There are two treatment options for patients with breast cancer. The first is a breast conserving surgery (BCS) which removes the cancerous lump (lumpectomy) followed by irradiation treatment. The second option is a mastectomy which removes the entire breast. Lecia Apantaku claims in the American Family Physician journal in 2002, that “survival rates following breast conservation surgery plus radiation are equivalent to those following mastectomy.”
A 2003 Health Services Research paper by Hadley, et al. hypothesizes that differences in Medicare fees for the two procedures affects the probability that one or the other procedure will be used by the physician. To prove this point, the authors use 1994 Medicare claims data for a sample of 1,787 Medicare patients who were treated for early stage breast cancer. The authors compare Medicare fee rates in various geographic areas. The prediction is that in areas with relatively higher physician compensation for BCS, there will be more BCS procedures performed. In areas with relatively higher surgery fees for mastectomies, the opposite will hold. The authors also take into account: input costs using HCFA values of the Geographic Adjustment Factor (GAF), physician year of graduation to control for surgical preferences of a cohort, whether the patient had supplemental insurance, as well as various demographic variables. A mutinomial logit regression framework was use in which the dependent variables were: 1) BCS only, 2) BCS with radiation, and 3) mastectomy.
The authors find that Medicare fees were significant factors in the choice between mastectomy and breast conserving surgery with radiation. A ten percent increase in the BCS with radiation fee (i.e.: about $30) increased the relative odds of BCS with radiation relative to a mastectomy to 1.34 (p-value 0.02). A 10% decrease in the mastectomy fee increased the relative odds of BCS with radiation relative to a mastectomy to 1.84 (p-value <0.01). The affect of fees for 'BCS only' did not lead to a statistically significantly impact on the probability of having a BCS only procedure, but this may be due to the fact that BCS only procedures are relatively infrequent.
The authors claim that this evidence “is consistent with the hypothesis that physicians are responsive to financial incentives when the alternative procedures have clinically equivalent outcomes, and patient clinical condition does not dominate the treatment choice” [my emphasis]. The authors wisely note there could be a reverse causality here. Physicians may tend to charge more for the procedure which is performed most often in the region. Other problems are that the data sample is small, the data are over ten years old, and the authors do not model patient preference for one procedure over the other.
Hadley; Mandelblatt; Mitchell; Weeks; Guadagnoli; Hwang; (2003) “Medicare breast surgery fees and treatment received by older women with localized breast cancer” Health Services Research vol 28, no. 2, pp. 553-573.