3rd-party Payer Research Articles

The cost-effectiveness of primary prophylaxis with granulocyte colony-stimulating factor in docetaxel-containing adjuvant chemotherapy in early breast cancer: The impact of risk of febrile neutropenia and its mortality.

6086 Background: Studies have shown higher rates of febrile neutropenia (FN) with docetaxel (D) containing chemotherapy (C) in early breast cancer (BC) patients than those in clinical trials (CTs). Previous cost-effectiveness analyses (CEA) on FEC-D vs FEC and primary prophylaxis (PP) of granulocyte colony stimulating factor (GCSF) were based on FN risk from CTs that may not reflect the real world. These CEA lacked the complexity to model the risk of FN per cycle, address use of PP vs secondary prophylaxis (SP) & examine long term efficacy of FEC-D vs FEC jointly. Methods: A 2-stage Markov model was developed for a hypothetical cohort of patients age 50 with early BC. First stage modeled costs/outcomes of 6 cycles C (FEC or FEC-D), including events related to FN, complications and G-CSF use (either PP or SP). Second stage modeled costs/outcomes of local/distant relapse, and death from BC (10 year horizon). Efficacy data of C and G-CSF, and utility were obtained from published data. Model was based on 3rd party payer (2010 Canadian dollars - 3% discounting rate). 4 strategies were used: (S1) FEC x 6 with SP, (S2) FEC x 3 with SP → D x 3 with SP, (S3) FEC x 3 with SP → D x 3 with PP, (S4) FEC x 3 with PP → D x 3 with PP. Results: At a willingness-to-pay (WTP) threshold of $50,000/QALY, S2 is preferred to S1 when risk of FN with D per cycle without G-CSF is < 9%, 6% or 4% if risk of death from FN is 1%, 5% or 10% respectively. S3 may be preferred if the risk of death from FN is > 14%. At a WTP of $100,000/QALY, S3 is preferred to S2 when risk of FN with D per cycle is > 12%, 4% or 2% if the risk of death from FN is 1%, 5% or 10% respectively. S4 is preferred to S3 only if risk of death from FN is > 18%. S1 is preferred only if risk of FN with D per cycle is much > 40%. Conclusions: We developed an economic model to determine the cost-effectiveness of different C/GCSF strategies in early BC, calibrated to the efficacies reported in CTs. In the “real world”, the most cost-effective strategy will depend on accurate understanding of the risk of developing/dying from FN in the non CTs setting. Societal WTP threshold will have a significant impact on defining the optimal systemic approach.

Cost-Effectiveness of Genexol-PM for Treating Metastatic Breast Cancer

Purpose: The aim of this study was to determine the incremental effectiveness (the differences in progression-free survival between treatments), the incremental cost and the incremental cost-effectiveness of Genexol-PM compared to Paclitaxel when these drugs were used as treatment for patients with metastatic breast cancer. Methods: In the absence of any comparative direct evidence of the relative efficacy of Paclitaxel and Genexol-PM in this setting, a meta-analysis was conducted to determine the effects of the Paclitaxel on the health outcome. The decision tree model was constructed to evaluate the two treatment regimens. All the costs are in 2008 Korean Won (KW) and they were evaluated according to the 3rd party payer perspective, and the direct nonmedical and indirect costs were excluded. Results: When compared with Paclitaxel, Genexol-PM was shown to increase the response rate and the time to progression for patients with metastatic breast cancer. Although the overall treatment costs of Genexol-PM were slightly higher than those of Paclitaxel, Genexol-PM was associated with a delayed time to progression of 4.78 months per patient. The incremental cost effectiveness ratio for Genexol-PM versus Paclitaxel was KW 2,295,228 per year gained, which is far below the per capita GDP or the threshold of the willingness-to-pay in Korea. Conclusion: Compared with Paclitaxel, Genexol-PM for treating metastatic breast cancer is within the acceptable range of the cost-effectiveness ratio for medical intervention.

Providers’ and payers’ endorsements of empirically supported therapy: A power–knowledge relationship?

Abstract The promotion of empirically supported therapies (ESTs) has been prompted in part by the need to meet perceived demands of 3rd-party payers. Yet little communication has occurred between psychologists and payers as to how decisions regarding treatment are made. In this study, providers of psychological treatment and representatives of the insurance industry were interviewed about their views on this topic. Transcriptions of the interviews were analyzed using an approach derived from the grounded-theory method. In addition to the expected influence by payers on providers for lowered costs and “objective” outcomes, it was evident that both payers and providers were influenced by providers’ promotion of cognitive–behavior therapy as an EST. The respective practices of providers and payers were interpreted to constitute a complex matrix of joint influence. In light of the literature suggesting little compelling evidence for the exclusionary claims made for ESTs, the relevance of Foucault's notions re...

Cost-effectiveness projections of FOLFOX vs. IFL in first-line therapy of metastatic colorectal cancer in the context of the U.S. health care system

3531 Background: A randomized comparison has shown FOLFOX to be superior to the previous U.S. standard of care, IFL for 1st-line therapy (Rx) of metastatic colon cancer. The tradeoffs between costs and survival for these two regimens have not been explored. Methods: A post-hoc incremental cost-effectiveness (ICE) projection using simulated cohorts of patients starting FOLFOX or IFL was tracked for major clinical events, toxicities and survival for 5 years using the perspective of Medicare as a 3rd party payer. Recurrence and survival risks were based on clinical trial data. Resource use was projected using observed dose intensity, duration of and delays in Rx, and grade >2 toxicities. Use of 2nd-line Rxs was estimated based on patterns observed for trial patients as well as contemporary estimates. Results: Initial Rx with FOLFOX v IFL had an average incremental cost of $29,523, a survival benefit of 4.4 months and an ICE of $80,410 per life yr (LY). The table compares component costs. Using the 95% confidence interval for the time to progression observed in N9741, the ICE associated with FOLFOX ranged from $121,220 to $59,250 per LY. In the clinical trial, dose delays and skipped doses were frequent. If progression-free pts were treated without delay for the first yr or lifetime, the ICE for FOLFOX increased to $117,910 and $222,200 per LY, respectively. Otherwise, the ICE changed minimally across a range of plausible parameters. The ICE increased to $84,780 per LY when the model used a revised IFL schedule with lower early toxicity and similar rates of Rx with 2nd-line regimens. Conclusions: Compared to IFL, FOLFOX provides substantial benefit at substantial increase in cost. The ICE falls in the upper range of commonly accepted oncology interventions in the U.S. This cost analysis supports FOLFOX as a standard for future comparisons to regimens that incorporate biologic agents. Author Disclosure Employment or Leadership Consultant or Advisory Role Stock Ownership Honoraria Research Funding Expert Testimony Other Remuneration Sanofi-Synthelabo Pfizer, sanofi-aventis, Sanofi- Synthelabo Pfizer, sanofi-aventis, Sanofi-Synthelabo Pfizer, Sanofi-Synthelabo

How Much Does It Cost to Change the Behavior of Health Professionals? A Mathematical Model and an Application to Academic Detailing

Several strategies have shown to be effective at enhancing the implementation of research findings in daily practice. These implementation strategies improve the delivery of preventive or therapeutic care by successfully educating health professionals. On the other hand, little is known about the costs of these implementation strategies. The goal of this article is to present a mathematical model that predicts implementation costs by using published data. As an important feature, the model portrays the relationship between the degree of treatment underuse and implementation costs. Two application examples of outreach programs for the prevention of stroke and coronary disease analyze the relevance of implementation costs with respect to the cost-effectiveness ratio and total costs. They demonstrate that implementation costs may have little impact on the cost-effectiveness ratio but may nevertheless be relevant to a 3rd-party payer who needs to stay within the budget and ensure that care is provided to a large underserved population. The model and its consideration of implementation costs may contribute to a more efficient use of health care resources.

Empirical support for psychological assessment in clinical health care settings.

Psychologists in health care settings today find it increasingly difficult to obtain authorization and appropriate reimbursement for psychological assessments from 3rd party payers. Authorization and reimbursement denials often are based on allegations that empirical support for the utility and validity of psychological tests is nonexistent or limited. This article reviews a sample of the considerable empirical support that exists for the utility and validity of a variety of psychological tests for a wide range of clinical health care applications. Informed by data such as these, psychologists should become more effective in their abilities to seek authorization and reimbursement for assessment and overturning denials.

Public health surveillance and information technology.

Applying Modern Information Technology to Reporting for Public Health—the Role of Standards Clement McDonald, Indiana University School of Medicine, discussed the role of standards in the application of modern information technology to public health reporting. He pointed to the rich data sources stored electronically in clinical laboratories, pathology and cytology reporting systems, pharmacies, and hospitals, and emphasized the trend toward increasing automation. Interest and demand for electronic delivery of data come from many interested parties—3rd party payers, researchers, physicians, and public health officials. However, substantial barriers to smooth electronic flow of this information include the storage of data in isolated areas, varying internal structures among information systems, and considerable variation in codes (e.g., for laboratory tests and results). Overcoming these barriers requires defining, adopting, and implementing standards for messages, codes, identification (e.g., persons, providers, places), and security.

Use of personality assessment instruments in empirically guided treatment planning.

Treatment planning and monitoring are essential components of mental health service delivery in the era of managed care. Personality assessment instruments have long been used by practitioners to assist in psychodiagnosis and the identification of treatment needs and goals. Nevertheless, managed-care companies and 3rd-party payers are reluctant to authorize psychological assessment service and, instead, prefer that clinicians base their plans on clinical interviews. Research is reviewed documenting the utility of personality assessment instruments in empirically guided treatment planning and the superiority of this method over clinical interviewing. A new psychological test designed specifically for use in treatment planning, the Butcher Treatment Planning Inventory (J. N. Butcher, in press), is introduced and described.

Hospitalization for Tubal Sterilization

The article by Peter M. Layde, M.D., et. al (1981;245:714) warrants further comment and an update on the subject. Substantial reductions in the length of stay (LOS) after sexual tubal sterilization (STS) have been achieved in the past 5 years since those described by Layde et. al. Many contemporary facilities have now settled on a stay of 4-6 hours postoperatively, in fact, as the standard. In achieving this, the laparoscope was but 1 of the technical innovations contributing to the reduction, and other important changes were in progress over the last 10 years which brought the short LOS about. Favorable experience with STS by family planners in India and Southeast Asia during the early 1970s performed in freestanding clinics and tubectomy camps used little or no analgesia or anesthesia, and minimal postoperative supervision was needed for safe recovery. Later, Lubell and Frischer demonstrated that the concept of short stay was equally as safe and applicable in this country. Moreover, consumer demands for same-day surgery gave further impetus to this new trend. Additionally, because of economic motivations, 3rd party payers added further pressure toward the reduction in postoperative stay. Our personal experience with more than 500 patients undergoing vaginal tubal sterilizations performed under general anesthesia have proved the safety and utility of the short-stay approach to STS, regardless of the technology or methodology applied. No doubt when LOS statistics become available for STS in this country between 1975-9, enormous additional reductions in hospital time and monetary expenditures will be appreciated. Using the Association for Voluntary Sterilization estimate of 4 million women undergoing STS from 1976-9, and the reduction of the average LOS from 4 nights to no overnight stay, an impressive $160 million could be added to the estimate by Layde et. al of $200 million savings over the pre-1970 procedures. Finally, we take exception with the concept of "strike while the iron is hot" as it relates to the timing of STS. While it is inevitable that STS will continue to be requested and performed immediately after vaginal or cesarean births, this is probably the worst possible timing. The risk of complications, failure, or subsequent regret of having been sterilized is highest at that time. Day surgery makes interval STS cost-efficient and more readily acceptable to the sterilization candidate, and thus avoids those problems associated with puerperal sterilization.

Policy Formulation and Technology Assessment

Describes technology assessment and its application to the health field; examines evaluation of efficacy, safety, and cost effectiveness; discusses the use of technology assessment in policy formulation, especially by federal programs; suggests a system for assessment of medical technologies; and offers some observations about the future of technology assessment in policy making. Technology assessment began formally in 1965 in the Committee on Science and Astronautics of the House of Representatives as a process of examining technology and its impacts. Only a few attempts have been made since then to apply the concepts of technology assessment to health care. The amount of money currently devoted to assessing the efficacy and safety of medical technologies is small, and many important technologies have not been assessed. Priorities for clinical trials should therefore be set. Cost effectiveness analysis is a useful tool in decision making but because of its inherent limitations, it should not be the sole or even primary determinant of a decision. Technology assessment is apparently infrequently used as a decision-assisting tool by 3rd party payers, federal government agencies funding biomedical research, or the federal program which is designed to control physician utilization of certain technologies. Only the FDA regularly utilizes technology assessment. A systematic program of technology assessment would require identification of technologies needing testing, setting of priorities for such tests, synthesizing of information gained and its dessemination to decision makers.

Court OK's Medicaid as 3rd Party Payer

Court OK's Medicaid as 3rd Party Payer