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The cost and quality of cancer care in Health Affairs' April issue

Health Affairs

Cancer Mortality Reductions Were Greatest Among Countries Where Cancer Care Spending Rose The Most, 1995-2007.
Warren Stevens of Precision Health Economics, Dana P. Goldman of the Schaeffer Center for Health Policy and Economics at the University of Southern California, and coauthors compared cancer care across sixteen countries over time, examining changes in cancer spending and two measures of cancer mortality (amenable and excess mortality). They found that, compared to low-spending health systems, high-spending systems had consistently lower cancer mortality in the period 1995-2007. Similarly, the authors found that the countries that increased spending the most had a 17 percent decrease in amenable mortality, compared to 8 percent in the countries with the lowest growth in cancer spending. For excess mortality, the corresponding decreases were 13 percent and 9 percent. Additionally, the rate of decrease for the countries with the highest spending growth was faster than the all-country trend. These findings are consistent with the existence of a link between higher cancer spending and lower cancer mortality.

Does increased spending on breast cancer treatment result in improved outcomes?
Aaron J. Feinstein of Yale University School of Medicine's Cancer Outcomes, Public Policy, and Effectiveness Research Center and coauthors compared care costs and survival rates among women ages 67-94 diagnosed with stage II or III breast cancer during two time periods, 1994-96 and 2004-06. They found that over the course of a decade, median cancer-related costs increased from $12,335 to $17,396 among women with stage II disease, and their five-year survival rate improved from 67.8 to 72.5 percent. For those women with stage III disease, costs increased from $18,107 to $32,598 with an accompanying five-year survival improvement from 38.5 to 51.9 percent. The cost increase was largely attributable to a substantial increase in the cost of chemotherapy and radiation therapy. The authors note that the price society is willing to pay for an additional year of life remains controversial in the United States and suggest that more research is needed to determine how to best contain costs while continuing to advance patient care.

False-positive mammograms and potential overdiagnoses cost the US $4 billion annually.
In recent years, the prevalence of false-positive mammography screenings and overdiagnosis of breast cancer (diagnosis of cancer that will never cause symptoms or death during a patient's lifetime) has been well-documented. Until now, however, the full, national-scale cost burden has not been documented. Mei-Sing Ong of the Boston Children's Hospital Informatics Program and Ken Mandl, Harvard Medical School professor and Boston Children's Hospital Informatics Program faculty member conducted a study to assess the costs as the result of false-positive mammograms and breast cancer overdiagnoses among more than 700,000 women ages 40-59 between 2011 and 2013. Average expenditures ranged from $852 for every false-positive mammogram to $12,369 for each misdiagnosis of ductal carcinoma in situ (abnormal changes in the cells of the milk ducts of the breast--the most common type of non-invasive breast cancer). The authors found that the national costs of false-positive mammograms and breast cancer overdiagnoses are $4 billion each year and note that these costs must be considered in debates about whether screening guidelines should take into account additional factors beyond age.

Other topics in the issue:

DataWatch: The Affordable Care Act's coverage provisions' impact on young adults.
Stacey McMorrow of the Urban Institute's Health Policy Center and coauthors examined data from the National Center for Health Statistics' National Health Interview Survey and found that young adults have experienced substantial gains in insurance from health reform. They found that the percent of young adults, ages 19-25, who were uninsured fell 11 percentage points--from 30 percent in the first quarter of 2009 to just 19 percent by the second quarter of 2014. The Affordable Care Act's dependent coverage expansion, which allows adults to remain on their parents' insurance until their twenty-sixth birthday, first took effect in September 2010, while the Medicaid expansion and Marketplace coverage began in January 2014. Coverage gains were concentrated among higher- and moderate-income young adults through 2013, while those with lower incomes were more likely to gain coverage in 2014, especially in states that expanded Medicaid. This study is part of Health Affairs' DataWatch series.

Under the new pay-for-performance models how do low performers fare?
Jessica Greene of George Washington University's School of Nursing and coauthors studied the impact of a primary care provider compensation model--that of Fairview Health Service, a Pioneer accountable care organization in Minnesota--in which 40 percent of providers' compensation was based on their clinic-level quality outcomes. The researchers examined providers' performance data before the model and two years after implementation, finding that the best predictor of improvement was the primary care providers' baseline quality performance. Researchers found that the providers whose baseline scores placed them in the lowest one-third in terms of performance on three quality metrics improved three times more, on average, than those in the middle-third, and almost six times as much as those in the top-third. The authors note that payment reform may help narrow variation in primary care performance.

One of the nation's largest fee-for-value initiatives among the first to show promise.
Christy Harris Lemak of the University of Alabama at Birmingham and coauthors analyzed Blue Cross Blue Shield of Michigan's Physician Group Incentive Program's impact on quality and spending for more than three million beneficiaries across 11,000 primary care practices from 2008 to 2011. They found practice participation in the fee-for-value program was associated with approximately 1.1 percent lower total spending for adults and a 5.1 percent reduction in total spending for children. At the same time, the practices maintained or improved performance on eleven of fourteen quality measures--including screenings for patients with diabetes, breast and cervical cancer screenings, and well-child visits. The authors note that the findings contribute to the growing body of evidence in favor of models that align physician payment with cost and quality performance.

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Health Affairs is the leading journal at the intersection of health, health care, and policy. Published by Project HOPE, the peer-reviewed journal appears monthly in print, online, on mobile, and on iPad. Additional and late-breaking content is found at http://www.healthaffairs.org in Web First papers, Health Affairs Blog, Health Policy Briefs, Videos and Podcasts, and more.

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