We assessed treatment for prostate cancer among urologists with varying levels of financial incentives favoring intervention. Those with stronger incentives, as determined by ownership interest in a radiation facility, were more likely to treat prostate cancer, even when treatment was unlikely to provide a survival benefit to the patient.

Background: Surgical care has been largely untargeted by Medicare payment reforms because episode costs associated with its delivery are not currently well understood. Objective: To quantify the costs of inpatient and outpatient surgery in the Medicare population. Methods: We analyzed claims data from a 20% national sample of Medicare beneficiaries (2008–2014). For a given study year, we identified all inpatient and outpatient procedures and constructed claims windows around them to define surgical episodes. After summing payments for services rendered during each episode, we totaled all inpatient and outpatient episode payments by surgical specialty. For inpatient episodes, we determined component payments related to the index hospitalization, readmissions, physician services, and postacute care. For outpatient episodes, we differentiated by the site of care (hospital outpatient department versus physician office versus ambulatory surgery center). We used linear regression to evaluate temporal trends in inpatient and outpatient surgical spending. Finally, we estimated the contribution of surgical care to overall Medicare expenditures. Results: Total Medicare payments for surgical care are substantial, representing 51% of Program spending in 2014. They declined modestly over the study period, from $133.1 billion in 2008 to $124.9 billion in 2014 (−6.2%, P = 0.085 for the temporal trend). While spending on inpatient surgery contributed the most to total surgical payments (69.4% in 2014), it declined over the study period, driven by decreases in index hospitalization (−16.7%, P = 0.002) and readmissions payments (−27.0%, P = 0.003). In contrast, spending on outpatient surgery increased by $8.5 billion (28.7%, P < 0.001). This increase was realized across all sites of care (hospital outpatient department: 36.6%, P < 0.001; physician office: 22.1%, P < 0.001; ambulatory surgery center: 36.6%, P < 0.001). Ophthalmology and hand surgery witnessed the greatest growth in surgical spending over the study period. Conclusions and Relevance: Surgical care accounts for half of all Medicare spending. Our findings not only highlight the magnitude of spending on surgery, but also the areas of greatest growth, which could be targeted by future payment reforms.

Survival in men with EMPD is lower among those with distant disease and primary tumors located in the perianal region. The reasons for increasing EMPD incidence over time and for the racial disparities in disease occurrence require further study.

Background Accountable Care Organizations (ACOs) were established to improve care and outcomes for beneficiaries requiring highly coordinated, complex care. Our objective was to evaluate the association between hospital ACO participation and outcomes of major surgical oncology procedures. Methods We performed a retrospective cohort study of Medicare beneficiaries >65 years old undergoing a major surgical resection for colorectal, bladder, esophageal, kidney, liver, ovarian, pancreatic, lung or prostate cancer from 2011 through 2013. We implemented a difference-in-differences analysis comparing the post-implementation period (January 2013 through December 2013) to the baseline period (January 2011 through December 2012), to assess the impact of hospital ACO participation on 30-day mortality, complications, readmissions and length of stay. Results Among 384,519 patients undergoing major cancer surgery at 106 ACO hospitals and 2,561 control hospitals, we identified a 30-day mortality rate of 3.4%, readmission rate of 12.5%, complication rate of 43.8% and prolonged LOS rate of 10.0% in control hospitals, with similar rates in ACO hospitals. We noted secular trends, with reductions in perioperative adverse events in control hospitals between the baseline and post-implementation periods: mortality (0.1% percentage point reduction, p=0.19), readmissions (0.4%, p=0.001), complications (1.0%, p<0.001) and prolonged LOS (1.1%, p<0.001). After accounting for these secular trends, we identified no significant effect of hospital participation in an ACO on the frequency of perioperative outcomes (difference-in-differences estimator p-values 0.24–0.72). Conclusions Early hospital participation in the MSSP ACO program was not associated with greater reductions in adverse perioperative outcomes for patients undergoing major cancer surgery compared to control hospitals.

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Background Abiraterone and enzalutamide are high‐cost oral therapies that increasingly are used to treat patients with advanced prostate cancer; these agents carry the potential for significant financial consequences to patients. In the current study, the authors investigated coping and material measures of the financial hardship of these therapies among patients with Medicare Part D coverage. Methods The authors performed a retrospective cohort study on a 20% sample of Medicare Part D enrollees who underwent treatment with abiraterone or enzalutamide between July 2013 and June 2015. The authors described the variability in adherence rates and out‐of‐pocket payments among hospital referral regions in the first 6 months of therapy and determined whether adherence and out‐of‐pocket payments were associated with patient factors and the socioeconomic characteristics of where a patient was treated. Results There were 4153 patients who filled abiraterone or enzalutamide prescriptions through Medicare Part D in 228 hospital referral regions. The mean adherence rate was 75%. The median monthly out‐of‐pocket payment for abiraterone and enzalutamide was $706 (range, $0‐$3505). After multilevel, multivariable adjustment for patient and regional factors, adherence was found to be lower in patients who were older (69% for patients aged ≥85 years vs 76% for patients aged <70 years; P < .01) and in those with low‐income subsidies (69% in those with a subsidy vs 76% in those without a subsidy; P < .01). Both Hispanic ethnicity and living in a hospital referral region with a higher percentage of Hispanic beneficiaries were found to be independently associated with higher out‐of‐pocket payments for abiraterone and enzalutamide. Conclusions There were substantial variations in the adherence rate and out‐of‐pocket payments among Medicare Part D beneficiaries who were prescribed abiraterone and enzalutamide. Sociodemographic patient and regional factors were found to be associated with both adherence and out‐of‐pocket payments.

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Key Points Question What are the projected size and demographic characteristics of the urology workforce per capita in the US through 2060? Findings In this cross-sectional study, 2 stock and flow models of continued (13.8%) and stagnant (0%) growth of the urology workforce based on the American Urological Association Annual Census data in 2019 and the US Census Bureau’s projections showed that within the context of the impending urology workforce shortage, there will be an exaggerated shortage of total urologists per capita for populations aged 65 years and older. Meaning These findings highlight the need for structural changes and advocacy to increase the available urology workforce.