Medicare Claim Processors’ Reimbursement and G-CSF Choice Among Non-Hodgkin Lymphoma Patients | Page 4
Published Online: August 21, 2013
Xiaoyun Pan, PhD and Usha Sambamoorthi, PhD
Our study findings revealed that G-CSF prescription was less likely in counties with higher average estimated physician reimbursement amount compared with those with lower average estimated physician reimbursement amount. This finding along with variations in average reimbursement amount across Medicare claim processors suggest that the likelihood of G-CSF prescription is influenced by reimbursement policies of the Medicare claim processors. Our study did not survey the physicians to elicit information on reasons for adding or not adding G-CSF prescriptions to chemotherapy regimens. However, we can speculate as to why G-CSF prescription rates varied across Medicare carries. It is plausible that G-CSF prescriptions in addition to standard chemotherapy regimens may increase a physician’s revenue. Prior empirical research suggests that higher average physician reimbursement amounts closely reflect physicians’ profi t or income.6 Thus, physicians contracting with Medicare claim processors with higher average reimbursement amounts may have had higher incomes compared with their counterparts contracting with Medicare claim processors with low reimbursement amounts. Based on economic theory,11 one could postulate that substitution effect could be responsible for observing lower likelihood of G-CSF prescription among physicians contracting with Medicare claim processors with higher reimbursement. Under substitution-effect theory, these physicians may derive smaller marginal benefi ts from additional income due to prescription of G-CSF drugs. Alternatively, onecould speculate that income effect may have been responsible for the observed pattern. Under the incomeeffect theory, physicians contracting with Medicare claim processors with low reimbursement amounts may have low income and hence may need to increase their income by providing supplemental services and products. Thus in our case, physicians contracting with Medicare claim processors with low reimbursement amount may augment standard chemotherapy regimens with G-CSF for patients with NHL and therefore may be more likely to prescribe G-CSF.
It has to be noted that we did not consider other factors that may discourage the addition of G-CSF. For example, the physician may need to consider the patient’s burden as well. Adding G-CSF to a chemotherapy regimen may involve high out-of-pocket costs for the patient,20 greater travel time to get the injections,27 and impaired quality of life due to possible side effects.27 However, such factors may not explain the systematic variation in G-CSF prescriptions by reimbursement amounts.
Although we focused on the relationship between reimbursement policies and G-CSF prescription, it has to be noted that G-CSF prescription also involves clinical decision making. We found compared with patients in the age group 66 to 70 years, older patients were more likely to receive G-CSF. A plausible explanation for this fi nding could be the increased risk of neutropenia and neutropenia-associated hospitalization with increasing age.28-31 Therefore, physicians may consider age a highrisk factor and prescribe prophylactic G-CSF to older patients.
Furthermore, we found that patients with less toxic chemotherapy regimens such as non-ABC chemotherapy and rituximab with non-ABC chemotherapy were less likely to receive G-CSF compared with highly toxic chemotherapy regimen (ie, ABC chemotherapy). We also found patients with ABC without rituximab were less likely to be treated with G-CSF compared with those with ABC and rituximab. Taken together these fi ndings suggest that greater toxicity of chemotherapy regimens may be associated with greater risk of neutropenia and physicians may prescribe G-CSF as a prophylactic agent.
Diffuse large B-cell lymphoma was found to be significantly associated with G-CSF use. The result conforms to American Society of Clinical Oncology (ASCO) 2006 guideline recommendation “Prophylactic CSF for patients with diffuse aggressive lymphoma aged 65 years and older treated with curative chemotherapy (the regimen—cyclophosphamide, doxorubicin, vincristine, and prednisone [CHOP] or more aggressive regimens) should be given to reduce the incidence of febrile neutropenia and infections.”32 The study showed there was an increased trend of G-CSF prescription across years. The odds ratio for time trend variable was 1.354. The increased likelihood of prescribing G-CSF over time may be because of innovation diffusion, dissemination, and increasing adoption of ASCO guidelines.
The study findings need to be interpreted in light of the strengths and limitations. The strengths were large study population, availability of clinical variables, longitudinal design, and ability to identify chemotherapy and GCSF prescription from claims (not subject to recall bias). The study was potentially limited by its selection criteria.
The study population consisted of Medicare elderly NHL patients without inpatient or ED claims in the fi rst cycle of chemotherapy. We did not control for eligibility for G-CSF (ie, patients who are at high risk of neutropenia). We used surrogate variables for reimbursement policies. Therefore, our fi ndings could at best be considered an indirect evidence of the relationship between reimbursement policies and G-CSF choice. In addition, our grouping of Medicare claim processors may have affected our findings.
Despite these weaknesses, our study is the first to explore Medicare reimbursement policies across different claim processors and its association with prescribing volume for patients with cancer. While our study only measured bundled payment policies through an indirect approach, it also provided some useful insights as to the association between bundled payment policies and provision of care for patients with NHL. Future studies need to obtain the actual payment policies at the claim processor level to further elucidate the relationship between bundled payments and physician practice patterns.
Author Affiliations: From Pharmaceutical System and Policy (XP, US), School of Pharmacy, West Virginia University, Morgantown, WV.
Funding Source: Dr Sambamoorthi was partially supported for infrastructure from West Virginia Collaborative Health Outcomes Research of Therapies and Services (WV CoHORTS) Center.
Author Disclosures: The authors (XP, US) report no relationship or financial interest with any entity that would pose a conflict of interest with the subject matter of this article.
Authorship Information: Concept and design (XP); acquisition of data (XP); analysis and interpretation of data (XP, US); drafting of the manuscript (XP, US); critical revision of the manuscript for important intellectual content (XP, US); statistical analysis (XP); and obtaining funding (US).
Address correspondence to: Xiaoyun Pan, PhD, West Virginia University, Health Science Center North, School of Pharmacy, PO Box 9510, Morgantown, WV 26505. E-mail: firstname.lastname@example.org.
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