A utilization management policy promoting hypofractionated radiotherapy is associated with the improvement of evidence-based cancer care for women with early breast cancer, researchers found.
A retrospective economic analysis determined that there was a higher uptake of hypofractionated radiotherapy among women who were either directly subject to, or indirectly exposed to the policy.
However, Ravi B. Parikh, MD, MPP, Perelman School of Medicine, University of Pennsylvania, Philadelphia, and colleagues found that the utilization management policy did not result in measurable cost savings.
In 2011, hypofractionated radiotherapy was recommended by the American Society for Radiation Oncology (ASTRO) for women older than 50 years with early-stage breast cancer, and it expanded that recommendation to nearly all patients with localized breast cancer in 2018. However, many women eligible for the therapy still don’t receive it.
According to Parikh and his colleagues, while utilization management strategies have been associated with cost savings and uptake of evidence-based practice in some clinical settings, there is little evidence of its effectiveness in oncology care.
In this study the authors investigated a utilization management policy developed by a larger commercial payer in 2016, and its association with the uptake of hypofractionated radiotherapy for patients with early-stage breast cancer, as well as its associated costs.
Their analysis was conducted using administrative claims data from patients managed by 14 commercial health plans distributed across the U.S. They identified 10,540 women, 18 years or older, with early-stage breast cancer, and who were eligible for hypofractionated radiotherapy according to 2011 ASTRO guidelines.
According to the authors, under the utilization management policy claims for extended-course radiotherapy were not reimbursed for fully insured women who were eligible for hypofractionated radiotherapy. The policy did not apply to women in self-insured or Medicare supplemental insurance plans, which allowed these groups to serve as a comparison group in the study.
Parikh and his colleagues found that the percentage of fully insured patients and self-insured patients who received hypofractionated radiotherapy increased significantly during the time of the study (from 22.4% in 2012 to 82.3% in 2018, and 20.3%-79.8%, respectively).
Because of this “secular trend” of an increasing use of hypofractionated radiotherapy, “the magnitude of the isolated policy’s association with outcomes was not large,” the authors reported. They found that compared with self-insured patients who were not subject to the policy, there was an increase in hypofractionated radiotherapy among fully insured patients subject to the policy (adjusted percentage point difference-indifference, 4.2%; 95% CI, 0.0%-8.4%). Thus, there was a 4.2% absolute association of the policy with rates of hypofractionated radiotherapy.
And spillover analyses showed a higher uptake of hypofractionated radiotherapy among self-insured patients who were indirectly exposed to the policy (but whose physicians were exposed to the policy) compared with those who were not exposed (adjusted percentage point difference-indifference, 8.5%; 95% CI, 3.6%-13.5%). This suggests that the use of hypofractionated radiotherapy extended beyond the policy’s target audience, the authors wrote.
“We did not find a direct association or a spillover association between the utilization management policy and spending,” Parikh and his colleagues reported. “Given that one of the purported benefits of utilization management is spending control, policy makers must balance the possible effect of this policy and similar policies against their additional administrative costs.”
Parikh and his colleagues concluded that the utilization management was associated with improved cancer care for women both subject to, and indirectly exposed to the policy. However, they also recommended that health systems and policy makers should regularly evaluate such programs to assess their overall costs and benefits.
In a commentary accompanying the study, Eric M. Chang, MD, Department of Radiation Medicine, Oregon Health & Science University, Portland, and colleagues agreed with Parikh and his colleagues that utilization management programs should periodically be reevaluated to ensure they remain beneficial, particularly if the data shows that deviating from guidelines has no significant effect.
For example, they noted that while there was an uptake of hypofractionated radiotherapy in 80% of patients by the end of the study, that still left 20% who continued to receive standard fractionation.
“Further exploration of this population is warranted,” wrote Chang and his colleagues. “If use of standard fractionation is consolidated among a group of outlier clinicians, it would potentially argue for selective implementation of utilization management tools among a subset of clinicians, while sparing most physicians (and therefore patients) the administrative hassle.”
- Implementation of a utilization management policy resulted in a significantly higher uptake of hypofractionated radiotherapy among eligible women.
- Be aware that, unlike other utilization management strategies, this one did not result in significant cost savings.
Michael Bassett, Contributing Writer, BreakingMED™
Parikh reported receiving personal fees from GNS Healthcare Inc, Cancer Study Group, and Medscape; and receiving grants from VA Center for Health Equity Research and Promotion, MUSC Transdisciplinary Collaborative Centerin Precision Medicine and Minority Men’s Health, Conquer Cancer Foundation, and Embedded Healthcare outside the scope of this work.
Cat ID: 22
Topic ID: 78,22,730,22,691,192,925,482
Parikh Ravi, et al “Association of utilization management policy with uptake of hypofractionated radiotherapy among patients with early-stage breast cancer” JAMA Oncol 2020; DOI: 10.1001/jamaoncol.2020.0449.
Chang E, et al “Evaluating a utilization management policy in radiation oncology” JAMA Oncol 2020; DOI: 10.1001/jamaoncol.2020.0447.