JAMA Study Shows Utilization Management Increases Short-Course Radiation in Breast Cancer Patients Directly and Not Directly Exposed to Policy
Hypofractionated, or shorter-course radiation, is equally as effective as conventional, or longer-course radiation, for patients with early-stage breast cancer. It’s also more convenient with fewer side effects. The American Society for Radiation Oncology (ASTRO) recommends shorter-course radiation for nearly all patients with localized breast cancer.
Despite these benefits and guidelines, as of 2013, only 35 percent of eligible women received a shorter course of treatment.1
In 2016, a large commercial health plan developed a utilization management policy, administered by AIM Specialty Health, in accordance with ASTRO guidelines, promoting shorter-course radiation for patients with early-stage breast cancer.
Under the new policy, claims for longer-course radiation were not reimbursed for fully insured patients, including Medicare Advantage Plan patients eligible for shorter-course radiation. This policy did not apply to self-insured patients, including members with Medicare supplemental insurance.
HealthCore’s Translational Research team evaluated this utilization management policy to find that it was not only effective among fully insured patients under policy, but it also led to an increase in utilization rates among self-insured patients to whom the policy did not apply. Because radiation participating oncologists may have incorporated shorter-course radiation into their everyday practices, changes in radiation choices for fully insured enrollees appeared to ‘spill over’ to self-insured enrollees.
This utilization policy had a moderate effect by increasing 4.2 percentage points in the shorter course of radiation utilization =t (p=0.05).
Additionally, researchers found a significantly higher uptake of shorter course radiation among self-insured patients who were indirectly exposed to the policy (8.5 adjusted ppd, 95% CI 3.6 to 13.5, p=0.001), compared to those who were not exposed.
The policy implementation did not result in significant cost savings; however, this study shows that utilization management in oncology can lead to increases in evidence-based practice in populations that are both directly and not directly exposed to the policy. Furthermore, such policy can have an impact over and above a prominent secular trend on uptake of evidence-based practice.
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