Introduction%20to%20Pharmacoeconomics

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Impact of Under-insurance on Patients with Breast
Cancer Related Lymphedema
National Congress on the Un and Under
Insured Impact of Being Uninsured or Underinsured
Individuals with Cancer December 11th, 2007
Ya-Chen Tina Shih, Ph.D. Associate
Professor Section of Health Services
Research Department Biostatistics Division of
Quantitative Sciences University of Texas MD
Anderson Cancer Center
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Breast Cancer Related Lymphedema (BCRL)

• Upper extremity lymphedema (persistent arm
  swelling) is one of the most dreaded sequelae of
  breast cancer treatment
• BCRL affects 15-30 of breast cancer pts
• Risk factors of BCRL
• Axillary node dissection
• Axillary radiation therapy
• Mastectomy
• High body mass index
• Chemotherapy

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Clinical Management of BCRL

• No cure for BCRL to date, the mainstay of
  treatment is symptom control
• Clinical management includes
• Compression therapy
• Massage therapy
• Use of elastic garment or pneumatic pumps
• Manual lymph drainage
• Complications of BCRL
• Lymphangitis and cellulites
• Other infections
• The distressing symptoms of lymphedema has caused
  some patients to describe this condition as
  worse than cancer

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Coverage of BCRL Treatments

• Under Womens Health and Cancer Rights Act
  (WHCRA) of 1998, group health plans, insurance
  companies and HMOs offering mastectomy coverage
  also must provide coverage for certain services
  relating to the mastectomy, including lymphedema
• Not all states passed state laws conforming to
  the lymphedema treatment provision of the WHCRA
• As of Dec 31, 2006, only 21 states required
  private insurance to provide coverage for
  lymphedema treatment incident to breast cancer

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State Laws Mandated Private Insurance to Cover
BCRL Treatment in 1998 - 2004
1998
1998
2004
N1
N21
Source NCI, State Cancer Legislative Database
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Study Objective and Hypothesis

• Objective to compare total health care costs
  between BCRL patients in states with versus
  without coverage mandate (i.e., the under-insured
  states)
• Hypothesis the under-insured states will incur
  lower costs in the short run but higher costs in
  the long run due to a higher rate of costly
  complications

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Data MarketScan HPM, 1997-2003

• MarketScan nationwide employment-based claims
  data
• Insurance claims from over 100 payers from 45
  large employers
• Medical and outpatient prescription drug claims
• Include employees, spouses, and dependents
• Health and Productivity Management (HPM)
• Productivity information (time lost from work)
  for a subset of employees
• Include work loss due to absence, short-term
  disability, or workers compensation

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Study Sample and Measures

• Inclusion
• lymphedema ICD-9 codes 457.0 457.1
• BC-related codes
• Two or more claims on different dates with BC DX
• One or more claim indicate BC-related surgery
  (i.e., mastectomy or lumpectomy)
• Two or more claims for non-surgical definitive
  treatment (i.e., chemo or radiation)
• Two or more RX claims for tamoxifen or aromatase
  inhibitors (AIs)
• Exclusion
• Duration of continuous enrollment lt 12 months
• Calculation of BCRL-related costs
• Collect all claims for the study sample
  identified above
• Excluded claims related to BC treatment
• Surgery mastectomy, lumpectomy
• Radiation
• Chemotherapy
• Prescriptions of tamoxifen or AIs
• Supportive care due to cancer treatment
• Tests to determine staging
• Excluded claims related to routine screening
  and/or testing

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Descriptive Statistics

• Age mean 49.5 SD8.15
• Relationship with employers
• employee 306 (48)
• spouse 328 (52)
• Regions
• Northeast 138 (21.8)
• Northcentral 200 (31.5)
• South 218 (34.4)
• West 76 (12.0)
• Unknown 2 (0.3)
• Sample size variations by duration of continuous
  enrollment
• One-year N 634
• Two-year N 447
• Three-year N 278

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Comparisons of Total Costs of BCRL Patients by
State Coverage
0 12 months 0 12 months 0 18 months 0 18 months 0 24 months 0 24 months
Not covered Covered Not covered Covered Not covered Covered
Sample size 504 130 438 92 383 64
Rate of cellulitis or lymphangitis 11.9 10.8 16.2 8.7 18.0 10.9
Rate of cellulitis or lymphangitis P0.72 P0.72 P0.07 P0.07 P0.16 P0.16
Total payment 24,103 25,147 32,020 30,280 38,878 33,164
Difference -1,044 (P0.01) -1,044 (P0.01) 1,740 (P0.006) 1,740 (P0.006) 5,714 (P0.031) 5,714 (P0.031)
Out-of-pocket pay 1,460 1,521 2,833 2,195 3,279 2,537
Difference -62 (P0.01) -62 (P0.01) 638 (P0.02) 638 (P0.02) 743 (P0.03) 743 (P0.03)
Note Costs in this table include treatment costs
related to breast cancer ?2 test was used to
compared the rate of cellulitis between groups
Mann-Whitney two-sample test was used to compare
costs between groups
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Cost Comparison by State Coverage
Note Costs excluded claims possibly related to
breast cancer treatment
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Cost Comparison by State Coverage
Note Costs excluded claims possibly related to
breast cancer treatment
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Cost Comparison by State Coverage
Note Costs excluded claims possibly related to
breast cancer treatment
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Discussion and Conclusion

• Compared with BCRL patients in the under-insured
  states, those resided in the covered states had
• Similar rate of complication in the first 12
  months, but lower rate in the first 18 and 24
  months
• Higher total costs in the first 12 months, but
  significantly lower costs in the first 18 and 24
  months
• Slightly higher out-of-pocket payment in the
  first 12 months, but significantly lower OOP in
  the first 18 and 24 months
• In year 2 lower total costs, and much lower
  inpatient costs
• Findings confirmed our hypothesis that BCRL
  patients resided in the under-insured states
  incur higher long-term costs from poorly managed
  lymphedema
• Exploratory ? need a larger sample size to
  confirm!!

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Acknowledgement

• Funding Source American Cancer Society
• Collaborators
• HSR/Epidemiology Linda S. Elting, DrPH
• Surgical oncology Janice N. Cormier, MD, MPH
• Breast medical oncology Sharon H. Giordano, MD
• Radiation oncology Thomas A. Buchholze, MD
• Radiation oncology George Perkins, MD
• HSR/Stat analyst Ying Xu, MD, MS
• Nursing, Vanderbilt Univ. Sheila H. Ridner, PhD,
  RN