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Medicare News
Medicare Pays Doctors More for Bladder Biopsies in
Office; Dramatic Increase Occurs?
Medicare’s hope was to save money by escaping
hospital costs but it has opposite effect
 Feb. 8, 2010 - Increased Medicare payments to
physicians for outpatient surgeries for bladder cancer have led to a
dramatic rise in the number of these procedures being performed and an
overall increase in cost to the healthcare system. That is the
conclusion of a new study published early online in Cancer, a
peer-reviewed journal of the American Cancer Society. The findings
indicate that some Medicare policies aimed at decreasing costs may
instead be contributing to an increase in healthcare expenditures.
Because bladder cancer is the most expensive cancer
to treat, its management places a significant economic burden on the
United States healthcare system, which costs two to four times that of
healthcare systems in any other industrialized nation.
In an attempt to reduce costs, in 2005 Medicare
increased physician reimbursement for office-based endoscopic bladder
procedures, such as biopsies. Moving these procedures from the more
expensive inpatient hospital setting to the presumably less expensive
outpatient office setting could cut costs provided that they are
performed for the same indications, are equally efficacious, and are
tolerable to patients.
The reimbursement change was expected to alter
physician incentives, leading to increased use of outpatient endoscopic
surgery, a decline in hospital-based endoscopic surgery and,
consequently, a reduction in healthcare-related costs.
To evaluate this hypothesis, Micah Hemani, MD, and
Samir Taneja, MD, of the Division of Urologic Oncology at the New York
University Langone Medical Center and their colleagues assessed
treatment patterns in their practice before and after the Medicare
change in physician reimbursement.
The investigators found that the number of
outpatient bladder surgeries doubled after Medicare reimbursements rose,
but the number of hospital-based surgeries did not significantly
decline. As a result, there was a 50% increase in overall Medicare
costs.
While there was an increase in patient referrals
for outpatient surgeries, it was not sufficient enough to account for
the increased use of these procedures. There was, however, a rise in the
redundant use of outpatient surgery on patients who also underwent
hospital-based surgery for the same condition.
Also, while the number of outpatient procedures
increased, the likelihood that a procedure would lead to a bladder
cancer diagnosis declined.
"We believe these trends are disturbing as they may
reflect both diagnostic and therapeutic over-utilization of office-based
endoscopic bladder surgery," the authors wrote.
The reasons for this surge in use of outpatient
procedures are unknown but might include improvements in office-based
equipment for surgery, improved physician comfort and skill with these
operations, and the incentive of receiving increased financial
reimbursement. Whatever the cause, these findings suggest that Medicare
financial incentives for the outpatient treatment of bladder cancer may
actually increase overall costs without improving care.
Dr. Hemani noted that the study's results
illustrate a need for clinical guidelines for these office-based
surgeries, as well as a need for policy measures that ensure
accountability for physicians who perform them.
"Given the ongoing healthcare debate in Congress
regarding reforming the current system, one wonders if many of the
changes currently being proposed in Washington might not have similar
effects to what we are seeing in this one isolated example," said David
Penson, MD, MPH, of Vanderbilt University in Nashville, who was not
involved with the study but wrote an accompanying editorial.
"Sometimes, policies have the exact opposite effect
of what was intended," he cautioned.
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