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Cuts in doctor-payments cut unproven ADT use

Posted by medconsumers on November 12, 2010

Is there any way to stop urologists from inflicting an unnecessary, expensive treatment on men with early-stage prostate cancer? Well yes, big cutbacks in payments to doctors will do the trick. That was the upshot of a new study that followed the treatment of men after overly generous Medicare reimbursements were downsized, starting in 2003. By that time, it had become clear that a drastic treatment, known as androgen-deprivation therapy (ADT) is not only useless but also harmful to men with low- to moderate-risk tumors (to learn why click here).

Yet half of the men in the study who fit this description received ADT, which stops androgen production and is, in fact, drug-induced castration. This finding is from a study of Medicare claims, conducted by a research team led by Vahakn B. Shahinian, M.D., University of Michigan, Ann Arbor and published in The New England Journal of Medicine.

Shahinian and colleagues provide the back-story for how this treatment became a money-making machine for urologists. And here’s the short of it: ADT originally meant stopping androgen with surgical removal of the testicles. It was, and still is, a palliative treatment intended to ease the symptoms of men with advanced prostate cancer that has spread to other organs. Medicare unwittingly made it profitable for urologists to stop androgen production with injectable drugs (e.g., Lupron, Zoladex) around 1990 when the agency announced it would reimburse for injectable drugs but not oral drugs (an across-the-board policy, not one aimed solely at urologists).

Urologists, spurred on by the drug makers, now had a way to make major increases in their incomes. By the end of the 1990s, use of ADT with injectable drugs had doubled, and nearly half of all prostate cancer patients were receiving ADT within a year of diagnosis. The urologists were purchasing their drugs directly from the drug companies and billing Medicare in much the same way that office-based oncologists have been purchasing chemotherapy drugs.

It would take years for the federal government to learn that large discounts offered by drug makers directly to doctors were encouraging misuse with high-profit margins largely hidden from Medicare. This allowed profits constituting up to 40% of urologists’ revenues in private practice. Concerns about ADT misuse reached a crisis point in 2003 when payments from Medicare Part B for ADT drugs amounted to nearly $1 billion.

Enter the researchers led by Shahinian. In studying Medicare claims, they expected to see a drop in ADT use after 2003 and then again after 2005 when the federal government made a more substantial cutback in doctor-payments. For example, reimbursements for ADT fell from $356 per dose in 2003 to $311 in 2004 and then $176 per dose in 2005.

The researchers wanted to see whether the reduced payments had any effect on the inappropriate use of ADT—that is, for indications that are not evidence based. When assessing data from the Medicare claims database, they concentrated on the nearly 55,000 men who were diagnosed with prostate cancer in 2003 through 2005. All were at least 65 years or older at the time of diagnosis.

As expected, the findings did show a drop in inappropriate ADT use. Unfortunately, it wasn’t all that large, decreasing from 38% of men with low-risk cancer in 2003, down to 31% in 2004, and then 26% in 2005. There were no drops in appropriate usage, such as treatment of men with advanced prostate cancer.

The findings are troubling, though, because they leave open the possibility that one in four newly diagnosed men may still be receiving unnecessary ADT. Furthermore, the fact that the drop in ADT use was confined to inappropriate use indicates that many urologists knew ADT was unproven for low-risk men but stopped administering it only because their payments were cut back.

We all hope our doctors are guided by evidence. Unfortunately, this study shows the stronger influence may be the perverse incentives of our fee-for-service Medicare system that encourages doctors to do more procedures to increase their incomes. Here’s one of the most depressing stats generated by Shahinian and colleagues when describing the motivation for their study: “During the 1990s, use of primary ADT increased by a factor of eight among men who were 80 years of age or older and had low-risk, localized tumors, patients who would almost certainly be asymptomatic [no symptoms] and die from causes unrelated to prostate cancer.”

This study, which was funded by the American Cancer Society, made no mention of the 180-pound gorilla in the room, namely, the PSA screening test for prostate cancer (click here). This is clearly the cause of finding the many prostate cancers that either are slow-growing or would remain dormant. Why search for symptomless early-stage prostate cancer in elderly men when no treatment is a valid option once it’s found? Why pay for an unproven treatment?

Maryann Napoli, Center for Medical Consumers©

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