Projected Savings for Generic Oncology Drugs Purchased via Mark Cuban Cost Plus Drug Company Versus in Medicare

PURPOSE

Self-administered oncology drugs contribute disproportionately to Medicare Part D spending; prices often remain high even after generic entry. Outlets for low-cost drugs such as Mark Cuban Cost Plus Drug Company (MCCPDC) offer opportunities for decreased Medicare, Part D, and beneficiary spending. We estimate potential savings if Part D plans obtained prices such as those offered under the MCCPDC for seven generic oncology drugs.

METHODS

Using the 2020 Medicare Part D Spending dashboard, Q3-2022 Part D formulary prices, and Q3-2022 MCCPDC prices for seven self-administered generic oncology drugs, we estimated Medicare savings by replacing Q3-2022 Part D unit costs with costs under the MCCPDC plan.

RESULTS

We estimate potential savings of $661.8 million (M) US dollars (USD; 78.8%) for the seven oncology drugs studied. Total savings ranged from $228.1M USD (56.1%) to $2,154.5M USD (92.4%) compared with 25th and 75th percentiles of Part D plan unit prices. The median savings replacing Part D plan prices were abiraterone $338.0M USD, anastrozole $1.2M USD, imatinib 100 mg $15.6M USD, imatinib 400 mg $212.0M USD, letrozole $1.9M USD, methotrexate $26.7M USD, raloxifene $63.8M USD, and tamoxifen $2.6M USD. All 30-day prescription drug prices offered by MCCPDC generated cost savings except for three drugs offered at the 25th percentile Part D formulary pricing: anastrozole, letrozole, and tamoxifen.

CONCLUSION

Replacing current Part D median formulary prices with MCCPDC pricing could yield significant savings for seven generic oncology drugs. Individual beneficiaries could save nearly $25,200 USD per year for abiraterone or between $17,500 USD and $20,500 USD for imatinib. Notably, Part D cash-pay prices for abiraterone and imatinib under the catastrophic phase of coverage were still more expensive than baseline MCCPDC prices.

Specialized Medical Weight Management Intervention for High-Risk Obesity

Background: Bundled payments are services rendered at pre-determined costs with the goal of providing high value care. Our institution's Episodes of Care team partnered with its tertiary care obesity center to design a novel medical weight management bundle for employers that would collectively deliver high value obesity services. Objective: As a first step, we sought to evaluate short-term medical weight loss outcomes over 6 months at the obesity center. Methods: We retrospectively analyzed weight loss outcomes on 157 patients with commercial insurance coverage over a period of 6 months. Results: Patients ranged in age from 18-72 years, and 77.7% were female. Patients ranged in weight from 160-443 pounds, with a mean body mass index (BMI) of 42.7 kg/m2 (Class 3a severe obesity; BMI range 28.4-74.5). The prevalence of any obesity-related medical condition was 54.1%; at least a quarter of the patients had either prediabetes or Type 2 diabetes mellitus, approximately a third had hypertension, and over 8% had hyperlipidemia. Mean weight loss from the initial program start date was 6.28% (+/-0.48% standard error of mean [SEM]; 95% confidence interval [CI] 5.34-7.23%). Completers (defined as having at least 6 visits with a medical provider) achieved a higher percentage of weight loss (7.06%) from the initial program start compared to non-completers (4.68%; at least 4-5 visits with a medical provider; P<0.0158). Approximately 50% of patients were able to achieve >7% weight loss, with over 55% of patients achieving at least 3% weight loss or higher irrespective of BMI classification. Conclusions: Specialized medical weight intervention is effective in treating high-risk obesity with complications. This has implications for enhanced long-term cost savings related to employer coverage of such programs for their employees with obesity.

Value-Based Healthcare in Urology: A Collaborative Review

CONTEXT

In response to growing concerns over rising costs and major variation in quality, improving value for patients has been proposed as a fundamentally new strategy for how healthcare should be delivered, measured, and remunerated.

OBJECTIVE

To systematically review the literature regarding the implementation and impact of value-based healthcare in urology.

EVIDENCE ACQUISITION

A systematic review was performed to identify studies that described the implementation of one or more elements of value-based healthcare in urologic settings and in which the associated change in healthcare value had been measured. Twenty-two publications were selected for inclusion.

EVIDENCE SYNTHESIS

Reorganization of urologic care around medical conditions was associated with increased use of guidelines-compliant care for men with prostate cancer, and improved outcomes for patients with lower urinary tract symptoms. Measuring outcomes for every patient was associated with improved prostate cancer outcomes, while the measurement of costs using time-driven activity-based costing was associated with reduced resource utilization in a pediatric multidisciplinary clinic. Centralization of urologic cancer care in the UK, Denmark, and Canada was associated with overall improved outcomes, although systems integration in the USA yielded mixed results among urologic cancer patients. No studies have yet examined bundled payments for episodes of care, expanding the geographic reach for centers of excellence, or building enabling information technology platforms.

CONCLUSIONS

Few studies have critically assessed the actual or simulated implementation of value-based healthcare in urology, but the available literature suggests promising early results. In order to effectively redesign care, there is a need for further research to both evaluate the potential results of proposed value-based healthcare interventions and measure their effects where already implemented.

PATIENT SUMMARY

While few studies have evaluated the implementation of value-based healthcare in urology, the available literature suggests promising early results.

Association of Preoperative Patient Frailty and Operative Stress With Postoperative Mortality

Importance

Patients with frailty have higher risk for postoperative mortality and complications; however, most research has focused on small groups of high-risk procedures. The associations among frailty, operative stress, and mortality are poorly understood.

Objective

To assess the association between frailty and mortality at varying levels of operative stress as measured by the Operative Stress Score, a novel measure created for this study.

Design, Setting, and Participants

This retrospective cohort study included veterans in the Veterans Administration Surgical Quality Improvement Program from April 1, 2010, through March 31, 2014, who underwent a noncardiac surgical procedure at Veterans Health Administration Hospitals and had information available on vital status (whether the patient was alive or deceased) at 1 year postoperatively. A Delphi consensus method was used to stratify surgical procedures into 5 categories of physiologic stress.

Exposures

Frailty as measured by the Risk Analysis Index and operative stress as measured by the Operative Stress Score.

Main Outcomes and Measures

Postoperative mortality at 30, 90, and 180 days.

Results

Of 432 828 unique patients (401 453 males [92.8%]; mean (SD) age, 61.0 [12.9] years), 36 579 (8.5%) were frail and 9113 (2.1%) were very frail. The 30-day mortality rate among patients who were frail and underwent the lowest-stress surgical procedures (eg, cystoscopy) was 1.55% (95% CI, 1.20%-1.97%) and among patients with frailty who underwent the moderate-stress surgical procedures (eg, laparoscopic cholecystectomy) was 5.13% (95% CI, 4.79%-5.48%); these rates exceeded the 1% mortality rate often used to define high-risk surgery. Among patients who were very frail, 30-day mortality rates were higher after the lowest-stress surgical procedures (10.34%; 95% CI, 7.73%-13.48%) and after the moderate-stress surgical procedures (18.74%; 95% CI, 17.72%-19.80%). For patients who were frail and very frail, mortality continued to increase at 90 and 180 days, reaching 43.00% (95% CI, 41.69%-44.32%) for very frail patients at 180 days after moderate-stress surgical procedures.

Conclusions and Relevance

We developed a novel operative stress score to quantify physiologic stress for surgical procedures. Patients who were frail and very frail had high rates of postoperative mortality across all levels of the Operative Stress Score. These findings suggest that frailty screening should be applied universally because low- and moderate-stress procedures may be high risk among patients who are frail.

Hospitalisation and readmission costs after radical cystectomy in a nationally representative sample: does urinary reconstruction matter?

OBJECTIVE

To investigate the impact of continent urinary diversion on readmissions and hospital costs in a nationally representative sample of radical cystectomies (RCs) performed in the USA.

PATIENTS AND METHODS

The 2010-2014 Nationwide Readmissions Database was queried for patients with a diagnosis of bladder cancer who underwent RC. We identified patients undergoing continent (neobladder or continent cutaneous reservoir) or incontinent (ileal conduit) diversions. Multivariable logistic regression models were used to identify predictors of 90-day readmission, prolonged length of stay, and total hospital costs.

RESULTS

Amongst 21 126 patients identified, 19 437 (92.0%) underwent incontinent diversion and 1 689 (8.0%) had a continent diversion created. Continent diversion patients were younger, healthier, and treated at high-volume metropolitan centres. Continent diversions resulted in fewer in-hospital complications (37.3% vs 42.5%, P = 0.02) but led to more 90-day readmissions (46.5% vs 39.6%, P = 0.004). In addition, continent diversion patients were more often readmitted for infectious complications (38.7% vs 29.4%, P = 0.004) and genitourinary complications (18.5% vs 13.0%, P = 0.01). On multivariable logistic regression, patients with a continent diversion were more likely to be readmitted within 90 days (odds ratio [OR] 1.55, 95% confidence interval [CI]: 1.28, 1.88) and have increased hospital costs during initial hospitalisation (OR 1.99, 95% CI: 1.52, 2.61). Continent diversion led to a $4 617 (American dollars) increase in initial hospital costs ($36 640 vs $32 023, P < 0.001), which was maintained at 30 days ($48 621 vs $44 231, P < 0.001) and at 90 days ($56 380 vs $52 820, P < 0.001).

CONCLUSION

In a nationally representative sample of RCs performed in the USA, continent urinary diversion led to more frequent readmissions and increased hospital costs. Interventions designed to address specific outpatient issues with continent diversions can potentially lead to a significant decrease in readmissions and associated hospital costs.

Hospital Charges and Length of Stay Following Radical Cystectomy in the Enhanced Recovery After Surgery Era

OBJECTIVE

To report our center's experience with enhanced recovery after surgery (ERAS) pathway for radical cystectomy (RC), specifically evaluating complications, LOS, 30- and 90-day readmissions, and hospital charges. Pathways of this type have been shown to decrease the length of stay (LOS) and postoperative ileus. However, concerns persist that ERAS is costly and increases readmissions. To date, limited studies have evaluated these concerns.

MATERIALS AND METHODS

Our ERAS protocol was implemented for RC in December 2015. Outcomes in ERAS patients were compared with those in RC patients from the time period before ERAS. Patients were excluded if they underwent concomitant nephroureterectomy.

RESULTS

Fifty-six consecutive ERAS patients were compared with 54 pre-ERAS patients. The median charge for index hospitalization was $31,090 in the ERAS group and $35,489 in the pre-ERAS group (P = .036). The median LOS was 5.0 days in the ERAS group and 8.5 days in the pre-ERAS group (P = < .001). The pre-ERAS group had a significantly increased use of nasogastric tube (13.8% vs 30.0%) and parenteral nutrition (6.9% vs 20.4%). The overall complication rate (including infectious, renal, deep vein thrombosis and pulmonary embolism, myocardial infarction and stroke, and respiratory and gastrointestinal-related complications) was similar between the 2 groups (51.7% in the ERAS group and 62.0% in the pre-ERAS group, P = .28). Thirty- and 90-day readmissions also remained similar (19.0% vs 14.8%, P = .55, and 31.0% vs 27.7%, P = .64). The most common readmission reason was infection, specifically urinary tract infection.

CONCLUSION

Implementation of the ERAS pathway at our center resulted in significantly reduced LOS and total hospital charge, with comparable rates of complication and readmission, highlighting the need for ERAS pathways in patients undergoing RC.

Causes, Timing, Hospital Costs and Perioperative Outcomes of Index vs Nonindex Hospital Readmissions after Radical Cystectomy: Implications for Regionalization of Care

PURPOSE

We compared the timing, causes, hospital costs and perioperative outcomes of index vs nonindex hospital readmissions after radical cystectomy.

MATERIALS AND METHODS

The 2013 Nationwide Readmissions Database was queried for patients with bladder cancer undergoing cystectomy. Sociodemographic characteristics, hospital costs and causes of readmission were compared among index and nonindex readmitted patients. Univariable and multivariable logistic regression models were used to identify predictors of nonindex readmissions, mortality during the first readmission and subsequent readmission.

RESULTS

Among 4,991 patients identified 29% (1,447) and 11% (571) experienced an index and nonindex readmission, respectively. Compared to index readmissions, nonindex readmissions were more likely late readmissions (p <0.001) of older patients (p=0.047) who underwent cystectomy at higher volume hospitals (p=0.02) and were readmitted to hospitals located in less populated areas (p <0.001). Compared to index readmissions the percentage of nonindex readmissions for cardiovascular complications was higher (7.6% vs 2.9%, p=0.003), while the percentage of nonindex readmissions for gastrointestinal (6.0% vs 11.0%, p=0.04) and wound (5.3% vs 16.7%, p=0.0001) complications was lower. Predictors of nonindex readmission included longer length of stay (OR 1.02; 95% CI 1.001, 1.04), patient location in less populated areas, nonteaching hospital (OR 0.52; 95% CI 0.31, 0.86) and discharge to facility (OR 2.82; 95% CI 1.75, 4.55) or with home health (OR 1.49; 95% CI 1.05, 2.10). Nonindex readmissions had comparable mean readmission hospital costs ($14,147 vs $15,102, p=0.7), in-hospital mortality (OR 1.11; 95% CI 0.42, 2.87) and subsequent readmission (OR 1.32; 95% CI 0.87, 2.00) to index readmissions.

CONCLUSIONS

This nationally representative study of patients undergoing radical cystectomy demonstrated comparable perioperative outcomes and hospital costs between index and nonindex readmitted patients, which supports the continued regionalization of cystectomy care.

Implementation of a Surgeon-Level Comparative Quality Performance Review to Improve Positive Surgical Margin Rates during Radical Prostatectomy

PURPOSE

Success in the era of value-based payment will depend on the capacity of health systems to improve quality while controlling costs. Comparative quality performance review can be used to drive improvements in surgical outcomes and thereby reduce costs. We sought to determine the efficacy of a comparative quality performance review to improve a surgeon-level measure of surgical oncologic quality, that is the positive surgical margin rate at the time of radical prostatectomy.

MATERIALS AND METHODS

Eight surgeons who performed consecutive radical prostatectomies at a single high volume institution between January 1, 2015 and December 31, 2015 were included in analysis. Individual surgeons were provided with confidential report cards every 6 months detailing their case mix, case volume and pT2 radical prostatectomy positive surgical margin rate relative to 1) their own self-matched data, 2) the de-identified data of their colleagues and 3) institutional aggregate data during the study period. Positive surgical margin rates were compared before and after intervention. Hierarchal logistic regression analysis was used to examine the association of study period on the odds of positive surgical margins, adjusted for prostate specific antigen level and National Comprehensive Cancer Network® risk group.

RESULTS

Overall, 1,822 (1,392 before and 430 after intervention) radical prostatectomies were performed that met study inclusion criteria. The aggregate departmental unadjusted positive surgical margin rates were 10.6% and 7.4% in the pre-intervention and post-intervention groups, respectively. After adjusting for higher risk cancer in the post-intervention group, there was a significant protective association of post-intervention status on positive margins (OR 0.64, 95% CI 0.43-0.97, p = 0.03). All 5 surgeons with positive surgical margin rates higher than the aggregate department rate in the pre-intervention period showed improvement after intervention.

CONCLUSIONS

Comparative quality performance review can be implemented at the surgeon level and can promote improvement in an objective measure of surgical oncology quality.

Quantifying Nonindex Hospital Readmissions and Care Fragmentation after Major Urological Oncology Surgeries in a Nationally Representative Sample

PURPOSE

We quantified the underestimation of hospital readmission rates that can occur with institutional databases and the incidence of care fragmentation among patients undergoing urological oncology procedures in a nationally representative database.

MATERIALS AND METHODS

The 2013 Nationwide Readmissions Database was queried for patients undergoing prostatectomy, cystectomy, nephroureterectomy, nephrectomy, partial nephrectomy and retroperitoneal lymph node dissection for urological malignancies. Nationally representative 30 and 90-day readmission and care fragmentation rates were calculated for all procedures. Readmission rates with and without nonindex hospital readmissions were compared with Pearson's chi-square test. Multivariable logistic regression models were used to identify predictors of care fragmentation at 90-day followup.

RESULTS

For all surgical procedures readmission rates were consistently underestimated by 17% to 29% at 90-day followup. The rates of care fragmentation among readmitted patients were similar for all procedures, ranging from 24% to 34% at 90-day followup. Overall 1 in 4 readmitted patients would not be captured in institutional databases and 1 in 3 readmitted patients experienced care fragmentation. Multivariable models did not identify a predictor of care fragmentation that was consistent across all procedures.

CONCLUSIONS

The high rate of underestimation of readmission rates across all urological oncology procedures highlights the importance of linking institutional and payer claims databases to provide more accurate estimates of perioperative outcomes and health care utilization. The high rate of care fragmentation across all procedures emphasizes the need for future efforts to understand the clinical relevance of care fragmentation in patients with urological malignancies, and to identify patients at risk along with potentially modifiable risk factors for care fragmentation.

Medicaid Patient Access to Urological Care in the Era of the Patient Protection and Affordable Care Act: A Baseline to Measure Policy Effectiveness

INTRODUCTION

Medicaid expansion under PPACA (Patient Protection and Affordable Care Act) sought to increase access to health care by expanding access to insurance. The association between access to Medicaid and access to urological health care, however, has not been tested to our knowledge. To test this association we performed a prospective, survey based analysis of Medicaid acceptance rates and new appointment wait times for a patient seeking urological care. This study presents baseline data collected prior to Medicaid expansion in 2014.

METHODS

A primary cohort representing 20% of all urological surgeons in a nationwide database was surveyed using a simulated patient script. The data were collected in November 2013 prior to Medicaid expansion. The primary outcome measures were Medicaid acceptance and new patient appointment wait times. A practice level, secondary cohort was also analyzed.

RESULTS

A total of 650 urological surgeons were successfully sampled in the primary cohort, of whom 271 (41.7%) did not accept any Medicaid, 205 (31.5%) accepted some but not all Medicaid and 174 (26.8%) accepted all Medicaid insurance plans. The median wait time for a new patient appointment was 18 days. Medicaid acceptance rates were similar in the secondary cohort. The percentage of urologists accepting all forms of Medicaid varied by state, ranging from 10% to 90%.

CONCLUSIONS

Medicaid patient access to urological care is restricted, suggesting that access to Medicaid insurance coverage may not translate into access to urological care. Subsequent data collection will assess trends in Medicaid patient access to urological care following Medicaid expansion.

Professionalism and patient education in urologic surgery

Medical professionalism provides the guidelines that govern the patient-physician relationship. This implicit contract requires that patients be informed before making decisions regarding their medical care. Educating patients about diagnostic and treatment decisions is critical to an informed decision-making process. Shared decision-making is a recent paradigm shift in patient education that allows patients to make decisions based both on the counsel of their physicians and according to their own preferences and values. This approach moves away from previous models that focused on physicians or third-party payers as the arbiters of diagnostic and treatment choices. Urologic surgeons have been at the forefront of shared decision-making research and continue to promote this concept in the most recent American Urological Association Guideline on Detection of Prostate Cancer. Unfortunately, the fee-for-service financial structure that predominates in the United States’ health care system provides a disincentive for shared decision-making. By promoting patient volume rather than time spent with patients, this system rewards physicians who spend less time educating patients about diagnostic and treatment options. Therefore, to promote adherence to the educational responsibility inherent in medical professionalism, we recommend physician payment reform that rewards physicians for time spent with patients rather than the volume of patients seen.

Effect of preoperative nutritional deficiency on mortality after radical cystectomy for bladder cancer

PURPOSE

Poor preoperative nutritional status is a risk factor for adverse outcomes after major surgery. We evaluated the effect of preoperative nutritional deficiency on perioperative mortality and overall survival in patients undergoing radical cystectomy for bladder cancer.

MATERIALS AND METHODS

A total of 538 patients underwent radical cystectomy for urothelial carcinoma between January 2000 and June 2008, and had nutritional parameters documented. Patients with preoperative albumin less than 3.5 gm/dl, body mass index less than 18.5 kg/m(2) or preoperative weight loss greater than 5% of body weight were considered to have nutritional deficiency. Primary outcomes were 90-day mortality and overall survival. Survival was estimated using Kaplan-Meier analysis and compared using the log rank test. Cox proportional hazards models were used for multivariate survival analysis.

RESULTS

Of 538 patients 103 (19%) met the criteria for nutritional deficiency. The 90-day mortality rate was 7.3% overall (39 deaths), with 16.5% in patients with nutritional deficiency and 5.1% in the others (p < 0.01). Nutritional deficiency was a strong predictor of death within 90 days on multivariate analysis (HR 2.91; 95% CI 1.36, 6.23; p < 0.01). Overall survival at 3 years was 44.5% (33.5, 54.9) for nutritionally deficient patients and 67.6% (62.4, 72.2) for those who were nutritionally normal (p < 0.01). On multivariate analysis nutritional deficiency cases had a significantly higher risk of all cause mortality (HR 1.82; 95% CI 1.25, 2.65; p < 0.01).

CONCLUSIONS

Nutritional deficiency, as measured by preoperative weight loss, body mass index and serum albumin, is a strong predictor of 90-day mortality and poor overall survival. Prospective studies are needed to demonstrate the best indices of preoperative nutritional status and whether nutritional intervention can alter the poor prognosis for patients treated with radical cystectomy who have nutritional deficiencies.

Health care reform 2010: a fresh view on tort reform

PURPOSE

We reviewed the state of medical malpractice tort reform in the context of a new political climate and the current debate over comprehensive health care reform. Specifically we asked whether medical malpractice tort reform is necessary, and evaluated the strengths and weaknesses of contemporary reform proposals.

MATERIALS AND METHODS

The medical, legal and public policy literature related to medical malpractice tort reform was reviewed and synthesized. We include a primer for understanding the current structure of medical malpractice law, identify the goals of the current system and analyze whether these goals are presently being met. Finally, we describe and evaluate the strengths and weaknesses of the current reform proposals including caps on damages, safe harbors and health care courts.

RESULTS

Medical malpractice tort law is designed to improve health care quality and appropriately compensate patients for medical malpractice injuries, but is failing on both fronts. Of the 3 proposed remedies, caps on damages do little to advance the quality and compensatory goals, while safe harbors and health care courts represent important advancements in tort reform.

CONCLUSIONS

Tort reform should be included in the current health policy debate because the current medical malpractice system is not adequately achieving the basic goals of tort law. While safe harbors and health care courts both represent reasonable remedies, health care courts may be preferred because they do not rely on jury determination in the absence of strong medical evidence.

Early and late perioperative outcomes following radical cystectomy: 90-day readmissions, morbidity and mortality in a contemporary series

PURPOSE

Radical cystectomy remains associated with significant morbidity. Most series report outcomes with relatively short-term followup that may underestimate the true magnitude of the procedure and many report length of hospital stay but ignore readmission rates. We analyzed the predictors of early (30 days or less), late (31 to 90 days) and cumulative 90-day hospital readmissions, as well as morbidity and mortality rates.

MATERIALS AND METHODS

We reviewed our prospectively collected database of 753 patients who underwent radical cystectomy for urothelial cancer between January 2001 and December 2007. We examined the relationship between clinical variables and readmission rates during the early, late and 90-day postoperative period, and reviewed mortality and perioperative morbidity rates.

RESULTS

There were 200 (26.6%) patients readmitted in the first 90 days following radical cystectomy. Of these patients 148 (19.7%) were readmitted early, 81 (10.8%) were readmitted late, and 29 (3.9%) had an early and late readmission. Logistical regression revealed gender (OR 1.50, 95% CI 1.00-2.27, p = 0.05), age adjusted Charlson comorbidity index (OR 1.19, 95% CI 1.06-1.34, p = 0.003) and any postoperative complications before discharge home (OR 1.84, 95% CI 1.19-2.83, p = 0.006) as independent predictors of 90-day readmission. The 30 and 90-day mortality rates were 2.1% (16) and 6.9% (52), respectively.

CONCLUSIONS

Readmission rates after radical cystectomy are significant, approaching 27% within the first 90 days. Gender and age adjusted Charlson comorbidity index were independent predictors providing preoperative information identifying patients more likely to require readmission or possibly to benefit from a longer initial hospital stay.