Gonadotropin-releasing hormone agonist overuse: urologists’ response to reimbursement and characteristics associated with persistent overuse

Abstract

BACKGROUND Medicare reimbursement cuts have been associated with declining Gonadotropin-releasing Hormone (GnRH) agonist overuse in localized prostate cancer. Medical school affiliation and foreign training have been associated with persistent overuse. However, physician-level prescribing changes and the practice type of persistent overusers have not been examined. We sought to describe physician-level changes in GnRH agonist overuse and test the association of time in practice and solo practice type with GnRH agonist overuse. METHODS We matched American Medical Association physician data for 2,138 urologists to SEER–Medicare data for 12,943 men diagnosed with early stage and lower grade adenocarcinoma of the prostate between 2000 and 2007. We conducted a population-based, retrospective study using multi-level modeling to control for patient and provider characteristics. RESULTS Three distinct patterns of GnRH agonist overuse were observed. Urologists’ time in practice was not associated with GnRH agonist overuse (OR 0.89; 95% CI 0.75–1.05).However, solo practice type (OR 1.65; 95% CI 1.34–2.02), medical school affiliation (OR 0.65; 95% CI 0.55–0.77), and patient race were. Compared to non-Hispanic whites, non-Hispanic blacks (OR 1.76; 95% CI 1.37–2.27), Hispanics (OR 1.41; 95% CI 1.12–1.79) and men of “other” race (OR 1.44; 95% CI 1.04–1.99) had greater odds of receiving unnecessary GnRH agonists. CONCLUSIONS GnRH agonist overuse remains high among some urologists who may be professionally isolated and difficult to reach. These urologists treat more vulnerable populations, which may contribute to health disparities in prostate cancer treatment quality. Nonetheless, these findings provide guidance to develop interventions to address overuse in prostate cancer.

Perceived barriers to the adoption of active surveillance in low-risk prostate cancer: A Qualitative Analysis of Community and Academic Urologists

“…However, the community and private practice physicians (including the one working in a private IMRT facility, a care model at the center of controversy over physician-induced demand) described high volume workloads or patient panels not appropriate for AS. Other carefully designed studies that attempt to identify or explain apparent physician induced demand raise doubt that nancial incentives alone motivate urologists' treatment decisions [32,43,77,78]. Because the relationship between potential nancial motivations and treatment recommendations is not clear, more work may be needed to carefully untangle the circumstances in which nancial motivations may in uence care.…”

“…We conducted a cross-sectional retrospective study comprised of in-depth, qualitative interviews with practicing urologists. The conceptual model underlying this research follows from previous work on localized prostate cancer treatment delivery [29,32] and mirrors a behavioral model of clinician responses to incentives, which incorporates economic theory [33] to conceptualize how reimbursement context may in uence physicians to induce demand for health services [34,35]. Recognizing that additional macro-and micro-level factors affect treatment decisions, the model derives the concept of predisposing and enabling factors from Andersen and Aday's Behavioral Model of Health Service Use and reconceptualizes them from the healthcare providers' perspective [36,37] (Figure 1).…”

“…Because urologists' recommendations may weigh heavily in prostate cancer patients' treatment decisions [15,[21][22][23][24][25][26], exploring factors that in uence urologists' recommendations for AS is needed. Reimbursement, physician factors, [27], and practice setting may in uence the care that is delivered [28,29]. However, few studies have comprehensively investigated the physician, organizational, and policy factors and treatment characteristics that may shape urologists' beliefs about the appropriateness of AS [12,30,31].…”

Medication overuse in oncology: current trends and future implications for patients and society

“…ADT is not recommended as monotherapy for localized prostate cancer and is instead reserved for men with metastatic disease or as an adjuvant to radiation in some patients with higher-risk local disease. 63 In 2003, the Medicare Modernization Act (MMA) standardized Medicare reimbursement with an overall 50% reduction in ADT reimbursement rates. 64 Of the four studies 65–68 that evaluated ADT overuse, two analyses leveraged this policy change to investigate likely overuse, and found approximately 30% reductions in ADT use after 2003, 64,67 suggesting overuse prior to 2003, likely attributable to a financial incentive.…”

Are Small Reimbursement Changes Enough to Change Cancer Care? Reimbursement Variation in Prostate Cancer Treatment

“…Before 2005, when Medicare had a generous reimbursement policy for gonadotropinreleasing hormone (GnRH) agonists and other physicianadministered drugs reimbursed through the Part B medical benefit, this form of androgen-deprivation therapy (ADT) was widely used as primary treatment of localized prostate cancer, [6][7][8][9][10] despite the lack of recommendation by published guidelines for patients with early prostate cancer. 11,12 A sharp decline in GnRH use occurred after 2005, when the Medicare Modernization Act (MMA) of 2003 changed the pricing benchmark used in the reimbursement formula from an average wholesale price set by the manufacturers to average sales price on the basis of national sales, reducing reimbursement for GnRH agonists by 65%.…”