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Original Investigation
April 16, 2020

Association of Utilization Management Policy With Uptake of Hypofractionated Radiotherapy Among Patients With Early-Stage Breast Cancer

Author Affiliations
  • 1Perelman School of Medicine, University of Pennsylvania, Philadelphia
  • 2Penn Center for Cancer Care Innovation, Abramson Cancer Center, Philadelphia, Pennsylvania
  • 3Corporal Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, Pennsylvania
  • 4HealthCore Inc, Wilmington, Delaware
  • 5AIM Specialty Health, Chicago, Illinois
  • 6Department of Health Care Management, Wharton School, University of Pennsylvania, Philadelphia
JAMA Oncol. 2020;6(6):839-846. doi:10.1001/jamaoncol.2020.0449
Key Points

Question  Is the utilization management policy of large insurers associated with increased uptake of hypofractionated radiotherapy among patients with early-stage breast cancer?

Findings  In this economic analysis of 10 540 women with early-stage breast cancer, the utilization management policy was associated with an uptake of hypofractionated radiotherapy in populations directly subject to and indirectly exposed to the policy, even after accounting for a secular trend toward increased use of hypofractionated radiotherapy. Utilization management was not associated with measurable cost savings.

Meaning  A utilization management policy was associated with improvement of evidence-based cancer care for women directly subject to and women indirectly exposed to the policy; however, health systems and policy makers should periodically evaluate such programs to assess their overall costs and benefits.


Importance  Breast cancer accounts for the largest portion of cancer-related spending in the United States. Although hypofractionated radiotherapy after breast-conserving surgery is a cost-effective and convenient treatment strategy for patients with early-stage breast cancer, less than 40% of eligible women received hypofractionated radiotherapy in 2013.

Objective  To assess the association of a large commercial payer’s utilization management policy with the use of hypofractionated radiotherapy among women with early-stage breast cancer and its associated cost.

Design, Setting, and Participants  A retrospective, adjusted difference-in-differences economic analysis was conducted using administrative claims data from January 1, 2012, to June 1, 2018, of women 18 years or older with early-stage breast cancer who were eligible for hypofractionated radiotherapy according to 2011 guidelines from the American Society for Radiation Oncology and were continuously enrolled in 14 geographically diverse commercial health plans covering 6.9% of US adult women. Women who received mastectomy, brachytherapy, or less than 11 or more than 40 external beam fractions of radiotherapy were excluded. A utilization management policy was used to encourage the use of hypofractionated radiotherapy among women in fully insured and Medicare Advantage (fully insured) plans. Under the new policy, claims for extended-course radiotherapy were not reimbursed for fully insured women who were eligible for hypofractionated radiotherapy. This policy did not apply to women in self-insured or Medicare supplemental insurance (self-insured) plans, allowing these groups to serve as a comparison group.

Main Outcomes and Measures  The primary outcome was use of hypofractionated radiotherapy, and the secondary outcome was the cost of this type of radiotherapy.

Results  Of 10 540 eligible women, 3619 (34.3%) were in fully insured plans and thus subject to the policy. There were no meaningful differences between the fully insured and self-insured groups in mean (SD) age at the start of radiotherapy (63.8 [8.6] vs 65.0 [8.9] years), mean (SD) Charlson Comorbidity Index score (3.0 [1.5] vs 3.2 [1.6]), or practice setting (outpatient hospital setting, 2982 of 3619 [82.4%] vs 5600 of 6921 [80.9%]). The policy was associated with an increase in use of hypofractionated radiotherapy among fully insured patients subject to the policy (adjusted percentage point difference-in-difference, 4.2%; 95% CI, 0.0%-8.4%; P = .05) and a nonsignificant decrease in radiotherapy-associated expenditures (−$2275 relative to self-insured patients; P = .09). Spillover analyses revealed a significantly higher uptake of hypofractionated radiotherapy among self-insured patients who were indirectly exposed to the policy (adjusted percentage point difference-in-difference, 8.5%; 95% CI, 3.6%-13.5%; P < .001) compared with those who were not exposed.

Conclusions and Relevance  This study suggests that a payer’s utilization management policy was associated with direct and spillover increases in the use of hypofractionated radiotherapy, even after accounting for a long-term secular trend in the uptake of hypofractionated radiotherapy in the control groups. Utilization management may promote evidence-based cancer care.

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