Medicare Claim Processors’ Reimbursement and G-CSF Choice Among Non-Hodgkin Lymphoma Patients | Page 3
Published Online: August 21, 2013
Xiaoyun Pan, PhD and Usha Sambamoorthi, PhD
The study population consisted of 7249 patients; 38.45% had prophylactic G-CSF prescription during the first cycle of chemotherapy (data not presented in tabular form). The mean age was 76 years. An overwhelming majority of patients were white (92%). Fifty-one percent were females. The most common histology type at diagnosis was diffuse large cell lymphoma (DLC) (43%). A majority of patients were diagnosed with B symptom and others (54%) with stage I (26%), stage II (17%), stage III (18%), and stage IV (32%). Approximately 40% had at least 1 comorbid condition within the 12-month period before diagnosis. Forty-fi ve percent received ABC with rituximab and 9% patients received ABC without rituximab.
Determination of Reimbursement Policies
Table 1 describes the average estimated reimbursement amounts across all 108 Medicare claim processor groups and also estimated reimbursement amount at the patient level. The estimated average reimbursement amount at the patient level was $6239 and median was $6014. For ease of presentation, in this table we also grouped average reimbursement amounts in 4 categories: 1) less than $5669; 2) $5669 to $6901; 3) $6901 to $8094; and 4) greater than $8094. The top panel of the table presents the number and percentage of Medicare claim processor groups at different estimated average reimbursement levels.
The results from the OLS regressions on reimbursement amounts at patient level are summarized in the bottom panel of Table 1. F-test from the regression indicated that there were statistically significant variations in the estimated chemotherapy reimbursement amount across Medicare claim processor groups (P <.0001).
To identify reimbursement policies of the claim processors (bundled vs separate payments), we also examined chemotherapy administration codes across different Medicare claim processor groups. The average number of chemotherapy administration codes used in the first cycle of chemotherapy was 5 in top deciles, while the average number of chemotherapy administration codes was 3 in bottom deciles. We further identifi ed administration codes in top deciles and not in bottom deciles: Current Procedural Terminology (CPT) code 96408. The code indicates “more than once per day for each drug the oncologist provides.” Administration codes in bottom decile and not in top decile included CPT code 96523, indicating “only payable when not billed with other service.” Therefore, we speculated that bundling policy is more likely to be the source of variations in estimated chemotherapy reimbursement. It is plausible that Medicare claim processors with low estimated average reimbursement amounts were using bundled payments and those with high estimated average reimbursement amounts were using separatepayments for services and drugs delivered.
Association Between Reimbursement Policies and G-CSF Prescription. The adjusted odds ratios (AORs) and the associated 95% confidence intervals (CIs) from 2 logistic regressions are presented in Table 2. In the first model (without average chemotherapy reimbursement variable), the results showed that chemotherapy type, race, age group at diagnosis, histology, and time-trend were signifi cantly associated with G-CSF prescription. Results from the second model (with average chemotherapy reimbursement variable) revealed that while patient-level factors continued to have a statistically signifi cant association with G-CSF prescription, the average chemotherapy reimbursement level variable also contributed to G-CSF prescription. For ease of interpretation, estimated chemotherapy reimbursement amount from the OLS regression was divided by $1000. After controlling for patients’ demographic, clinical factors, and area socioeconomic status, we found that, for every $1000 increase in estimated physician reimbursement amounts, the likelihood of G-CSF prescription decreased. The AOR was 0.91 with 95% CI (0.85-0.97). If the reimbursement amounts were to be expressed in units of $100, this result would translate to a 0.9% decrease in G-CSF prescription likelihood for an average increase of $100 in chemotherapy reimbursement amounts.
Our study set out to examine the relationship between Medicare claim processors’ reimbursement policies and G-CSF prescription among patients with NHL. Reimbursement policies of Medicare claim processors were identified with an indirect approach using average estimated reimbursement amount for the fi rst cycle of chemotherapy (21 days) after initiation and the number of drugs and services delivered during this period. We found that Medicare claim processors with lower reimbursement amounts used bundled payment polices and those with higher average reimbursement amounts used separate payments for services and drugs. Our study did not assess the actual payment polices of each of the claim processors. Future studies are needed to relate the actual payment polices to physician reimbursement amounts for chemotherapy.
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