Patterns of Care for Medicare Beneficiaries With Metastatic Prostate Cancer.

INTRODUCTION: Therapeutic options for men with metastatic prostate cancer have increased in the past decade. We studied recent treatment patterns for men with metastatic prostate cancer and how treatment patterns have changed over time. METHODS: Using the Surveillance, Epidemiology, and End Results‒Medicare database, we identified fee-for-service Medicare beneficiaries who either were diagnosed with metastatic prostate cancer or developed metastases following diagnosis, as indicated by the presence of claims with diagnoses codes for metastatic disease, between 2007 and 2017. We evaluated treatment patterns using claims. RESULTS: We identified 29,800 men with metastatic disease, of whom 4721 (18.8%) had metastatic disease at their initial diagnosis. The mean age was 77 years, and 77.9% of patients were non-Hispanic White. The proportion receiving antineoplastic agents within 3 years of the index date increased over time (from 9.7% in 2007 to 25.9% in 2017; P < .001). Opioid use within 3 years of prostate cancer diagnosis was stable during 2007 to 2013 (around 73%) but decreased through 2017 to 65.5% (P < .001). Patients diagnosed during 2015 to 2017 had longer median survival (32.6 months) compared to those diagnosed during 2007 to 2010 (26.6 months; P < .001). CONCLUSIONS: Most metastatic prostate cancer patients do not receive life-prolonging antineoplastic therapies. Improved adoption of effective cancer therapies when appropriate may increase length and quality of survival among metastatic prostate cancer patients.

Variation in State-Level Mammography Use, 2012 and 2020.

OBJECTIVES: Mammography is a screening tool for early detection of breast cancer. Uptake in screening use in states can be influenced by Medicaid coverage and eligibility policies, public health outreach efforts, and the Centers for Disease Control and Prevention-funded National Breast and Cervical Cancer Early Detection Program. We described state-specific mammography use in 2020 and changes as compared with 2012. METHODS: We estimated the proportion of women aged ≥40 years who reported receiving a mammogram in the past 2 years, by age group, state, and demographic and socioeconomic characteristics, using 2020 Behavioral Risk Factor Surveillance System data. We also compared 2020 state estimates with 2012 estimates. RESULTS: The proportion of women aged 50-74 years who received a mammogram in the past 2 years was 78.1% (95% CI, 77.4%-78.8%) in 2020. Across measures of socioeconomic status, mammography use was generally lower among women who did not have health insurance (52.0%; 95% CI, 48.3%-55.6%) than among those who did (79.9%; 95% CI, 79.3%-80.6%) and among those who had a usual source of care (49.4%; 95% CI, 46.1%-52.7%) than among those who did not (81.0%; 95% CI, 80.4%-81.7%). Among women aged 50-74 years, mammography use varied across states, from a low of 65.2% (95% CI, 61.4%-69.0%) in Wyoming to a high of 86.1% (95% CI, 83.8%-88.3%) in Massachusetts. Four states had significant increases in mammography use from 2012 to 2020, and 8 states had significant declines. CONCLUSION: Mammography use varied widely among states. Use of evidence-based interventions tailored to the needs of local populations and communities may help close gaps in the use of mammography.

Cost-Effectiveness Analysis of Screening for Pancreatic Cancer Among High-Risk Populations.

PURPOSE: We evaluated the potential cost-effectiveness of combined magnetic resonance imaging (MRI) and endoscopic ultrasound (EUS) screening for pancreatic ductal adenocarcinoma (PDAC) among populations at high risk for the disease. METHODS: We used a microsimulation model of the natural history of PDAC to estimate the lifetime health benefits, costs, and cost-effectiveness of PDAC screening among populations with specific genetic risk factors for PDAC, including BRCA1 and BRCA2, PALB2, ATM, Lynch syndrome, TP53, CDKN2A, and STK11. For each high-risk population, we simulated 29 screening strategies, defined by starting age and frequency. Screening included MRI with follow-up EUS in a subset of patients. Costs of tests were based on Medicare reimbursement for MRI, EUS, fine-needle aspiration biopsy, and pancreatectomy. Cancer-related cost by stage of disease and phase of treatment was based on the literature. For each high-risk population, we performed an incremental cost-effectiveness analysis, assuming a willingness-to-pay (WTP) threshold of $100,000 US dollars (USD) per quality-adjusted life year (QALY) gained. RESULTS: For men with relative risk (RR) 12.33 (CDKN2A) and RR 28 (STK11), annual screening was cost-effective, starting at age 55 and 40 years, respectively. For women, screening was only cost-effective for those with RR 28 (STK11), with annual screening starting at age 45 years. CONCLUSION: Combined MRI/EUS screening may be a cost-effective approach for the highest-risk populations (among mutations considered, those with RR >12). However, for those with moderate risk (RR, 5-12), screening would only be cost-effective at higher WTP thresholds (eg, $200K USD/QALY) or with once-only screening.

Hospital ownership and admission rates from the emergency department, evidence from Florida.

OBJECTIVE: In light of Department of Justice investigations of for-profit chains for over-admitting patients, we sought to evaluate whether for-profit hospitals are more likely to admit patients from the emergency department. DATA SOURCES: We used statewide visit-level inpatient and emergency department records from Florida's Agency for Healthcare Administration for 2007-2019. STUDY DESIGN: We calculated differences in admission rates between for-profit and other hospitals, adjusting for patient and hospital characteristics. We also estimated instrumental variables models using differential distance to a for-profit hospital as an instrument. DATA COLLECTION/EXTRACTION METHODS: Our main analysis focuses on patients ages 65 and older treated in hospitals that primarily serve adults. PRINCIPAL FINDINGS: Adjusted admission rates among patients ages 65 and older were 7.1 percentage points (95% CI: 5.1-9.1) higher at for-profit hospitals in 2019 (or 18.8% of the sample mean of 37.8%). Differences in admission rates have remained constant since 2009. CONCLUSION: Our results are consistent with allegations that for-profit hospitals maintain lower admission thresholds to increase occupancy levels.

The cost burden of metastatic prostate cancer in the US populations covered by employer-sponsored health insurance.

BACKGROUND: Recent advancements in the clinical management of metastatic prostate cancer include several costly therapies and diagnostic tests. The objective of this study was to provide updated information on the cost to payers attributable to metastatic prostate cancer among men aged 18 to 64 years with employer-sponsored health plans and men aged 18 years or older covered by employer-sponsored Medicare supplement insurance. METHODS: By using Merative MarketScan commercial and Medicare supplemental data for 2009-2019, the authors calculated differences in spending between men with metastatic prostate cancer and their matched, prostate cancer-free controls, adjusting for age, enrollment length, comorbidities, and inflation to 2019 US dollars. RESULTS: The authors compared 9011 patients who had metastatic prostate cancer and were covered by commercial insurance plans with a group of 44,934 matched controls and also compared 17,899 patients who had metastatic prostate cancer and were covered by employer-sponsored Medicare supplement plans with a group of 87,884 matched controls. The mean age of patients with metastatic prostate cancer was 58.5 years in the commercial samples and 77.8 years in the Medicare supplement samples. Annual spending attributable to metastatic prostate cancer was $55,949 per person-year (95% confidence interval [CI], $54,074-$57,825 per person-year) in the commercial population and $43,682 per person-year (95% CI, $42,022-$45,342 per person-year) in the population covered by Medicare supplement plans, both in 2019 US dollars. CONCLUSIONS: The cost burden attributable to metastatic prostate cancer exceeds $55,000 per person-year among men with employer-sponsored health insurance and $43,000 among those covered by employer-sponsored Medicare supplement plans. These estimates can improve the precision of value assessments of clinical and policy approaches to the prevention, screening, and treatment of prostate cancer in the United States.

The Cost of Metastatic Prostate Cancer in the United States.

INTRODUCTION: We sought to estimate per patient and annual aggregate health care costs related to metastatic prostate cancer. METHODS: Using the Surveillance, Epidemiology, and End Results-Medicare database, we identified fee-for-service Medicare beneficiaries ages 66 and older diagnosed with metastatic prostate cancer or claims with diagnosis codes for metastatic disease (indicating tumor progression following diagnosis) between 2007 and 2017. We measured annual health care costs and compared costs between cases and a sample of beneficiaries without prostate cancer. RESULTS: We estimate that per-patient annual costs attributable to metastatic prostate cancer are $31,427 (95% CI: $31,219-$31,635; 2019 dollars). Annual attributable costs rose over time, from $28,311 (95% CI: $28,047-$28,575) in 2007-2013 to $37,055 (95% CI: $36,716-$37,394) in 2014-2017. In aggregate, health costs attributable to metastatic prostate cancer are $5.2 to $8.2 billion per year. CONCLUSIONS: The per patient annual health care costs attributable to metastatic prostate cancer are substantial and have increased over time, corresponding to the approval of new oral therapies used in treating metastatic prostate cancer.

Cancer Survivorship and Supportive Care Economics Research: Current Challenges and Next Steps.

BACKGROUND: Rapid growth in the number of cancer survivors raises numerous questions about health and economic outcomes among survivors along with their families, caregivers, and employers. Health economics theory and methods can contribute to many open questions to improve survivorship. METHODS: In this paper, we review key areas where more research is needed and describe strategies for improving data infrastructure, research funding, and capacity building to strengthen survivorship health economics research. CONCLUSIONS: Health economics has broadened an understanding of key supply- and demand-side factors that promote cancer survivorship. To ensure necessary research in survivorship health economics moving forward, we recommend dedicated funding, inclusion of health economics outcomes in primary data collection, and investments in secondary data sets.

Disparities in magnetic resonance imaging of the prostate for traditionally underserved patients with prostate cancer.

BACKGROUND: Prebiopsy magnetic resonance imaging (MRI) of the prostate improves detection of significant tumors, while decreasing detection of less-aggressive tumors. Therefore, its use has been increasing over time. In this study, the use of prebiopsy MRI among Medicare beneficiaries with prostate cancer was examined. It was hypothesized that patients of color and those in isolated areas would be less likely to undergo this approach for cancer detection. METHODS: Using cancer registry data from the Surveillance, Epidemiology, and End Results (SEER) program linked to billing claims for fee-for-service Medicare beneficiaries, men with nonmetastatic prostate cancer were identified from 2010 through 2015 with prostate-specific antigen (PSA) <30 ng/mL. Outcome was prebiopsy MRI of the prostate performed within 6 months before diagnosis (ie, Current Procedural Terminology 72197). Exposures were patient race/ethnicity and rural/urban status. Multivariable regression estimated the odds of prebiopsy prostate MRI. Post hoc analyses examined associations with the registry-level proportion of non-Hispanic Black patients and MRI use, as well as disparities in MRI use in registries with data on more frequent use of prostate MRI. RESULTS: There were 50,719 men identified with prostate cancer (mean age, 72.1 years). Overall, 964 men (1.9% of cohort) had a prebiopsy MRI. Eighty percent of patients with prebiopsy MRI lived in California, New Jersey, or Connecticut. Non-Hispanic Black men (0.6% vs 2.1% non-Hispanic White; odds ratio [OR], 0.28; 95% CI, 0.19-0.40) and men in less urban areas (1.1% vs 2.2% large metro; OR, 0.65; 95% CI, 0.44-0.97) were less likely to have prebiopsy MRI of the prostate. CONCLUSIONS: Non-Hispanic Black patients with prostate cancer and those in less urban areas were less likely to have prebiopsy MRI of the prostate during its initial adoption as a tool for improving prostate cancer detection.

The value of new drugs for advanced prostate cancer.

BACKGROUND: The US Food and Drug Administration has recently approved a number of new cancer drugs. The clinical trials that serve as the basis for new cancer drug approvals may not reflect how the drugs will perform in routine practice and do not measure the impact of the drugs on spending. The authors sought to evaluate the real-world effectiveness and value of drugs recently approved for advanced prostate cancer. METHODS: Using Surveillance, Epidemiology, and End Results-Medicare data, the authors identified fee-for-service Medicare beneficiaries aged 65 years or older who began treatment with a drug approved for metastatic castration-resistant prostate cancer in 2007-2009, when only 1 drug was approved for metastatic castration-resistant prostate cancer, and in 2014-2016, when 5 additional drugs were approved. They calculated life expectancy and lifetime medical costs (ie, Medicare reimbursements) for each group. RESULTS: Between 2007-2009 and 2014-2016, life expectancy increased by 12.6 months. Lifetime medical costs increased by $87,000. The incremental cost per life-year gained was $83,000. CONCLUSION: The release of 5 new drugs coincided with increases in survival rates and spending. This study's estimates indicate that the new drugs collectively were cost-effective.

Medicare fee reductions and the overuse of intensity-modulated radiotherapy.

OBJECTIVE: To estimate the impact of a large Medicare fee reduction for intensity-modulated radiation therapy (IMRT) on its use in prostate and breast cancer patients. DATA SOURCES/STUDY SETTING: SEER-Medicare. STUDY DESIGN: We compared trends in the use of IMRT between patients treated in practices directly affected by fee reductions (for prostate cancer, men treated in urology practices that own IMRT equipment; for breast cancer, women treated in freestanding radiotherapy clinics) and patients treated in other types of practices. DATA COLLECTION/EXTRACTION METHODS: We identified breast and prostate cancer patients receiving IMRT using outpatient and physician office claims. We classified urology practices based on whether they billed for IMRT and radiotherapy clinics based on whether they were reimbursed under the Physician Fee Schedule. PRINCIPAL FINDINGS: Between 2006 and 2015 the payment for IMRT delivered in freestanding clinics and physician offices declined by $367 (-54.7%). However, the use of IMRT increased in physician practices subject to payment cuts, both in absolute terms and relative to use in practices unaffected by the payment cut. Use of IMRT in prostate cancer patients treated at urology practices that own IMRT equipment increased by 9.1 (95% CI: 2.0-16.2) percentage points between 2005 and 2016 relative to use in patients treated at other urology practices. Use of IMRT in breast cancer patients treated at freestanding radiotherapy centers increased by 7.5 (95% CI: -5.1 to 20.1) percentage points relative to use in patients treated at hospital-based centers. CONCLUSIONS: A steep decline in IMRT fees did not decrease IMRT use over the period from 2006 to 2015, though use has declined since 2010.

Deterrence effects of antifraud and abuse enforcement in health care.

Estimates of the benefits of antifraud enforcement in health care typically focus on direct monetary damages. Deterrence effects are acknowledged but unquantified. We evaluate the impact of a Department of Justice investigation of hospitals accused of billing Medicare for unnecessary implantable cardiac defibrillator (ICD) procedures on their use. Using 100 % inpatient and outpatient procedure data from Florida, we estimate that the investigation caused a 22 % decline in ICD implantations. The present value of savings nationally over a 10 year period is $2.7 billion, nearly 10 times larger than the $280 million in settlements the Department of Justice recovered from hospitals. The investigation had a large and long-lasting effect on physician behavior, indicating the utility of antifraud enforcement as a tool for reducing wasteful medical care.

Trends in the use of active surveillance and treatments in Medicare beneficiaries diagnosed with localized prostate cancer.

BACKGROUND: The treatment for men diagnosed with localized prostate cancer has changed over time given the increased attention to the harms associated with over-diagnosis and the development of protocols for active surveillance. METHODS: We examined trends in the treatment of men diagnosed with localized prostate cancer between 2004 and 2015, using the most recently available data from Surveillance, Epidemiology, and End Results Program (SEER)-Medicare. Patients were stratified by Gleason score, age, and race groups. RESULTS: The use of active surveillance increased from 22% in 2004-2005 to 50% in 2014-2015 for patients with a Gleason score of 6 or below and increased from 9% in 2004-2005 to 13% in 2014-2015 for patients with a Gleason score of 7 or above. Patients with a Gleason score of 7 or above had increased use of intensity-modulated radiation therapy and prostatectomy, especially among patients aged 75 years and older. Among patients with a Gleason score of 6 or below non-Hispanic black men were less likely to undergo active surveillance than non-Hispanic white men. CONCLUSIONS: There has been a large increase in the use of active surveillance among men with a Gleason score of 6 or below. However, non-Hispanic black men with a Gleason score of 6 or below are less likely to receive active surveillance.

The eligibility and reach of the national breast and cervical cancer early detection program after implementation of the affordable care act.

INTRODUCTION: The uninsured rate declined following passage of the Affordable Care Act in 2010. It is unclear how this decrease affected the size of the population eligible for existing safety net programs. We evaluated trends in the number of women eligible for breast and cervical cancer screening and diagnostic services under the National Breast and Cervical Cancer Early Detection Program (NBCCEDP) and the reach of the program. METHODS: Using the Census Bureau's Small Area Health Insurance Estimates data, we calculated the number of women who met the NBCCEDP eligibility criteria based on age, income, and insurance status. We used these data in conjunction with program to estimate the proportion of eligible women served by the NBCCEDP. RESULTS: The number of women eligible for breast cancer screening and diagnostic services under the program declined from 5.4 (90% CI 5.2-5.6) to 2.8 (90% CI 2.6-3.0) million from 2011 to 2017. The number of women eligible for cervical cancer screening and diagnostic services declined from 10.3 (90% CI 10.0-10.6) to 5.3 (90% CI 5.1-5.6) million. The share of eligible women served by the program was 15.0% (90% CI 14.8-15.1%) for breast services in 2016-2017 and 6.8% (90% CI 6.7-6.8%) for cervical services in 2015-2017. CONCLUSION: Insurance coverage expansions may have contributed to a decrease in the number of program-eligible women. There are many more women eligible for the program than are served.

Payments and Patient Cost Sharing for Prostate Biopsies According to Image Guidance, Practice Site and Use of Anesthesia.

INTRODUCTION: Use of magnetic resonance imaging for prostate biopsies has increased and more biopsies are performed in nonoffice based settings. These changes will likely impact payments related to prostate biopsies. METHODS: Using private insurance claims from 2009 to 2015 we identified men who underwent transrectal ultrasound guided (CPT 55700) or transperineal (CPT 55706) prostate biopsies. We assumed any magnetic resonance imaging of the pelvis within 3 months prior to biopsy was for image based guidance. We assigned biopsy site as being performed in the office, ambulatory surgical center or hospital. Use of anesthesia was based on CPT codes 00100-01999. Our primary outcome was aggregate payments for anesthesia, pathology, imaging and procedural services. We also studied patient out-of-pocket costs. Multivariable regression was used to generate predicted payments based on magnetic resonance imaging performance, anesthesia and site of biopsy. RESULTS: We identified 304,388 biopsy episodes, of which 2.2% were magnetic resonance imaging guided and 0.7% were transperineal. Median cost of magnetic resonance imaging guided biopsies was greatest at $4,396 (IQR $2,784-$7,127) compared to the costs of transperineal and transrectal ultrasound guided biopsies. Imaging accounted for the greatest share of magnetic resonance imaging guided biopsy costs (median $1,704, IQR $975-$3,043). Magnetic resonance imaging guided biopsies in a hospital with anesthesia had the highest cost at $5,832 per episode (95% CI $5,732-$5,934). There was a fivefold difference in patient cost sharing between the least expensive (transperineal, office and no anesthesia $168) and most expensive (magnetic resonance imaging guided, ambulatory surgical center with anesthesia $891) modality. CONCLUSIONS: Total and out-of-pocket costs for prostate biopsies vary substantially based on modality, location and anesthesia use.

Association Between Self-Reported Hypertension and Antihypertensive Medication Use and Cardiovascular Disease-Related Events and Expenditures Among Patients Diagnosed With Hypertension.

OBJECTIVES: Research suggests that persons who are aware of the risk factors for cardiovascular disease (CVD) are more likely to engage in healthy behaviors than persons who are not aware of the risk factors. We examined whether patients whose insurance claims included an International Classification of Diseases, Ninth Revision (ICD-9) code associated with hypertension who self-reported high blood pressure were more likely to fill antihypertensive medication prescriptions and less likely to have CVD-related emergency department visits and hospitalizations (hereinafter, CVD-related events) and related medical expenditures than patients with these codes who did not self-report high blood pressure. METHODS: We used a large convenience sample from the MarketScan Commercial Database linked with the MarketScan Health Risk Assessment (HRA) Database to identify patients aged 18-64 in the United States whose insurance claims included an ICD-9 code associated with hypertension and who completed an HRA from 2008 through 2012 (n = 111 655). We used multivariate logistic regression analysis to examine the association between self-reported high blood pressure and (1) filling prescriptions for antihypertensive medications and (2) CVD-related events. Because most patients with hypertension will not have a CVD-related event, we used a 2-part model to analyze medical expenditures. The first part estimated the likelihood of a CVD-related event, and the second part estimated expenditures. RESULTS: Patients with an ICD-9 code of hypertension who self-reported high blood pressure had a significantly higher predicted probability of filling antihypertensive medication prescriptions (26.5%; 95% confidence interval, 25.7-27.3; P < .001), had a significantly lower predicted probability of a CVD-related event (0.6%, P < .001), and on average spent significantly less on CVD-related events ($251, P = .01) than patients who did not self-report high blood pressure. CONCLUSION: This study affirms that self-knowledge of high blood pressure, even among patients who are diagnosed and treated for hypertension, can be improved. Interventions that improve patients' awareness of their hypertension may improve antihypertensive medication use and reduce adverse CVD-related events.

Relationship Between Adherence to Antihypertensive Medication Regimen and Out-of-Pocket Costs Among People Aged 35 to 64 With Employer-Sponsored Health Insurance.

We used administrative claims data from 2014 on people with employer-sponsored health insurance to assess the proportion of patients taking antihypertensive medications, rates of nonadherence to these medication regimens, and out-of-pocket costs paid by patients. We performed multivariate logistic regression analysis to examine the association between out-of-pocket costs and nonadherence. Results indicated that patients filled the equivalent of 13 monthly prescriptions and paid $76 out of pocket over the calendar year; the likelihood of nonadherence increased as out-of-pocket costs increased (adjusted odds ratios ranged from 1.04 to 1.78; P < .001). These findings suggest a need for improvement in adherence among patients with employer-sponsored insurance.

Physician age and the abandonment of episiotomy.

OBJECTIVE: To determine whether women treated by older physicians are more likely to undergo episiotomy. DATA SOURCES/STUDY SETTING: Hospital discharge data from Pennsylvania for the period 1994 to 2010. STUDY DESIGN: We examined the impact of the year in which physicians started delivering babies (a proxy for age) in Pennsylvania on episiotomy rates using a linear probability model with hospital fixed effects. DATA COLLECTION/EXTRACTION METHODS: Using diagnosis and procedure codes, we identified women delivering vaginally (N = 1 658 327) and determined the proportion who had an episiotomy. PRINCIPAL FINDINGS: The average physician-level episiotomy rate declined from 54 percent in 1994 to 13 percent in 2010. Rates declined among older and younger physicians, but, at any point in time, women treated by older physicians were more likely to have an episiotomy. A 10-year difference in physician age is associated with a 6 percentage point increase in episiotomy rates. CONCLUSIONS: Results indicate that older physicians, who entered practice when episiotomy was common, were slow to adjust their practices in response to evidence showing that routine episiotomy is unnecessary.

Provider-owned insurers in the individual market.

OBJECTIVES: To describe the number and availability of individual market plans sold by provider-owned insurers and compare differences in premiums between traditional and provider-owned insurers. STUDY DESIGN: Cross-sectional analysis. METHODS: Using the Robert Wood Johnson Foundation's HIX Compare data, we identified insurers selling Affordable Care Act (ACA)-compliant policies in the individual market and identified those insurers owned by health systems by using information on their websites. We determined the number of insurers selling policies in each market and the size of the population living in areas where provider-owned insurers sold plans in 2016 and 2017. We used least squares regression to compare premiums between traditional and provider-owned insurers within markets, and we adjusted standard errors for clustering at the market and insurer level. RESULTS: There were 149 insurers that sold ACA-compliant plans in 2017, of which 51 were provider owned. Provider-owned insurers operated in 208 of the 503 exchange markets. We estimate that about 62% of US residents (more than 170 million people) live in a market in which a provider-owned insurer sells plans. Premiums did not differ significantly between traditional and provider-owned plans in 2017. CONCLUSIONS: Provider-owned insurers play a prominent role in the individual insurance market. Although health systems that sell insurance have incentives to reduce costs, provider-owned insurers and traditional insurers have similar premiums.