Do Case Rates Affect Physicians' Clinical Practice in Radiation Oncology?: An Observational Study

PLoS One. 2016 Feb 12;11(2):e0149449. doi: 10.1371/journal.pone.0149449. eCollection 2016.

Abstract

Case rate payments combined with utilization monitoring may have the potential to improve the quality of care by reducing over and under-treatment. Thus, a national managed care organization introduced case rate payments at one multi-site radiation oncology provider while maintaining only fee-for-service payments at others. This study examined whether the introduction of the payment method had an effect on radiation fractions administered when compared to clinical guidelines. The number of fractions of radiation therapy delivered to patients with bone metastases, breast, lung, prostate, and skin cancer was assessed for concordance with clinical guidelines. The proportion of guideline-based care ascertained from the payer's claims database was compared before (2011) and after (2013) the payment method introduction using relative risks (RR). After the introduction of case rates, there were no significant changes in guideline-based care in breast, lung, and skin cancer; however, patients with bone metastases and prostate cancer were significantly more likely to have received guideline-based care (RR = 2.0 and 1.1, respectively, p<0.05). For the aggregate of all cancers, the under-treatment rate significantly declined (p = 0.008) from 4% to 0% after the introduction of case rate payments, while the over-treatment rate remained steady at 9%, with no significant change (p = 0.20). These findings suggest that the introduction of case rate payments did not adversely affect the rate of guideline-based care at the provider examined. Additional research is needed to isolate the effect of the payment model and assess implications in other populations.

Publication types

  • Observational Study
  • Research Support, Non-U.S. Gov't

MeSH terms

  • Administrative Claims, Healthcare / economics
  • Health Expenditures
  • Humans
  • Insurance, Health, Reimbursement / economics
  • Neoplasms / economics
  • Neoplasms / radiotherapy*
  • Quality of Health Care / economics
  • Radiation Oncology / economics
  • Radiotherapy / economics*

Grant support

The authors received no specific funding for this work. This study was completed by Humana, Inc. and HealthHelp, LLC, and authors worked on it as a part of their duties for their respective organization. HealthHelp LLC and Humana Inc. provided support in the form of paid employment or consulting fees for all the authors. (Humana: BL, LH, JR, MM, and JL. HealthHelp: CS, AP, GS, and AG.). The specific roles of these authors are articulated in the ‘author contributions’ section. This research represents the findings of a quality improvement project conducted by the funding organizations, which were both actively involved in the study design, data collection and analysis, decision to publish, and preparation of the manuscript. URL of HealthHelp: www.healthhelp.com; URL of Humana: www.humana.com.