Impact of payment reform on chemotherapy at the end of life.

OBJECTIVES: To assess the impact of 2005 and 2006 reductions in chemotherapy reimbursement, mandated in the Medicare Modernization Act, on patterns of chemotherapy receipt in the last 14 days of life. PATIENTS AND METHODS: Included in the study were Medicare beneficiaries dying with poor-prognosis cancer from 2003 to 2007. We compared pre- and postreform probability and frequency of chemotherapy receipt in the last 14 days of life, a validated quality measure, using linear models. We assessed changes in chemotherapy use in physician offices (where prescribing is often directly linked to physician income) and hospital outpatient departments (where the link is indirect and likely weaker).
RESULTS: Among patients receiving chemotherapy in the 6 months before death in physicians' offices before the policy implementation (2003 to 2004), 18% received chemotherapy in the last 14 days of life. Those dying after implementation (2006 to 2007) were 3.5 percentage points (95% confidence interval [CI], -5.4 to -1.6; P <.001), or 20%, less likely to receive chemotherapy in the 14 days before death than those dying before implementation. By contrast, there was no significant change in the percentage of patients receiving chemotherapy in the last 14 days of life in hospital outpatient departments between 2003 and 2004 and between 2006 and 2007.
CONCLUSIONS: In physician offices, where drugs generate the majority of revenue, and prescribing patterns can determine physician income, use of chemotherapy at the end of life fell significantly after reimbursement reductions; no concurrent change occurred in hospital outpatient departments. These results suggest that payment reform may be used to better align appropriate financial incentives with better quality of care.