Certificate of need programs don’t slow IMRT use, prostate cancer costs

Certificate of need programs do not limit the use of intensity modulated radiation therapy (IMRT) or control overall prostate cancer healthcare costs, according to a study published in the January issue of Journal of Urology.

“There remains an unmet need to control the rapid adoption of new, more expensive therapies for prostate cancer that have limited cost and comparative effectiveness data,” wrote authors Abhinav Khanna, a student at the Baylor College of Medicine in Houston, and colleagues.

Certificate of need programs were mandated by the federal government in the 1970s and 1980s as a way of controlling healthcare costs at the state level, explained the authors. They required state approval before new health facilities can be established. The federal mandate has ended, but some states still use certificate of need programs to control costs.

IMRT, the radiation modality of choice for men with prostate cancer, comes with a steep costs and little comparative effectiveness data. To assess how IMRT use is affected by certificate of need programs, Khanna and colleagues looked at Medicare data from 2002 through 2009, which included nearly 14,000 men treated for prostate cancer in three regions with active certificate of need programs, and more than 44,500 men treated in nine regions without an active certificate of need program.

While the authors had hypothesized that a certificate of need program would regulate and reduce the use of IMRT, the results showed this was not the case. IMRT use increased from 2.3 percent to 46.4 percent of therapies in the regions with certificate of need programs compared with 11.3 percent to 41.7 percent of regions without such a program.

“Notably, we found that regions with active [certificate of need] programs regulating IMRT actually experienced greater growth in the use of IMRT,” wrote the authors. Over time, IMRT use grew faster in regions with a certificate of need program, though overall annual cost growth was similar between groups.

“It is possible that the presence of [certificate of need] regulations selects for areas in which the overuse of health services is already an issue, thus motivating these states to maintain active [certificate of need] regulations. In this case, there would be an inherent predisposition toward increased IMRT use in states with [certificate of need] programs,” wrote the authors.

Khanna and colleagues noted that mechanisms to control the rapid adoption of expensive, untested therapies are especially relevant in the current environment. “Alternative approaches to control the use of costly new technology include innovations in health delivery systems such as accountable care organizations, which may incentivize physicians to balance clinical benefit against cost.” They also suggested value-based insurance and reimbursement reform as methods for controlling costs as alternates to certificate of need programs.