Introduction
This document details the methodology for the Prostate Cancer measure and should be reviewed along with the Prostate Cancer Measure Codes List file, which contains the medical codes used in constructing the measure.
Measure Description
Episode-based cost measures represent the cost to Medicare for the items and services provided to a patient during an episode of care (“episode”). In all supplemental documentation, the term “cost” generally means the standardized1 Medicare allowed amount,2 and claims data from Medicare Parts A, B, and D3 are used to construct this episode-based cost measure.
The Prostate Cancer episode-based cost measure evaluates a clinician’s or clinician group’s risk-adjusted and specialty-adjusted cost to Medicare for patients who receive medical care to manage and treat prostate cancer. This chronic condition measure includes the costs of services that are clinically related to the attributed clinician’s role in managing care during a Prostate Cancer episode.
Measure Rationale
Prostate cancer is one of the most common solid tumors diagnosed in men.4 It is estimated that 112 per 100,000 men are reported to have prostate cancer, and over 224,000 new cases were reported in 2019.5 Prostate cancer care was estimated to be between $18-19 billion per year in 2020 and increasing faster than other cancer types.6,7
Prostate cancer has a relatively high survival rate, with patients more likely to die from natural causes or other diseases than from prostate cancer.8 While appropriate medical care is required to maintain quality of life for those living with prostate cancer, over-screening and aggressive treatments for older adults are considered to be less beneficial.9,10,11 Previous studies found no significant survival benefit within 10 years for screening in older men,12,13 and aggressive treatments, such as prostatectomy, also do not yield survival benefits in older men and may lead to sexual dysfunctions, bowel or urinary adverse effects.14,15
For lower-risk patients, reducing overtreatment of prostate cancer by using active surveillance is estimated to reduce Medicare spending by $413 million over the 3 years following prostate cancer diagnosis.16 For patients with limited spread or oligometastatic disease, using prostate radiation therapy with androgen deprivation therapy (ADT) is more cost effective than systemic therapies.17 For higher-risk patients with localized prostate cancer, upfront multimodality treatment is more cost effective over 10 years than single modality treatment.18 There’s also an opportunity to reduce costs by using generic drugs; in an evaluation of the use of bonemodifying medication for prostate cancer patients, a brand name drug was used instead of an available generic drug in 72% of high-intensity prostate cancer episodes.19
Given the prevalence of prostate cancer in the Medicare population, and the high costs associated with the management of the disease and its complications, the Prostate Cancer cost measure represents an opportunity for improvement on overall cost performance.
The Prostate Cancer episode-based cost measure was selected for development because of its high impact in terms of patient population, clinician coverage, and Medicare spending, and the opportunity to build a complex, yet feasible, chronic condition measure that would address a condition not captured by other cost measures. Following initial feedback gathered during the Wave 5 public comment period,20 the subsequent measure-specific clinician expert workgroup provided extensive, detailed input on this measure.
Measure Numerator
The measure numerator is the weighted average ratio of the winsorized21 scaled standardized observed cost to the scaled expected22 cost for all Prostate Cancer episodes attributed to a clinician, where each ratio is weighted by each episode’s number of days assigned to a clinician. This sum is then multiplied by the national average winsorized scaled observed episode cost to generate a dollar figure.
Measure Denominator
The measure denominator is the total number of days from Prostate Cancer episodes assigned to the clinician across all patients.
Data Sources
The Prostate Cancer measure uses the following data sources:
- Medicare Part A, B, and D claims data from the Common Working File (CWF)
- Enrollment Data Base (EDB)
- Long Term Care Minimum Data Set (LTC MDS)23
Care Settings
The Prostate Cancer measure focuses on the care provided by clinicians practicing in noninpatient hospital settings for patients with prostate cancer. The most frequent settings in which a Prostate Cancer episode is triggered include: office and outpatient hospital.
Cohort
The cohort for this cost measure consists of patients who are Medicare beneficiaries enrolled in Medicare fee-for-service who receive medical care to manage and treat prostate cancer.
The cohort for this cost measure is also further refined by the definition of the episode group and measure-specific exclusions (refer to Section 4).
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1 Claim payments are standardized to account for differences in Medicare payments for the same service(s) across Medicare providers. Payment standardized costs remove the effect of differences in Medicare payment among health care providers that are the result of differences in regional health care provider expenses measured by hospital wage indexes and geographic price cost indexes or other payment adjustments such as those for teaching hospitals. For more information, please refer to the “CMS Part A and Part B Price (Payment) Standardization - Basics" and “CMS Part A and Part B Price (Payment) Standardization - Detailed Methods” documents posted on the CMS Price (Payment) Standardization Overview page (https://www.resdac.org/articles/cms-price-payment-standardizationoverview).
Claim payments from Part D are payment standardized to allow resource use comparisons for providers who prescribe the same drug, even if the drug products are covered under varying Part D plans, produced by different manufacturers, or dispensed by separate pharmacies. For more information, please refer to the “CMS Part D Price (Payment) Standardization” document posted on the CMS Price (Payment) Standardization Overview page. (https://www.resdac.org/articles/cms-price-payment-standardizationoverview).
2 Cost is defined by allowed amounts on Medicare claims data, which include both Medicare trust fund payments and any applicable beneficiary deductible and coinsurance amounts.
3 Part D branded drug costs are also adjusted to account for post-point of sale drug rebates; more information can be found in the Methodology for Rebates in Part D Standardized Amounts on the CMS.gov QPP Cost Measures Information Page’s About Cost Measures page (https://www.cms.gov/medicare/quality-payment-program/cost-measures/about).
4 Siegel, Rebecca, D. Kimberly Miller, and Ahmedin Jemal. "Cancer statistics." CA Cancer J Clin (2017).
5 U.S. Cancer Statistics Working Group. U.S. Cancer Statistics Data Visualizations Tool, Centers for Disease Control and Prevention and National Cancer Institute (2022). https://www.cdc.gov/cancer/dataviz
6 Mariotto, A., K. Yabroff, Y. Shao, E. Feuer, and M. Brown. "Cancer care costs in the United States: projections 2010-2020." J. Natl. Cancer Inst 103 (2011).
7 Roehrig, Charles, George Miller, Craig Lake, and Jenny Bryant. "National Health Spending By Medical Condition, 1996–2005: Mental disorders and heart conditions were found to be the most costly." Health Affairs (2009)
8 Epstein, Mara M., Gustaf Edgren, Jennifer R. Rider, Lorelei A. Mucci, and Hans-Olov Adami. "Temporal trends in cause of death among Swedish and US men with prostate cancer." Journal of the National Cancer Institute (2012)
9Schnipper, Lowell E., Gary H. Lyman, Douglas W. Blayney, J. Russell Hoverman, Derek Raghavan, Dana S. Wollins, and Richard L. Schilsky. "American Society of Clinical Oncology 2013 top five list in oncology." Journal of Clinical Oncology (2013).
10Moyer, Virginia A., and US Preventive Services Task Force*. "Screening for prostate cancer: US Preventive Services Task Force recommendation statement." Annals of internal medicine (2012).
11Wolf, Andrew MD, Richard C. Wender, Ruth B. Etzioni, Ian M. Thompson, Anthony V. D'Amico, Robert J. Volk, Durado D. Brooks et al. "American Cancer Society guideline for the early detection of prostate cancer: update 2010." (2010).
12Andriole, Gerald L., E. David Crawford, Robert L. Grubb III, Saundra S. Buys, David Chia, Timothy R. Church, Mona N. Fouad et al. "Prostate cancer screening in the randomized Prostate, Lung, Colorectal, and Ovarian Cancer Screening Trial: mortality results after 13 years of follow-up." Journal of the National Cancer Institute (2012).
13Schröder, Fritz H., Jonas Hugosson, Monique J. Roobol, Teuvo LJ Tammela, Marco Zappa, Vera Nelen, Maciej Kwiatkowski et al. "Screening and prostate cancer mortality: results of the European Randomised Study of Screening for Prostate Cancer (ERSPC) at 13 years of follow-up." The Lancet (2014).
14Chen, Ronald C., Jack A. Clark, and James A. Talcott. "Individualizing quality-of-life outcomes reporting: how localized prostate cancer treatments affect patients with different levels of baseline urinary, bowel, and sexual function." Journal of Clinical Oncology (2009).
15Litwin, Mark S., Ron D. Hays, Arlene Fink, Patricia A. Ganz, Barbara Leake, Gary E. Leach, and Robert H. Brook. "Quality-of-life outcomes in men treated for localized prostate cancer." JAMA (1995).
16Trogdon JG, Falchook AD, Basak R, Carpenter WR, Chen RC. Total Medicare Costs Associated With Diagnosis and Treatment of Prostate Cancer in Elderly Men. JAMA Oncol. (2019).
17Lester-Coll NH, Ades S, Yu JB, Atherly A, Wallace HJ, Sprague BL. Cost-effectiveness of Prostate Radiation Therapy for Men With Newly Diagnosed Low-Burden Metastatic Prostate Cancer. JAMA Network Open. (2021).
18Gustavsen G, Gullet L, Cole D, Lewine N, Bishoff JT. Economic Burden of Illness Associated with Localized Prostate Cancer in the United States. Future Oncology. (2020).
19Hassol A, et al. Evaluation of the Oncology Care Model: Performance Periods 1-5. (2021). https://innovation.cms.gov/data-and-reports/2021/ocm-evaluation-pp1-5
20CMS, “Wave 5 Public Comment Summary”, CMS.gov QPP Cost Measure Information pages, https://www.cms.gov/files/document/wave-5-public-comment-summary-report.pdf
21For information on how costs are winsorized, please refer to Section 4.7.
22Expected costs refer to costs predicted by the risk adjustment model. For more information on expected costs and risk adjustment, please refer to Section 4.7.
23For information on how LTC MDS data are used in risk adjustment, please refer to Section 4.7.