Reimbursement and Managed Care News for February 2008

OBTNFebruary 2008
Volume 2
Issue 2

Topics covered in this issue include:1) A Need to Better Manage Use of CT Scans to Avoid Excess Cancer

A Need to Better Manage Use of CT Scans to Avoid Excess Cancer Risk?

The development of cancer in patients who do not seem to be at high risk has always been a mystery. For instance, how does lung cancer appear in a person who never smoked and whose exposure to second-hand smoke had been negligible? Are there genetic factors that have not been identified? Often, scientists ascribe these cases to environmental factors. These potential causes, for which little has been quantified or virtually nothing is known, range from air pollution to electromagnetic fields. One environmental factor is perhaps responsible for cancers than most researchers are willing to admit: the increasing use of diagnostic imaging and the harmful radiation it uses.

New England Journal of Medicine

An article in the points out that perhaps as many as 2% of all future cancers in the United States may be directly the result from the use of computed tomographic (CT) scanning. This report, from Columbia University, New York, states that medical radiation is responsible for more than 50% of our total radiation exposure, and that in 1980, medical radiation accounted for only 15% of the total. This means that medical radiation exposure, largely from the skyrocketing use of CT scans, is now even a greater contributor to population-wide radiation exposure than natural sources, such as soil-based radon and cosmic or solar particles.

Approximately 62 million CT scans were performed in 2006 in the United States, a 20-fold increase from 1980, when the technology was first becoming available. The researchers believe that ultrasound and magnetic resonance imaging are far safer options, as they do not rely on radiation exposure to obtain images.

Health plans and insurers have sought to decrease the amount of unnecessary and costly diagnostic scanning used in private practice, clinics, and hospital emergency rooms. This report may provide more fodder to require stricter prior authorization criteria before reimbursing for diagnostic CT imaging.

Typical organ radiation doses from various radiologic studies

Relevant Organ and Dose* (mGy or mSv)

Posterior—anterior chest x-ray

Lung 0.01

Lateral chest radiography

Lung 0.15

Screening mammography

Breast 3.0

Adult abdominal CT

Stomach 10.0

Barium enema

Colon 15.0

Neonatal abdominal CT

Stomach 20.0

CT= Computed tomographic.

The radiation dose, a measure of ionizing energy absorbed per unit of

mass, is expressed in grays (Gy) or milligrays (mGy); 1 Gy = 1 joule p/kg.

The radiation dose is often expressed as an equivalent dose in sierverts

(Sv) or millisierverts (mSv). For x-ray radiation, which is the type used

in CT scanners, 1 mSv = 1 mGy.

Adapted from Brenner DJ, Hall EJ: Computed tomography—

An increasing source of radiation exposure. N Engl J Med


Brenner DJ, Hall EJ: Computed tomography—An increasing source of radiation exposure


. N Engl J Med

Fuller Disclosure in Doctor-Ranking Models Nationwide

Physicians and their professional associations have complained that managed care’s attempts to rank their practices have long been based on cost but not on quality. These rankings had been used to develop tiered networks of physicians, in which members of managed care plans were incentivized to visit “higher-performing” providers. A deal reached by major insurers in New York State may help give consumers a clearer understanding of how these rankings are developed.

In a deal reached with New York State Attorney General Andrew Cuomo, some of the country’s largest health insurers, including WellPoint, UnitedHealth Group, Aetna, and Cigna, have agreed to disclose the basis for the rankings and demonstrate that it is not based solely on cost. They have also acknowledged that these changes will be made nationwide, not just for physicians based in New York. The insurers have also agreed to clearly distinguish any rankings that are in fact cost based.

New York State is working on bipartisan legislation that enforces a Doctor Ranking Model Code, which sets a standard for ranking physicians in this way, as a means to protect consumers. The Attorney General’s office expressed hope that this type of proposal will be utilized in other states.

Bray C: NY AG: NY Lawmakers to Adopt Doctor- Ranking Model as Law ( CmsPhoenix/DowJonesArticle.aspx?id=373492), November 27, 2007.

Which Is More Cost Effective: Rituximab or Stem-Cell Transplant for Follicular Lymphoma?

Although maintenance therapy with rituximab (Rituxan) and autologous stem-cell transplant have been found to be effective in patients with difficult-to-treat follicular lymphoma, the cost effectiveness of these alternatives has not been studied. Taking the perspective of the United Kingdom’s National Health Service, British economists and clinicians evaluated how costs are accrued if patients respond to induction chemotherapy but whose disease progresses and are seeking the option.

They conducted a literature review to assess the relative effectiveness of the two options postinduction chemotherapy with cyclophosphamide, doxorubicin, vincristine, prednisone, assuming that the patients treated are naive to rituximab. They calculated resource usage and health care costs from published National Health Service materials. To account for possible differences in effectiveness, the authors conducted a sensitivity analysis.

This cost-minimization analysis revealed that the estimated cost of maintenance rituximab was $24,358 per patient (at a conversion rate of $1.98 to %u20A41.0) compared with autologous stem-cell transplant, at $50,727 per patient. The sensitivity analysis indicated that in order for the incremental cost-effectiveness ratio to be equal, stem-cell transplant would have to provide 7.5 months greater overall survival in these patients. The authors noted that the literature does not support this difference in survival between the two therapeutic options; therefore, from the National Health Service perspective, rituximab maintenance therapy seems to be considerably more cost effective than autologous stem-cell transplant.

Millar DR, Lewis G, Marcus R: Cost effectiveness of rituximab maintenance (R-Maint) vs. autologous stem-cell transplant (ASCT) from the UK National Health Service perspective. Presented at the 49th annual meeting of the American Society of Hematology, Atlanta, December 10, 2007.

Colorectal Cancer Screening in Medicare Patients Still Largely Ignored

Strangely enough, since Medicare began covering the colorectal screening tests in full for the elderly, making them effectively free, a smaller percentage of Medicare beneficiaries have been undergoing them.

Authors from University Hospitals Case Medical Center in Cleveland analyzed the screening utilization of more than 153,000 surveys of Medicare beneficiaries (≥ 70 yr) in 1998 and in 2005. They investigated inpatient, physician, and outpatient Medicare claims for colorectal screening procedures from 1991 through 1997 and 1998 through 2004.

According to the investigators, “complete” screening was performed in 29% of the total population during the earlier period, and specifically 77% of those who were deemed to be at increased risk for colorectal cancer. Only 23% of other patients were screened. In the period after 1998, when Medicare began paying in full for the tests, the percentage of patients who underwent screening dropped to 25.4%. In this study cohort who underwent screening in the later period, colonoscopy (17.6%) was the most popular screening method, followed by flexible sigmoidoscopy (2.9%), yearly fecal occult blood testing (0.8%), barium enema (0.1%), and a combination of methods (4.1%). They pointed out that if the Medicare beneficiary had been screened in the past, they were more likely to undergo screening again.

Physicians from Thomas Jefferson University, Philadelphia, reemphasized that the primary care physician is the number 1 influencer of whether patients receive colorectal cancer screening. They point out that although primary care physicians routinely report that they perform and encourage such screening, the use of automatic reminder and tracking systems, along with routine office calls can significantly improve colorectal cancer screening rates.

Cooper GS, Doug Kou T: Underuse of colorectal cancer screening in a cohort of medicare benefi- ciaries

2008; 112: 293-299.

Sarfaty M, Wender R: How to increase colorectal cancer screening rates in practice.


. Cancer CA Cancer J Clin

Does Quality of Life Vary Among Chemotherapies in Advanced Non-Small Cell Lung Cancer?

Using state-of-the-art systemic chemotherapy regimens for the treatment of non—small cell lung cancer (NSCLC) seems to produce comparable, replicable survivals. However, researchers from the University of South Florida’s H. Lee Moffitt Cancer Center, Tampa, wondered whether these chemotherapies varied in terms of quality-of-life (QoL) outcomes.

Conducting a meta-analysis of randomized, controlled phase III trials in patients with advanced NSCLC, the researchers identified 14 trials in which QoL was a major endpoint. These trials comprised over 6,600 patients. Of these trials nine had reported baseline assessments and the compliance of the survivors in filling out QoL surveys were at least 50%.

The analysis revealed that only phase III investigation showed any significant differential in terms of QoL outcomes: Patients taking paclitaxel plus cisplatin had better QoL scores than those patients who were taking teniposide and cisplatin.

The researchers concluded that although the differences in global QoL outcomes were significant, it is based on one trial only. Overall, they found that QoL differences, although somewhat difficult to compare because rating systems were not the same across the studies, were minimal at best. It seems that most of the current therapeutic regimens for NSCLC provide similar clinical and QoL outcomes and that choice of therapy should remain an individualized decision between the physician and patient.

Tanvetyanon T, Soares HP, Djulbegovic B, et al: A systematic review of quality of life associated with standard chemotherapy regimens for advanced non—small cell lung cancer

2007;2: 1091-1097.

. J Thorac Oncol

Insurer and Oncology Group Begin Pay-for-Performance Arrangement

In what seems to be the first effort to produce a workable pay-for-performance initiative in an oncology practice, Premera Blue Cross of Spokane, Washington, has teamed up with one of its cancer care providers to lay the groundwork for quality measures that could result in additional physician revenue.

Using a formula that will also include clinical quality measures, the results of patient satisfaction surveys, and the use of electronic medical records, the special feature of this program is cost effectiveness. Cancer Care Northwest, an affiliate of the U.S. Oncology group, has worked with Premera to devise guidelines on the cost effectiveness of oncology protocols in four areas of cancer treatment. The insurer and the medical group considered that many of the regimens being used yielded similar results but the costs of those regimens ranged widely. Based on this understanding, Cancer Care Northwest (not the insurer) developed preferred clinical protocols for lung, colorectal, breast, or prostate cancer, considering evidence in the literature and the reported incidence of serious side effects. Part of the physician’s bonus will be linked to how well they comply with this oncologist-generated guideline.

Pay-for-performance programs have often used quality measures (whether they were based on structural, process, or outcomes measures), but never has this included nonpreventive oncology measures in a commercial plan. Medicare has been working on its Physician Quality Reporting Initiative, and the few oncology measures included in this group of 72 datareporting criteria do involve active treatment. Typical commercial health plans require data reporting on preventive measures, such as the frequency of Pap smears, mammography, and prostate cancer testing.

Importantly, Cancer Care Northwest’s affiliation with U.S. Oncology could result in an approach that extends to as many as 39 states.

Butcher L: Can insurer, oncology practice really work together? Premara Blue Cross and a large Spokane oncology practice agree on treatment protocols and on the importance of cost control


. Manag Care

Patients With Health Insurance Have Better Cancer Outcomes

CA: A Cancer Journal for Clinicians

In what may be argued as proof that our health system safety net is at further risk, a study appearing in found that patients without health insurance who receive cancer care have a significantly greater risk of death within five years of diagnosis compared with fully insured patients.

Researchers from the American Cancer Society studied data from 1,500 cancer treatment centers involving 600,000 non-Medicare beneficiaries, who received care between 1999 and 2000, and gathered insurance information from the National Health Interview Survey. A five-year follow-up revealed 35% of those without insurance had died compared with 23% of those with insurance, an excess risk of 52%. This result is not surprising, because the researchers found a distinct drop offin preventive screening as insurance status declined from fully insured to Medicaid to no insurance: “About three-quarters (74.5%) of women aged 40 to 64 years who had private health insurance had received a mammogram in the past two years compared with 56.1% of women with Medicaid insurance and 38.1% of uninsured women.”

The authors believe that “lack of adequate health insurance appears to be a critical barrier to receipt of appropriate health care services.” The trends they found were not altered by adjustment for age, race, or socioeconomic data.

Cancer screening frequencies and insurance status

Cancer Screen

Privately Insured



Colorectal Cancer*








Pap Smear




*Aged 50—64 yr, tested by endoscopy or fecal occult blood screen within 10 yr.

Ward E, Halpern M, Schrag N, et al: Association of insurance with cancer care utilization and outcomes.


CA Cancer J Clin

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