Is Utilization Management Policy Correlated with Uptake of Hypofractionated Radiotherapy in Early-Stage Breast Cancer?

A study evaluated the relationship between utilization management policy and uptake of hypofractionated radiotherapy in patients with early-stage breast cancer.

“Breast cancer accounts for the largest portion of cancer-related spending in the United States. Although hypofractionated radiotherapy after breast-conserving surgery is a cost-effective and convenient treatment strategy for patients with early-stage breast cancer, less than 40% of eligible women received hypofractionated radiotherapy in 2013,” observed the study authors.

The researchers retrospectively analyzed administrative claims data from Jan. 1, 2012, through June 1, 2018, of women aged ≥18 years with early-stage breast cancer who were eligible for hypofractionated radiotherapy based on 2011 American Society for Radiation Oncology guidelines. Women were continuously enrolled in one of 14 geographically diverse commercial health plans. Exclusion criteria included receipt of mastectomy, brachytherapy, or less than 11 or more than 40 external beam fractions of radiotherapy. The use of hypofractionated radiotherapy in patients with fully insured and Medicare Advantage plans was encouraged by a utilization management policy, which dictated that extended-course radiotherapy claims would not be reimbursed for fully insured women eligible for hypofractionated radiotherapy. A comparison group was comprised of women in self-insured or Medicare supplemental (self-insured) plans. The main outcome measure was hypofractionated radiotherapy use, with cost serving as a secondary outcome.

Data on 10,540 eligible women were identified, of whom about a third (n=3,619; 34.3%) were subject to the policy because they were enrolled in fully insured plans. Mean age at the start of radiotherapy was 63.8 years in the fully insured group and 65.0 years in the self-insured group. No significant differences were observed in mean baseline Charlson Comorbidity Index score (3.0 vs. 3.2, respectively) or practice setting (outpatient hospital setting, 82.4% vs. 80.9%, respectively). Among fully insured patients subject to the policy, it was associated with greater use of hypofractionated radiotherapy (adjusted percentage point difference-in-difference, 4.2%; 95% confidence interval (CI), 0.0% to 8.4%; P=0.05) as well as a nonsignificant decrease in radiotherapy-associated expenditures (−$2,275 relative to self-insured patients; P=0.09). Upon spillover analysis the researchers observed that hypofractionated radiotherapy increased significantly more among self-insured patients who were indirectly exposed to the policy (adjusted percentage point difference-in-difference, 8.5%; 95% CI, 3.6% to 13.5%; P<0.001) versus those not exposed.

The study was published in JAMA Oncology.

“This study suggests that a payer’s utilization management policy was associated with direct and spillover increases in the use of hypofractionated radiotherapy, even after accounting for a long-term secular trend in the uptake of hypofractionated radiotherapy in the control groups,” summarized the researchers. “Utilization management may promote evidence-based cancer care.”