Medicare Claim Processors’ Reimbursement and G-CSF Choice Among Non-Hodgkin Lymphoma Patients
Published Online: August 21, 2013
Xiaoyun Pan, PhD and Usha Sambamoorthi, PhD
Recent health policy efforts have targeted healthcare financing to reduce the escalating healthcare costs and improve patient care.1 One of the hallmarks of the healthcare reform is to provide patient-centric high quality care through innovative payment initiatives. For example, the Centers for Medicare & Medicaid Services (CMS) has proposed “bundled” payments for acute and post-acute care.2,3 Use of reimbursement policies to contain costs is not new. In a simulation analysis Welch suggested that bundling payments may not increase the financial risk to hospitals.4 However, the effect of reimbursement policies on services provided by physicians through augmentation of standard regimens with supplemental services has not been examined.
Medicare payments of chemotherapy for cancer patients are determined by the local Medicare claim processing agents. Such discretion often results in different payment polices across these claim processors. The claim processors often have the option of making a single, prospective bundled payment for all items and services provided, or making separate payments to the physician for each of the drugs and services delivered.5 As reimbursement amounts to physicians are linked to their profits,6 differences in reimbursement amounts can affect physicians’ income and can lead to variations in physician practices including cancer care.
However, to date there has been no research examining the association between Medicare claim processor reimbursement policies and physicians’ prescriptions of supplemental products among cancer patients. Due to lack of published literature in this area, we extrapolate the effect of differences in reimbursement policies on cancer care using studies that have analyzed the association between fee changes over time and the response of physicians in increasing or decreasing the volume of services. Reimbursement changes (ie, reduction in Medicare payments) on physician behavior have been investigated in many areas: cesarean delivery, major joint repair/replacement procedures, coronary artery bypass grafting, and physician consultation services.7-10 In these studies, no conclusive evidence was found in terms of linking reduction in Medicare payments to increased volume of services provided to the patients. Physician’s response to reduction in Medicare payments for surgical procedures including cataract, hip repair, hip replacement, knee replacement, and joint procedures was dependent on the type of procedures and physician specialties.8 In addition, physician’s response was dependent on what proportion of the income was affected by the fee change.7,11-15 If one applies these findings to assess the relationship between reimbursement policies and prescribing volume, one can conclude there is considerable uncertainty and there is a critical need for studies in this area.
In this context, potential variations in Medicare claim processors’ reimbursement policies for cancer care, specifically chemotherapy, can be considered a “natural experiment” that allows us to examine the association between reimbursement amounts and physicians’ prescribing practices. The perspective of the current study is different from studies that examined changes in Medicare fees on physicians’ volume of services for which fee changes were enacted. Rather, we focus on the relationship between reimbursement policies and change in provision of a supplemental product or service because physicians may respond to variations in reimbursement policies by offering a different mix of services including supplemental products or services.16
Therefore, the primary objective of the current study is to analyze the relationship between reimbursement policies and prescription of supplemental products among patients with cancer. For the purposes of this article, we consider use of granulocyte colony-stimulating factor (G-CSF) as the supplemental product during an episode of cancer care. We selected cancer patients with non-Hodgkin lymphoma (NHL) for several reasons. The main modality of treatment for patients with NHL is chemotherapy. Chemotherapy regimens are sometimes augmented with G-CSF as a prophylaxis to prevent febrile neutropenia,17 a life-threatening condition with low white blood cells and high fever18 among cancer patients on chemotherapy.19 In addition, G-CSF is listed as one of the top 10 most expensive Medicare Part B drugs, with average reimbursement amounts for 11 days of supply ranging from $2136 to $3442.20 Thus, augmenting chemotherapy with G-CSF may provide increased revenue for the physicians.
We used a retrospective longitudinal design using linked cancer registry data from 2002 through 2007 and Medicare claims data from 2001 through 2008. Patients were followed for the fi rst 5 months after diagnosis of NHL to define the fi rst course of chemotherapy.21
The data for the current study come from the Surveillance, Epidemiology, and End Results (SEER)-Medicare linked database. The SEER data contain 13 cancer registries with demographic information (age, gender, race, county of residence), area-level socioeconomic status, Medicare enrollment status, and clinical information (diagnosis date, histology, stage, lymph node involvement, and grade). The current study uses the “Patient Entitlement and Diagnosis Summary File” (PEDSF), a customized file of SEER data. SEER data were linked with Medicare fi les to allow us to analyze Medicare-covered healthcare services.
Patients With NHL. Cancer registry data were used to identify patients over age 66 years and diagnosed with NHL anytime between 2002 and 2007 using primary diagnosis (N = 33,017). Other exclusion criteria were: patients without a reliable death date (N = 45), not continuously enrolled in Medicare Part A and/or Part B, enrolled in Medicare HMO (N = 9908), cancer site was any part of the central nervous system (N = 2322), did not have the fi rst course of chemotherapy and hospitalized or had emergency department (ED) visits during the fi rst cycle of chemotherapy (N = 13,366), and patients who had missing information of area socioeconomics, node, stage, and histology type (N = 127). Thus, the fi nal study population consisted of 7249 patients with NHL.
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