Chicago, IL—It may come as no surprise that financial incentives can influence the behavior of physicians and the actions of healthcare systems. Elena B. Elkin, PhD, MPH, Health Outcomes Research Group, Memorial Sloan-Kettering Cancer Center, New York, discussed this topic at ASCO 2013.
Although the association between incentives and behavior is often maligned, policymakers use it to their advantage, Dr Elkin pointed out.
“When we find providers acting in ways that may be undesirable—referral to physician-owned facilities, prescribing influenced by drug reimbursement—we find public outrage. But, at the same time, we see policymakers wanting to capitalize on the incentives that are related to behavior, linking doctor payments to performance and income to quality of care,” she noted.
The medical literature suggests that incentives can influence behavior. For example, a shift in the reimbursement policy favoring office-based endoscopy over hospital-based endoscopy led to more office-based procedures for bladder lesions. When Medicare chemotherapy reimbursements were reduced for the treatment of metastatic cancer, the receipt of any chemotherapy versus no chemotherapy did not change, but the use of more expensive regimens increased. The decline in reimbursement for androgen-deprivation therapy led to a decrease in the utilization of this modality, but its appropriate use did not change.
“Utilization patterns often track with changes in reimbursement,” Dr Elkin said.
Lack of Evidence: Brachytherapy for Breast Cancer
Among the newer options for adjuvant radiotherapy in breast cancer are whole breast irradiation and partial breast irradiation, such as external beam radiotherapy and brachytherapy. Randomized controlled trials comparing these approaches are ongoing; meanwhile, dissemination of the new technologies has been rapid.
In the absence of clinical trial data and evidence regarding patient selection, the American Society for Radiation Oncology (ASTRO) developed guidelines based mainly on observational and nonrandomized trial data to define patient groups who are and are not suitable for partial breast irradiation and patients in whom partial breast irradiation should be used with caution.
In 2002, the US Food and Drug Administration approved an accelerated partial breast irradiation device, balloon brachytherapy (MammoSite), and its use sharply increased in all patient groups, even among patients deemed unsuitable for it (Hattangadi JA, et al. J Natl Cancer Inst. 2012;104:29-41). By the end of 2007, 2.6% of patients receiving radiotherapy had MammoSite, and 65.8% of them were classified as cautionary or unsuitable. By ASTRO criteria, MammoSite was used by 5% of suitable patients, 3.4% of cautionary patients, and by 1.6% of unsuitable patients.
In a study presented at the meeting (see article on page 11), Sen and colleagues showed greater use of brachytherapy in women aged ≥66 years at for-profit hospitals (20.2%) versus at nonprofit hospitals (15.2%). In women aged ≥80 years, there was greater use of any radiotherapy at for-profit hospitals, which was primarily driven by the use of brachytherapy.
“The bottom line is, in planning treatment, does the breast cancer treatment team have the patient’s best interest in mind, or are they thinking about which option will be the most profitable for them and their institution, and does this vary according to provider incentives?” Dr Elkin asked.
She added, “We need to understand incentives and monitor their effects on utilization and cost and health outcomes. We can also consider changing incentives, such as is being done with value-based insurance, where we directly link reimbursement to the value of the service provided. Finally, with patient-centered care becoming so important, we can consider providing decision support tools for patients that would facilitate informed, shared decision-making between patients and physicians.”