Reimbursement and Managed Care News

OBTNJuly 2008
Volume 2
Issue 7

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Reimbursement and Managed Care NewsHow Much Do Patients With Cancer Pay Out-of-Pocket for Care?

The costs associated with oncologic therapies, particularly biologic agents, can be a stifling burden on patients, as many treatments cost thousands (even tens of thousands of dollars). Even with health insurance, many treatments are on coinsurance tiers, that is, the patient pays a percentage of total cost, unlike fixed copayments for conventional medications. With the influx of “high-deductible health plans,” which are less expensive than insurance offering first-dollar coverage, patients pay up to $5,000 before insurance payments contribute to the cost of care. Researchers from HealthCore in Wilmington, Delaware sought to determine how much patients with commercial insurance pay out-of-pocket when cancer is being treated.

The investigators retrospectively identified oncology claims from a managed care database. Four years of patient records (ending in 2006) were studied. Patients were included in the study if they had at least two medical claims for breast, colorectal, or lung cancer, or non- Hodgkin’s lymphoma. Patient-paid amounts and health plan payments were recorded for each year to detect trends.

A total of 74,630 patients were included in the study cohort. For these patients, health plan payments rose 57% from 2003 to 2006. However, the rise in out-of-pocket costs to the patient was even higher—109%, reaching $5,094 in 2006. Alarmingly, patient out-of-pocket expenses jumped 54% from 2005 to 2006, which may be ascribed to the expansion in high-deductible health plans.

The researchers found that the proportion of biologic drugs was still only 10% of the total costs. The remainder was for medical services, imaging studies, and other care.

Although this study covered a population with health insurance, it is a particularly worrisome trend that patients are paying far more out of their own wallets and purses than they were in the past for oncological care.

Willey VJ, Pollack MF, Lawless GD: Oncology health care and patient out-of-pocket cost trends in a commercially insured population. Presented at the 2008 annual meeting of the American Society of Community Oncology, Chicago, June 3, 2008.

Will Congress Mandate Minimum Hospital Stays for Breast Cancer?

A Congressional hearing in late May made it clear that health plans and insurers should be on their guard: U.S. Representatives don’t like the idea of drive-through breast cancer surgery, and are prepared to detour it.

Although 20 states already have minimum stay bills in place (no less than 48 hours for mastectomies or lumpectomies), breast cancer advocates claim that federal legislation is needed to bring the rest of the states in line. In remarks at the hearing, Representative Frank Pallone (D-NJ) said, “having access to appropriate medical care should not be dependent on the state you live in.” Representative Pallone chairs the important health subcommittee of the Congressional Energy and Commerce Committee.

A representative of the insurance industry’s trade organization, America’s Health Insurance Plans, Susan Pisano, countered that the health plans will cover longer stays, depending on medical necessity. “We do not think that it is a good idea on the state level or the federal level to be putting clinical guidelines into statute," she said.

The proposal, the Breast Cancer Patient Protect Action of 2007 (H.R. 119) has 219 sponsors and bipartisan support. A similar bill in the Senate (S.B. 459) has 19 sponsors at this time. Assuming a consensus conference passes this proposal and it lands on President George Bush’s desk, it is expected that the President will exercise his veto.

Dixon K: U.S. panel mulls minimum breast cancer hospital stay. Reuters May 21, 2008.

Bump in Oncology Costs Is Generally From Increased Utilization of Adjuvant Therapies

The cost to treat cancer has risen significantly, as more tools are at the disposal of clinicians, and more biopharmaceuticals have been approved, generally at higher cost compared with older therapies. The National Cancer Institute, Bethseda, Maryland, has attempted to quantify how these costs have increased over an 11-year period for four different common cancers.

Investigators evaluated 1992—2002 information from the Surveillance, Epidemiology, and End Results database on Medicare beneficiaries for the care of breast, colorectal, lung, and prostate cancer, starting from two months before diagnosis to 12 months postdiagnosis. Data obtained on nearly 307,000 patients revealed that average payments for lung cancer rose to $39,891 by 2002, up 22% after adjusted for inflation from 1991 (Figure). Interestingly, the average payment for initial prostate cancer care actually fell by $196, to a total of $18,261 in 2002.

Inflation-adjusted percent change in the cost ofinitial cancer care (1991 - 2002)

Breast Cancer

25 %

Colorectal Cancer


Lung Cancer


Prostate Cancer


Although the researchers noted that the vast majority of the payments were for hospital services, the use of adjuvant chemotherapy increased markedly for the cancers studied. The use of radiation therapy also increased for the breast, lung, and prostate cancer but not colorectal cancer.

Warren JL, Yabroff KR, Meekins A: Evaluation of trends in the cost of initial cancer treatment.

2008; 100:888-897.

J Natl Cancer Inst

Oncology Case Drives Health Plans to Reinstate Cancelled Coverage for Californians

The case of a California hair salon owner who was undergoing cancer chemotherapy when her insurer, Health Net, cancelled her individual coverage in 2004, inflamed the Governor and the California Department of Managed Health Care. A jury awarded the woman $9 million this year, and it compelled insurers in the state to begin reconsidering their cancellation initiatives.

Health insurers have been reviewing the original applications of high-cost members to check if a mistake on the application or outright fraudulent information (e.g., withholding information about pre-existing medical conditions) could be grounds for canceling the policy. More than 5,000 coverage cancellations had been reported since 2004 (for reasons other than nonpayment of premiums), and virtually all involve individual, not group, policies.

Under a settlement brokered by the state regulator in the face of a glut of lawsuits for wrongful termination of coverage, Health Net and Kaiser Permanente will reinstate the health coverage of 1,092 Californians. If former enrollees accept the settlement, they will be able to seek up to $15,000 in reimbursement for uncovered medical expenses. Otherwise, they may opt to re-enroll for insurance but still take their claims individually to court. The Department of Managed Care is trying to come to similar terms with Blue Shield of California, PacifiCare, and Anthem Blue Cross, which terminated the policies of 4,000 members.

There are no regulations in California that currently codify when a health insurer can terminate a policy.

Girion L: 1,200 people to have canceled healthcare coverage restored.

May 16, 2008.

Los Angeles Times

Which Are the Best Insurers in Terms of Payment for Services?

A physician practice management consultant conducted a survey to determine which insurers paid claims most efficiently in 2006, and found that two national insurers were among the best, and apparently, getting better.

AthenaHealth, which conducts the survey each year, found that Aetna took an average 27 days to pay physicians, and denied 5.9% of all claims. Its denial rate was 10% lower than that reported in 2006. The survey, which includes data from 12,000 medical providers, found that Cigna took the number 2 spot, taking an average 33 days to adjudicate claims, and it resolved 96% of all claims on the first attempt. Its claims denial rate, 6.6%, was only slightly higher than Aetna’s reported rate. Rounding out the top 5 were Humana, Medicare part B claims, and UnitedHealth Group.

Of the Blue Cross Blue Shield regional plans Blue Cross and Blue Shield of Rhode Island took top honors, with the Kansas City affiliate following in second place. Empire Blue Cross and Blue Shield of New York was rated last, and Blue Cross of California took second-to-last place.

The survey revealed that New York State’s Medicaid program was the worst performing payer overall, taking an average 137 days to pay a claim.

Aetna ranks first in 2008 PayerView(SM) ranking; pays medical providers the fastest among national commercial insurers (press release). May 29, 2008. AthenaHealth (http:// cfm?ReleaseID=312767).

Is Managed Care Paying for Colonoscopies in the Wrong Patients?

Managed care plans are seeking to limit costs or unnecessary spending in multiple areas of care. Recently, some national managed care organizations indicated that they would no longer pay for anesthesia services during colonoscopies. However, appropriateness of care remains an important focus for these organizations. A study from the National Cancer Institute, Bethseda, Maryland, lends credence to the belief that low-risk patients are being screened too often for colorectal adenomas and high-risk patients are not being screened often enough, in the face of limited resources.

This study followed 1,297 participants in the Polyp Prevention Trial, who completed a four-year trial and who were followed up for at least an additional six years. Over the course of the initial trial, individuals who completed it had undergone an average of 3.1 colonoscopies. During the follow-up, 774 (60%) had additional colonoscopies. Of these, just 41% of the participants deemed high risk had a repeat procedure during the first three years of follow-up. The investigators reported that 63% had received a repeat colonoscopy by six years of follow-up. These 55 individuals had had advanced adenoma or at least three non-advanced adenomas after the initial study. Those with advanced adenoma at the end of the original trial had a 5.2 higher risk of having an advanced adenoma within the next six years.

The investigators also pointed out that 30% of those deemed low risk to be low risk also underwent repeat colonoscopies within four years of follow-up. The researchers concluded, “Overutilization of surveillance colonoscopy was observed in low-risk subjects with a corresponding low yield of advanced adenoma detection, whereas underutilization was observed among high-risk subjects.” This pattern of utilization has important economic implications, considering the cost and efficiency of colonoscopy.

Laiyemo AO, Pinsky P, Marcus P et al: The continued follow-up study of the Polyp Prevention Trial: A prospective study of utilization and yield of surveillance colonoscopy. Presented at 2008 Digestive Disease Week, San Diego, May 28, 2008.

Oncologists Versus Managed Care Payers

It seems that the prognosis and treatment of patients with colorectal cancer should be based on whether the lesion has extended through the bowel wall, according to a review of phase 3 clinical trials and the National Cancer Institute patient registries.

Conventional classifications are of patients with stage 3, 3 into 3A, 3B, or 3C categories, based on lymph node positivity. However, it was suggested that the categorization of patients with stage 3 disease should be refined, because patients with T1-2N2 tumors demonstrated better survival than others with stage 3 cancer. To validate whether this was actually the case, members of the American Joint Commission on Cancer studied outcomes data from 1992 to 2004.

They found that survival was directly related to how the tumor penetrated the bowel wall. That is, a patient with a stage 3 lesion (meaning that local lymph node biopsies are positive) that was confined to the bowel wall had better survival than patient with stage 2 lesions that did penetrate the wall (Table).

Tumor staging and survival for patients with colon cancer

Tumor Classification


5-year Survival






55.7% 44.7%












48.2% 24.3%

The Commission members noted that although patients with stage 2 disease do not generally receive chemotherapy after surgical excision, the outcomes data demonstrate that this may not be the best approach. Additionally, patients with stage 3 disease but with tumors restricted to the bowel wall may not necessarily need adjuvant chemotherapy, which is currently the standard of practice. The trends were similar for rectal cancer and colon cancer.

The Commission did emphasize that the number of positive nodes affect survival and that the trend for increasing number of positive nodes was related to lower survival within each staging class.

Gunderson LL, Jessup JM, Sargent FL, et al: TN categorization for rectal and colon cancers based on national survival outcome data. Presented at 2008 annual meeting of the American Society of Community Oncologists, Chicago, June 3, 2008.

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