LHRH Treatment or Orchiectomy? The Influence of Medicare Reimbursement
Abstract & Commentary
By William B. Ershler, MD, Editor
Synopsis: Orchiectomy rates have increased and LHRH prescriptions have decreased over the past 5 years. Could this be related to Medicare reimbursement?
Source: Weight CJ, et al. Androgen deprivation falls as orchiectomy rates rise after changes in the reimbursement in U.S. Medicare population. Cancer. 2008;112:2195-2201.
In the late 1990s and through 2003 there was widespread use of lutenizing hormone-releasing hormone (LHRH) agonists as a form of "medical castration" for patients with prostate cancer. When compared with the alternative (surgical) castration, patients generally preferred the medical approach and the Medicare reimbursement schedules may have provided an economic incentive as well. In fact in 2001, expenditures for this class of drugs exceeded all others at 1 billion dollars, and this led to heightened scrutiny and ultimately the Medicare Modernization Act (MMA) which was approved in 2003 and implemented in 2004. This mandated a decline in reimbursement to 80% to 85% of the average wholesale price starting in 2004 followed by a more significant reduction in 2005 to a level of approximately 50% of 2003 values.
To assess whether such reimbursement changes influenced treatment patterns, Weight and colleagues at the Cleveland Clinic examined the publicly available Medicare Part B Extract Summary System dataset from 2001 to 2005 for trends in the number of allowed services and dollar amounts of allowed charges and payments. The reimbursable Medicare codes of J9217 (leuprolide acetate), J9202 (goserelin acetate), J9219 (leuprolide acetate implant), and J3315 (triptorelin pamoate) were examined for medical castration. The code for simple orchiectomy, 54520, was used for surgical castration.
Between 2001 and 2003, the frequency of "medical castration" increased whereas surgical castration decreased. Total allowed charges for medical castration peaked in 2003 at $1.23 billion. After the enactment of the MMA, surgical castration rates increased, and medical castration decreased. Total allowed charges for medical castration in 2005 dropped 65% from the 2003 peak.
Commentary
This is an interesting and provocative piece. Of course, there are a number of alternative explanations, such as a change in prostate cancer demographics, clinical reports that might have indicated that orchiectomy is more effective or a trend to using the longer acting LHRH preparations, which might contribute to the apparent reduction in LHRH use. However, the greatest likelihood is that physicians, particularly urologists in this case, changed their pattern of treatment based upon, at least in part, the loss of the financial incentive of LHRH injection.
Is this bad? On the one hand, it has long been felt that medical and surgical approaches to hormonal ablation are comparable.1,2 Yet, the advantage of the medical approach relates to its temporary rather than permanent effect and to the psychological effect of orchiectomy experienced by many men. Under certain circumstances, such as when used as an adjunct to surgery or radiation, current recommendations include hormonal ablation for a limited period of time. Only in the case of patients with metastatic disease is continuous and indefinite hormonal ablation called for. Thus, if the MMA resulted in patients for whom current evidence warrants short-term ablation but for whom orchiectomy was performed to achieve hormonal blockade, it is fair to say that patient care has been compromised.
Who's to blame? Well, we all are. First, physicians practicing in the pre-MMA era took advantage of a Medicare glitch to such an extent that drugs in this class ranked number 1 in Medicare drug expenditures and thereby heightened scrutiny. Secondly, those who craft Medicare reimbursement schedules. Currently, although drugs in this class have distinct advantages over orchiectomy for at least a subset of prostate cancer patients, for many practitioners the reimbursement has been cut to such an extent that they lose money with each patient treated. For those in the private sector this is not consistent with a successful business plan. But, no matter why or how this has come about, those who are hurt the most are the patients who have had more effective or desirous treatment legislated away.
References
1. Peeling WB. Phase III studies to compare goserelin (Zoladex) with orchiectomy and with diethylstilbestrol in treatment of prostatic carcinoma. Urology. 1989;33(5 Suppl):45-52.
2. Vogelzang NJ, et al. Urology. 1995;46(2):220-2266.
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