HMAs), are expensive, it is unclear whether MDS-related costs of care are associated with overall survival. This study evaluated the relation between MDS-related costs and survival among Medicare beneficiaries with MDS. METHODS Eligible patients were identified from the Surveillance, Epidemiology, and End Results-Medicare database with codes for MDS from International Classification of Diseases for Oncology, 3rd edition. The patients were diagnosed between January 1, 2005 and December 31, 2011, were 66 years old or older, and were followed through death or the end of study (December 31, 2012). Medicare payments were used to estimate costs. Cumulative costs in a propensity score-matched group of cancer-free Medicare beneficiaries were subtracted from costs in the MDS cohort in each registry to estimate MDS-related costs. Hazard ratios (HRs) and 95% confidence intervals (CIs) were derived from multivariate Cox proportional hazards models adjusted for patient and disease characteristics. RESULTS There were 8580 eligible patients, and 1,267 (14.7%) received HMAs. The overall 2-year survival rate was 48.7%, and the 2-year registry-specific MDS-related cost per patient ranged from $40,793 to $78,156 across 16 registries. The 2-year MDS-related cost was not associated with survival in the overall study population (first tertile, reference; second tertile, HR, 0.96; 95% CI, 0.89-1.04; P = .29; third tertile, HR, 0.98; 95% CI, 0.91-1.06; P = .64) or in subgroups of patients who did or did not receive HMAs. CONCLUSIONS Medicare expenditures for elderly patients with MDS varied across registries but were not associated with survival. A lack of an association between costs and outcomes warrants additional research because it may help to identify potential areas for cost-saving interventions without compromising patient outcomes. Cancer 2016;122:1598-607. © 2016 American Cancer Society.
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Affiliation(s)
- Amer M Zeidan
- Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut.,Yale Cancer Outcomes, Public Policy, and Effectiveness Research Center, New Haven, Connecticut
| | - Rong Wang
- Yale Cancer Outcomes, Public Policy, and Effectiveness Research Center, New Haven, Connecticut.,Department of Chronic Disease Epidemiology, Yale School of Public Health, New Haven, Connecticut
| | - Amy J Davidoff
- Yale Cancer Outcomes, Public Policy, and Effectiveness Research Center, New Haven, Connecticut.,Department of Health Policy and Management, Yale School of Public Health, New Haven, Connecticut
| | - Shuangge Ma
- Department of Biostatistics, Yale School of Public Health, New Haven, Connecticut
| | - Yinjun Zhao
- Department of Biostatistics, Yale School of Public Health, New Haven, Connecticut
| | - Steven D Gore
- Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Cary P Gross
- Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut.,Yale Cancer Outcomes, Public Policy, and Effectiveness Research Center, New Haven, Connecticut
| | - Xiaomei Ma
- Yale Cancer Outcomes, Public Policy, and Effectiveness Research Center, New Haven, Connecticut.,Department of Chronic Disease Epidemiology, Yale School of Public Health, New Haven, Connecticut
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