From the Journals

STUDY: Oncologists alter treatment based on financial incentives



Oncologists frequently alter their treatment recommendations based on reimbursement incentives, an analysis suggests.

Lead author Aaron P. Mitchell, MD, of Memorial Sloan Kettering Cancer Center, New York, and his colleagues conducted a systematic review of 18 studies that examined the association between reimbursement incentives and oncology care delivery. Researchers obtained study data through PubMed/MEDLINE, Web of Science, Proquest Health Management, Econlit, and Business Source Premier. There were no date restrictions on the data.

The majority of studies (15 of 18) showed an association between reimbursement and care delivery consistent with physician responsiveness to financial incentives. Specifically, the review suggests that self-referral arrangements may increase radiotherapy use and that profitability of systemic anticancer agents may affect physicians’ choice of cancer medication, according to the analysis published in JAMA Oncology.

Of the 18 studies, 4 found that physicians respond to reimbursement incentives by preferentially using more-profitable treatments over less-profitable treatments, while 1 found evidence that reimbursement may be associated with doctors’ surgical approach to breast cancer. Particularly, oncologists were more likely to use breast-conserving therapy plus adjuvant radiotherapy rather than mastectomy alone when either reimbursement for breast-conserving therapy was higher or payment for mastectomy was lower. However, the same study did not find a statistically significant increase in breast-conserving therapy without adjuvant radiotherapy in association with the same reimbursement differences.

Another analysis in the data set determined preference for administering treatment in a more-profitable hospital outpatient setting, compared with an office setting. Meanwhile, five studies found that physicians are more likely to use radiotherapy when they or their practices profited through self-referral for radiotherapy or when practicing in freestanding facilities. (Urology practices are able to bill for radiotherapy services when using the in-office referral exception to the Stark Law.) Two of the four studies found that self-referral for radiotherapy was associated with increased use of intensity-modulated radiotherapy, while one study found that self-referral was associated with both receipt of any active therapy (radiotherapy, surgery, cryotherapy, or androgen deprivation therapy) and with receipt of radiotherapy specifically.

In relation to cancer drugs, one study found that physicians decreased their use of medications that showed the greatest declines in profitability. Another study found that after changes in compensation for drug administration resulting from the Medicare Modernization Act of 2003, patients dying of cancer were less likely to receive systemic therapy within the last 30 days of life. Another study found that physicians used less irinotecan after the drug’s patent protection expired and a lower-cost, less-profitable generic alternative became available. In addition, there was a significant increase in office-based cystoscopic procedures following an increase in reimbursement for procedures performed in the office setting and the absence of a coincident change in procedures performed in the hospital or ambulatory surgery settings, where reimbursement did not change, one of the studies found.

The authors concluded that some oncologists may, in certain circumstances, alter treatment recommendations based on personal revenue considerations. Changing such practices could lower health care spending and prevent potentially inappropriate treatment.

Dr. Walter Stadler

Dr. Walter Stadler

The findings from the systematic review are not surprising, said Walter Stadler, MD, a professor at the University of Chicago and chief of the hematology/oncology section.

“Financial incentives are always going to influence physicians and you cannot fully prevent that,” he said in an interview. “We all like to believe, we are all completely altruistic, but physicians respond to the same financial pressures that anybody else responds to. We’re not unique in that way.”

Particularly, when two treatment modalities are equally efficacious, it makes sense that financial incentives may impact the doctor’s choice.

“There are always outliers, but physicians as a community are not necessarily going to do something that is directly harmful for patients based only on financial incentives,” he said. “But if there are two medically equivalent choices, than financial incentives will play a role.”

Dr. Wheeler has received research grant funding from Pfizer unrelated to this work. No other disclosures were reported.

SOURCE: Mitchell AP et al. JAMA Oncol. 2019 Jan 3. doi: 10.1001/jamaoncol.2018.6196.

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