Reimbursement cuts improved evidence-based use of prostate drugs

Medicare reimbursement cuts were associated with reduced use of androgen-deprivation therapy (ADT) for prostate cancer, particularly among men for whom the benefits of such therapy were unclear.

Researchers identified from the Surveillance, Epidemiology, and End Results Medicare database 54,925 men who received a diagnosis of incident prostate cancer from 2003 through 2005. Of this group, 43.2% received ADT within six months after diagnosis. Results appeared in the Nov. 4 issue of the New England Journal of Medicine.

Researchers divided the men into groups according to the strength of the indication for ADT use, defined as:

• inappropriate for men with localized cancers of a low-to-moderate grade (T1 or T2, for whom a survival benefit of such therapy was improbable),appropriate as adjuvant therapy with radiation therapy for men with locally advanced cancers (T3 or T4, for whom a survival benefit was established), anddiscretionary for men receiving either primary or adjuvant therapy for localized but high-grade tumors.

In the 1990s, Medicare reimbursed gonadotropin-releasing hormone (GnRH) agonists based on 95% of the average wholesale price. But the Government Accountability Office found that physicians typically bought them at an average of 82% of the average wholesale price, and that profits could make up 40% of urologists' revenues. Medicare reduced reimbursement for ADT moderately in 2004 and substantially in 2005.

Reimbursement for a monthly dose of GnRH agonists fell from $356 in 2003 to $311 in 2004 to $176 in 2005. While there was no decline in the appropriate-use group, the rate of use in the inappropriate group fell from 39.0% in the fourth quarter of 2003 to 30.3% in the first quarter of 2004. The rate reached a plateau of 22.4% by the end of 2005. In the discretionary-use subgroups, use was highest through 2003, gradually declined in 2004 and markedly dropped in 2005.

Authors wrote, "... [R]eductions in reimbursement may influence the delivery of care in a potentially beneficial way, with even the modest changes in 2004 associated with a substantial decrease in the use of inappropriate therapy. The corollary is that reimbursement policies should be carefully considered to avoid providing incentives for care for which no clear benefit has been established. The extreme profitability of the use of GnRH during the 1990s probably contributed to the rapid growth in the use of ADT for indications that were not evidence based."