Payer Utilization Management Increases Use of Evidence-Based Care

Payer adoption of a utilization management policy increased the use of hypofractionated radiotherapy, a guideline-recommended treatment, for eligible patients with early-stage breast cancer, according to results from a retrospective, administrative claims database.¹

Many patients with early-stage breast cancer receive whole-breast irradiation. The American Society for Radiation Oncology (ASTRO) recommends hypofractionated radiotherapy over the course of 3 to 5 weeks as an alternative to conventional fractionation radiotherapy, with similar efficacy, improved convenience, and lower cost. However, it is estimated that only about a third of eligible women receive hypofractionated radiotherapy. The aim of this study was to determine if the implementation of a utilization management policy could increase the use of hypofractionated radiotherapy and its cost.

This retrospective study analyzed administrative claims data from between January 2012 and June 2018 for adults with early-stage breast cancer who were eligible for hypofractionated radiotherapy, as defined by the 2011 ASTRO guideline. Although these criteria have since been updated, the 2011 criteria were: aged 50 years or older at diagnosis; pathologic stage T1-2 N0 and underwent breast-conserving surgery; did not receive systemic chemotherapy; and the minimum dose within the breast along the central axis is no less than 93% and the maximum dose is no greater than 107% of the prescription dose.²

The utilization management policy was adopted by a large commercial insurer for patients who were fully-insured or who were enrolled in Medicare Advantage; it was not adopted for women who were self-insured or who had Medicare supplemental insurance. The primary endpoint was use of hypofractionated radiotherapy and the secondary outcome was its associated cost.¹

The analysis identified 10,540 eligible patients, of whom, 3619 (34.3%) were fully insured and were therefore subject to the utilization management policy. There was no significant difference in mean age at start of treatment, Charlson comorbidity index score, or practice setting between patients who were fully insured and those who were self-insured.

The use of hypofractionated therapy was significantly increased among the group of fully-insured patients compared with the group of patients who were self-insured or who had Medicare supplemental insurance, with an adjusted difference-in-difference of 4.2% (95% CI, 0.0%-8.4%; p=.05). These data were adjusted to account for long-term secular trend in the use of hypofractionated radiotherapy observed in the control groups. The decrease in radiotherapy-associated costs between the fully-insured and self-insured groups was $2275, which was nonsignificant (P=.09).

The authors concluded that these data suggest that “a payer’s utilization management policy was associated with direct and spillover increase in the use of hypofractionated radiotherapy.” They added that, “utilization management may promote evidence-based cancer care.”

Reference

1. Parikh RB, Fishman E, Chi W, et al. Association of utilization management policy with uptake of hypofractionated radiotherapy among patients with early-stage breast cancer. JAMA Oncol. Epub 2020 April 16.
2. Smith BD, Bentzen SM, Correa CR, et al. Fractionation for whole breast irradiation: an American Society for Radiation Oncology (ASTRO) evidence-based guideline. Int J Radiation Oncology Biol. 2011;81:59-68.