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1 Medicre Clim Processors Reimursement nd G-CSF Choice Among Non-Hodgkin Lymphom Ptients At Glnce Prcticl Implictions p 148 Author Informtion p 153 Full text nd PDF Originl Reserch Xioyun Pn, PhD; nd Ush Smmoorthi, PhD Recent helth policy efforts hve trgeted helthcre finncing to reduce the esclting helthcre costs nd improve ptient cre. 1 One of the hllmrks of the helthcre reform is to provide ptient-centric high qulity cre through innovtive pyment inititives. For exmple, the Centers for Medicre & Medicid Services (CMS) hs proposed undled pyments for cute nd post-cute cre. 2,3 Use of reimursement policies to contin costs is not new. In simultion nlysis Welch suggested tht undling pyments my not increse the finncil risk to hospitls. 4 However, the effect of reimursement policies on services provided y physicins through ugmenttion of stndrd regimens with supplementl services hs not een exmined. Medicre pyments of chemotherpy for cncer ptients re determined y the locl Medicre clim processing gents. Such discretion often results in different pyment polices cross these clim processors. The clim processors often hve the option of mking single, prospective undled pyment for ll items nd services provided, or mking seprte pyments to the physicin for ech of the drugs nd services delivered. 5 As reimursement mounts to physicins re linked to their profits, 6 differences in reimursement mounts cn ffect physicins income nd cn led to vritions in physicin prctices including cncer cre. However, to dte there hs een no reserch exmining the ssocition etween Medicre clim processor reimursement policies nd physicins prescriptions of supplementl products mong cncer ptients. Due to lck of pulished literture in this re, we extrpolte the effect of differences in reimursement policies on cncer cre using studies tht hve nlyzed the ssocition etween fee chnges over time nd the response of physicins in incresing or decresing the volume of services. Reimursement chnges (ie, reduction in Medicre pyments) on physicin ehvior hve een investigted in mny res: cesren delivery, mjor joint repir/replcement procedures, coronry ABSTRACT Ojective: To exmine the ssocition etween Medicre clim processors reimursement policies (undled pyments vs seprte pyments for ech of the drugs nd services) nd physicin s prescription of grnulocyte colony-stimulting fctor (G-CSF). Study Design: Retrospective longitudinl nlyses of linked cncer registry nd Medicre clims dt on ptients with non- Hodgkin lymphom (NHL). Methods: Using the Surveillnce, Epidemiology nd End Results (SEER)-Medicre linked dtse, we studied ptients 66 yers or older dignosed with NHL etween 2002 nd Averge chemotherpy physicin reimursement mount nd the numer of chemotherpy dministrtion codes were considered s proxies for Medicre clim processors reimursement policies. Logistic regression ws used to ssess the ssocition etween Medicre clim processors' reimursement policies nd prescription ptterns for G-CSF, fter controlling for clinicl nd non-clinicl fctors. Results: We oserved sttisticlly signifi cnt vritions in verge physicin reimursement mounts (F-vlue = 4.41, P <.0001). Across clim processors, n increse in chemotherpy reimursement mount ws ssocited with lower likelihood of receiving G-CSF; the djusted odds rtio ws 0.91 with 95% confi dence intervl ( ). Conclusions: The negtive reltionship etween estimted verge physicin reimursement mounts nd G-CSF prescription my e n indirect evidence of the reltionship etween Medicre clim processors reimursement policies nd physicins prescription of G-CSF for ptients with NHL. Am J Phrm Benefi ts. 2013;5(4): Vol. 5, No. 4 The Americn Journl of Phrmcy Benefi ts 147

2 Pn Smmoorthi PRACTICAL IMPLICATIONS Our study investigted the effect of reimursement policies on ugmenttion of stndrd cncer therpy with grnulocyte colonystimulting fctor (G-CSF) prescription nd found tht G-CSF choice during the fi rst cycle of chemotherpy ws infl uenced y clinicl nd non-clinicl fctors, specifi clly undled versus non-undled pyments. Our study fi ndings cn shed light on emerging pyment methodology (eg, Provider pyment Reform for Outcomes, Mrgins, Evidence, Trnsprency, Hssle-reduction, Excellence, Understndility nd Sustinility [PROMETHEUS]), which uses episode-of-cre driven pyments for the purpose of contining helthcre costs. Bundled pyments my hve unintentionl consequences nd my encourge physicin use of ugmented cncer therpies. rtery ypss grfting, nd physicin consulttion services In these studies, no conclusive evidence ws found in terms of linking reduction in Medicre pyments to incresed volume of services provided to the ptients. Physicin s response to reduction in Medicre pyments for surgicl procedures including ctrct, hip repir, hip replcement, knee replcement, nd joint procedures ws dependent on the type of procedures nd physicin specilties. 8 In ddition, physicin s response ws dependent on wht proportion of the income ws ffected y the fee chnge. 7,11-15 If one pplies these findings to ssess the reltionship etween reimursement policies nd prescriing volume, one cn conclude there is considerle uncertinty nd there is criticl need for studies in this re. In this context, potentil vritions in Medicre clim processors reimursement policies for cncer cre, specificlly chemotherpy, cn e considered nturl experiment tht llows us to exmine the ssocition etween reimursement mounts nd physicins prescriing prctices. The perspective of the current study is different from studies tht exmined chnges in Medicre fees on physicins volume of services for which fee chnges were encted. Rther, we focus on the reltionship etween reimursement policies nd chnge in provision of supplementl product or service ecuse physicins my respond to vritions in reimursement policies y offering different mix of services including supplementl products or services. 16 Therefore, the primry ojective of the current study is to nlyze the reltionship etween reimursement policies nd prescription of supplementl products mong ptients with cncer. For the purposes of this rticle, we consider use of grnulocyte colony-stimulting fctor (G-CSF) s the supplementl product during n episode of cncer cre. We selected cncer ptients with non-hodgkin lymphom (NHL) for severl resons. The min modlity of tretment for ptients with NHL is chemotherpy. Chemotherpy regimens re sometimes ugmented with G-CSF s prophylxis to prevent ferile neutropeni, 17 life-thretening condition with low white lood cells nd high fever 18 mong cncer ptients on chemotherpy. 19 In ddition, G-CSF is listed s one of the top 10 most expensive Medicre Prt B drugs, with verge reimursement mounts for 11 dys of supply rnging from $2136 to $ Thus, ugmenting chemotherpy with G-CSF my provide incresed revenue for the physicins. METHODS Study Design We used retrospective longitudinl design using linked cncer registry dt from 2002 through 2007 nd Medicre clims dt from 2001 through Ptients were followed for the first 5 months fter dignosis of NHL to define the first course of chemotherpy. 21 Dt The dt for the current study come from the Surveillnce, Epidemiology, nd End Results (SEER)-Medicre linked dtse. The SEER dt contin 13 cncer registries with demogrphic informtion (ge, gender, rce, county of residence), re-level socioeconomic sttus, Medicre enrollment sttus, nd clinicl informtion (dignosis dte, histology, stge, lymph node involvement, nd grde). The current study uses the Ptient Entitlement nd Dignosis Summry File (PEDSF), customized file of SEER dt. SEER dt were linked with Medicre files to llow us to nlyze Medicre-covered helthcre services. Study Popultion Ptients With NHL. Cncer registry dt were used to identify ptients over ge 66 yers nd dignosed with NHL nytime etween 2002 nd 2007 using primry dignosis (N = 33,017). Other exclusion criteri were: ptients without relile deth dte (N = 45), not continuously enrolled in Medicre Prt A nd/or Prt B, enrolled in Medicre HMO (N = 9908), cncer site ws ny prt of the centrl nervous system (N = 2322), did not hve the first course of chemotherpy nd hospitlized or hd emergency deprtment (ED) visits during the first cycle of chemotherpy (N = 13,366), nd ptients who hd missing informtion of re socioeconomics, node, stge, nd histology type 148 The Americn Journl of Phrmcy Benefi ts July/August

3 Medicre Clim Processors Reimursement (N = 127). Thus, the finl study popultion consisted of 7249 ptients with NHL. Key Vrile: Medicre Clim Processors. This vrile ws derived using informtion on ptients county of residence within SEER progrms nd Medicre clim processors recorded in Medicre Prt B clims. For ech county, we used the most frequently illed Medicre clim processor. When 2 or more Medicre clim processors served prticulr county we hd comintion code. For exmple, the highest percentge of physicin visit clims in Johnson County, Iow, were sumitted to the Medicre clim processor Iow Wellmrk Inc, nd the highest percentge of outptient clims in Johnson county were sumitted to Nersk Blue Cross. Therefore, for Johnson County, we comined oth clim processors: Iow Wellmrk nd Nersk Blue Cross. Becuse clim processors serving county might chnge cross yers (eg, some clim processors were terminted in prticulr yer), the clim processors were ssigned nnully to ech county. After grouping of clim processors y ech county, there were 108 Medicre clim processor groups in our study popultion. Determintion of Reimursement Policies. Reimursement policies were identified in 2 steps using the verge physicin reimursement mount for the first cycle of chemotherpy nd the numer of chemotherpy dministrtion codes. In the first step, for ech ptient, we defined the first cycle of chemotherpy s fixed period of 21 dys following the initition of chemotherpy. We chose 21 dys s the cutoff period ecuse most chemotherpy regimens lst for 21 dys. 22 Chemotherpy ws identified from the outptient nd physicin visit clims. Helthcre Common Procedures Clssifiction System (HCPCS) codes (J8999-J9999, Q0083, Q0084, Q0085, J7150, 964XX, nd 965XX) nd revenue center codes (0331, 0332, nd 0335) were used to identify chemotherpy regimens nd dministrtion procedures. Only for yer 2005, the following codes were lso used to identify chemotherpy clims: 51720, G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, nd G In this step, totl physicin reimursement mount derived from outptient nd physicin visit clims during the first cycle of chemotherpy ws used to define reimursement policies. As our study period covered multiple yers, totl physicin reimursement mount ws converted to 2008 dollrs sed on the Consumer Price Index for medicl services pulished y the ureu of lor sttistics. 24 Medicre pyments lso include the Geogrphicl Prctice Cost Index (GPCI) component nd reflect costof-living djustments sed on geogrphicl region. To stndrdize the different price levels for helthcre inputs cross loction nd time, we divided the reimursement mount y the GPCI from Federl Register. We estimted verge reimursement mount for ech Medicre clim processor fter controlling for clinicl nd non-clinicl fctors using regression techniques. In the second step, the verge estimted reimursement mount per clim processor computed from the regression ws grouped into top nd ottom deciles. Medicre clim processors in these deciles were further exmined for chemotherpy dministrtion codes to determine single undled pyment nd seprte pyments for services nd drugs. Prescription of G-CSF. We constructed n indictor vrile representing presence or sence of ny G-CSF prescription during the first cycle of chemotherpy (ie, within 21 dys following the initition of chemotherpy). G-CSF drug ws identified from outptient nd physicin visits sed on HCPCS codes (J1440, J1441, Q0453, S0135, nd J2505). Other Independent Vriles. Demogrphic vriles were: ptient s ge t dignosis (66-70, 71-75, 76-80, 81-84, >85 yers), gender (femle/mle), rce (white, Africn Americn, other). Ptients clinicl chrcteristics were: histology type, stge of cncer, lymph node involvement, prior-dignosis inptient nd outptient comoridities, nd grde. We used oth physicin nd inptient clims to identify comorid conditions 1 yer prior to NHL dignosis. Using methodology developed y Klunde et l, 25 comoridity index ws computed using non-cncer Chrlson condition 26 from inptient clims nd physicin or outptient clims. Our comoridity index my e limited in scope ecuse it did not include ll co-occurring conditions present in n individul. Are-level socioeconomic vriles such s income level, eduction level, nd percentge of white were used s independent vriles s well. Type of chemotherpy (nthrcycline-sed chemotherpy [ABC] with rituxim, ABC without rituxim, rituxim with other non-abc chemotherpy, other non-abc chemotherpy only, nd rituxim only) ws used s n independent vrile ecuse reimursement mounts my vry y type of chemotherpy. Site of visit (outptient vs office-sed physicin visits) ws lso distinguished nd used s one of the independent vriles. Yer of first chemotherpy tretment ws included s Vol. 5, No. 4 The Americn Journl of Phrmcy Benefi ts 149

4 Pn Smmoorthi time trend vrile to ccount for differences in tretment ptterns over time. Sttisticl Techniques. Reimursement policies were mesured using estimtes from n ordinry lest squre regression (OLS) model. The dependent vrile ws totl physicin reimursement mount derived from outptient nd physicin visit clims during the first cycle of chemotherpy. Indictor vriles for ech of the 108 Medicre clim processor groups were the key explntory vriles in the model. The reference group for Medicre clim processor vriles ws the clim processor group with the lowest estimted chemotherpy reimursement mount. In ddition to Medicre clim processor vriles, this regression lso included ptient-level demogrphic nd clinicl fctors nd relevel socioeconomic sttus listed in the mesures section. Adjusted differences in verge totl reimursement mounts y Medicre clim processor groups were tested y Chow F-sttistics. The verge estimted chemotherpy reimursement mount y clim processor group ws computed using the regression coefficients nd intercept. To evlute the ssocition etween G-CSF prescription nd verge estimted reimursement mounts, we conducted logistic regressions. In the first model, we included only ptient-level demogrphic, clinicl fctors, nd re socioeconomic sttus to descrie the ssocition etween these vriles nd G-CSF prescription. In the second model, we dditionlly included policy-level vrile (ie, verge chemotherpy reimursement levels y clim processor groups estimted from OLS regression). RESULTS The study popultion consisted of 7249 ptients; 38.45% hd prophylctic G-CSF prescription during the first cycle of chemotherpy (dt not presented in tulr form). The men ge ws 76 yers. An overwhelming mjority of ptients were white (92%). Fifty-one percent were femles. The most common histology type t dignosis ws diffuse lrge cell lymphom (DLC) (43%). A mjority of ptients were dignosed with B symptom nd others (54%) with stge I (26%), stge II (17%), stge III (18%), nd stge IV (32%). Approximtely 40% hd t lest 1 comorid condition within the 12-month period efore dignosis. Forty-five percent received ABC with rituxim nd 9% ptients received ABC without rituxim. Determintion of Reimursement Policies Tle 1 descries the verge estimted reimursement mounts cross ll 108 Medicre clim processor groups nd lso estimted reimursement mount t the ptient level. The estimted verge reimursement mount t the ptient level ws $6239 nd medin ws $6014. For ese of presenttion, in this tle we lso grouped verge reimursement mounts in 4 ctegories: 1) less thn $5669; 2) $5669 to $6901; 3) $6901 to $8094; nd 4) greter thn $8094. The top pnel of the tle presents the numer nd percentge of Medicre clim processor groups t different estimted verge reimursement levels. The results from the OLS regressions on reimursement mounts t ptient level re summrized in the ottom pnel of Tle 1. F-test from the regression indicted tht there were sttisticlly significnt vritions in the estimted chemotherpy reimursement mount cross Medicre clim processor groups (P <.0001). To identify reimursement policies of the clim processors (undled vs seprte pyments), we lso exmined chemotherpy dministrtion codes cross different Medicre clim processor groups. The verge numer of chemotherpy dministrtion codes used in the first cycle of chemotherpy ws 5 in top deciles, while the verge numer of chemotherpy dministrtion codes ws 3 in ottom deciles. We further identified dministrtion codes in top deciles nd not in ottom deciles: Current Procedurl Terminology (CPT) code The code indictes more thn once per dy for ech drug the oncologist provides. Administrtion codes in ottom decile nd not in top decile included CPT code 96523, indicting only pyle when not illed with other service. Therefore, we speculted tht undling policy is more likely to e the source of vritions in estimted chemotherpy reimursement. It is plusile tht Medicre clim processors with low estimted verge reimursement mounts were using undled pyments nd those with high estimted verge reimursement mounts were using seprte pyments for services nd drugs delivered. Assocition Between Reimursement Policies nd G-CSF Prescription. The djusted odds rtios (AORs) nd the ssocited 95% confidence intervls (CIs) from 2 logistic regressions re presented in Tle 2. In the first model (without verge chemotherpy reimursement vrile), the results showed tht chemotherpy type, rce, ge group t dignosis, histology, nd time-trend were significntly ssocited with G-CSF prescription. Results from the second model (with verge chemotherpy reimursement vrile) reveled tht while ptient-level fctors continued to hve sttisticlly significnt ssocition with G-CSF prescription, the 150 The Americn Journl of Phrmcy Benefi ts July/August

5 Medicre Clim Processors Reimursement Tle 1. Descriptive Tle of Estimted Averge Reimursement Amount From OLS Regression No. of clim processors Estimted verge reimursement vrile ($) (unit of nlysis: clim processor group level) (percentge) Clim processor reimursement < (25%) 5669 <clim processor reimursement < (25%) 6901 <clim processor reimursement < (25%) 8094 <clim processor reimursement < 28, (25%) Descriptive sttistics of estimted reimursement (unit of nlysis: ptient-level) Men $ Stndrd error $904.0 Medin $ % $ % $ % $ % $ OLS regression results Model F vlue P vlue <.0001 Adjusted R-squre F test in OLS regression ssessing clim processor reimursement vrition F vlue 4.41 P vlue <.0001 G-CSF indictes grnulocyte colony-stimulting fctor; OLS, ordinry lest squres. Note: Bsed on 7249 ptients nested within 108 Medicre clim processor groups. The ordinry lest squres regression on reimursement mount from physicin visit nd outptient clims during the fi rst cycle of chemotherpy (21 dys) included indictors for ech of the Medicre clim processors. The regression lso controlled for ptient-level fctors such s gender, rce/ethnicity, ge, dignosis yer, stge of cncer, histology, lymphom node involvement, type of chemotherpy, nd use of G-CSF drug. The reference group for chemotherpy type is nthrycline with rituxim. verge chemotherpy reimursement level vrile lso contriuted to G-CSF prescription. For ese of interprettion, estimted chemotherpy reimursement mount from the OLS regression ws divided y $1000. After controlling for ptients demogrphic, clinicl fctors, nd re socioeconomic sttus, we found tht, for every $1000 increse in estimted physicin reimursement mounts, the likelihood of G-CSF prescription decresed. The AOR ws 0.91 with 95% CI ( ). If the reimursement mounts were to e expressed in units of $100, this result would trnslte to 0.9% decrese in G-CSF prescription likelihood for n verge increse of $100 in chemotherpy reimursement mounts. DISCUSSION Our study set out to exmine the reltionship etween Medicre clim processors reimursement policies nd G-CSF prescription mong ptients with NHL. Reimursement policies of Medicre clim processors were identified with n indirect pproch using verge estimted reimursement mount for the first cycle of chemotherpy (21 dys) fter initition nd the numer of drugs nd services delivered during this period. We found tht Medicre clim processors with lower reimursement mounts used undled pyment polices nd those with higher verge reimursement mounts used seprte pyments for services nd drugs. Our study did not ssess the ctul pyment polices of ech of the clim processors. Future studies re needed to relte the ctul pyment polices to physicin reimursement mounts for chemotherpy. Our study findings reveled tht G-CSF prescription ws less likely in counties with higher verge estimted physicin reimursement mount compred with those with lower verge estimted physicin reimursement mount. This finding long with vritions in verge reimursement mount cross Medicre clim processors suggest tht the likelihood of G-CSF prescription is influenced y reimursement policies of the Medicre clim processors. Our study did not survey the physicins to elicit informtion on resons for dding or not dding G-CSF prescriptions to chemotherpy regimens. However, we cn speculte s to why G-CSF prescription rtes vried cross Medicre crries. It is plusile tht Vol. 5, No. 4 The Americn Journl of Phrmcy Benefi ts 151

6 Pn Smmoorthi Tle 2. Multivrite Logistic Regression Model of Fctors on G-CSF Prescription (N = 7249) Model Without Reimursement Vrile Model With Reimursement Vrile AOR 95% CI P AOR 95% CI P Estimted chemotherpy reimursement in $1000 chemotherpy type (ref = ABC with R) 0.91 [ ] ABC no R 0.53 [ ] 0.53 [ ] Non-ABC with R 0.1 [ ] 0.1 [ ] Non-ABC without R 0.12 [ ] 0.12 [ ] Unknown 0.03 [ ] 0.03 [ ] Rce (ref = White) Asin 0.73 [ ] 0.69 [ ] c Blck 0.7 [ ] c 0.71 [ ] Ntive 0.53 [ ] 0.51 [ ] Other 1.34 [ ] 1.31 [ ] Age group t dignosis (ref = 66-70) y 1.17 [ ] c 1.17 [ ] y 1.29 [ ] 1.28 [ ] y 1.31 [ ] 1.3 [ ] 85+ y 1.02 [ ] 1.01 [ ] Histology (ref = folliculr) DLC 1.43 [ ] 1.43 [ ] Other 1.2 [ ] 1.2 [ ] T-cell 1.41 [ ] 1.37 [ ] Unknown 0.82 [ ] 0.82 [ ] Unspecifi ed 0.96 [ ] 0.95 [ ] Yer of chemotherpy 1.36 [ ] 1.35 [ ] ABC indictes nthrcycline-sed chemotherpy; AOR, djusted odds rtio; CI, confi dence intervl; DLC, diffuse lrge cell lymphom; R, rituxim. P < < P <.01. c.01 < P <.05. Note: Time trend vrile T time is set to e the sequence of 0, 1, 2, 3 up to the vlue of 6 indicting tretment in Other independent vriles were not shown in the tle. These vriles include gender, grde t dignosis, node involvement, stge t dignosis, comoridity score, re income level, re eduction level, nd re percentge of white. G-CSF prescriptions in ddition to stndrd chemotherpy regimens my increse physicin s revenue. Prior empiricl reserch suggests tht higher verge physicin reimursement mounts closely reflect physicins profit or income. 6 Thus, physicins contrcting with Medicre clim processors with higher verge reimursement mounts my hve hd higher incomes compred with their counterprts contrcting with Medicre clim processors with low reimursement mounts. Bsed on economic theory, 11 one could postulte tht sustitution effect could e responsile for oserving lower likelihood of G-CSF prescription mong physicins contrcting with Medicre clim processors with higher reimursement. Under sustitution-effect theory, these physicins my derive smller mrginl enefits from dditionl income due to prescription of G-CSF drugs. Alterntively, one could speculte tht income effect my hve een responsile for the oserved pttern. Under the incomeeffect theory, physicins contrcting with Medicre clim processors with low reimursement mounts my hve low income nd hence my need to increse their income y providing supplementl services nd products. Thus in our cse, physicins contrcting with Medicre clim processors with low reimursement mount my ugment stndrd chemotherpy regimens with G-CSF for ptients with NHL nd therefore my e more likely to prescrie G-CSF. It hs to e noted tht we did not consider other fctors tht my discourge the ddition of G-CSF. For exmple, the physicin my need to consider the ptient s urden 152 The Americn Journl of Phrmcy Benefi ts July/August

7 Medicre Clim Processors Reimursement s well. Adding G-CSF to chemotherpy regimen my involve high out-of-pocket costs for the ptient, 20 greter trvel time to get the injections, 27 nd impired qulity of life due to possile side effects. 27 However, such fctors my not explin the systemtic vrition in G-CSF prescriptions y reimursement mounts. Although we focused on the reltionship etween reimursement policies nd G-CSF prescription, it hs to e noted tht G-CSF prescription lso involves clinicl decision mking. We found compred with ptients in the ge group 66 to 70 yers, older ptients were more likely to receive G-CSF. A plusile explntion for this finding could e the incresed risk of neutropeni nd neutropeni-ssocited hospitliztion with incresing ge Therefore, physicins my consider ge highrisk fctor nd prescrie prophylctic G-CSF to older ptients. Furthermore, we found tht ptients with less toxic chemotherpy regimens such s non-abc chemotherpy nd rituxim with non-abc chemotherpy were less likely to receive G-CSF compred with highly toxic chemotherpy regimen (ie, ABC chemotherpy). We lso found ptients with ABC without rituxim were less likely to e treted with G-CSF compred with those with ABC nd rituxim. Tken together these findings suggest tht greter toxicity of chemotherpy regimens my e ssocited with greter risk of neutropeni nd physicins my prescrie G-CSF s prophylctic gent. Diffuse lrge B-cell lymphom ws found to e significntly ssocited with G-CSF use. The result conforms to Americn Society of Clinicl Oncology (ASCO) 2006 guideline recommendtion Prophylctic CSF for ptients with diffuse ggressive lymphom ged 65 yers nd older treted with curtive chemotherpy (the regimen cyclophosphmide, doxoruicin, vincristine, nd prednisone [CHOP] or more ggressive regimens) should e given to reduce the incidence of ferile neutropeni nd infections. 32 The study showed there ws n incresed trend of G-CSF prescription cross yers. The odds rtio for time trend vrile ws The incresed likelihood of prescriing G-CSF over time my e ecuse of innovtion diffusion, dissemintion, nd incresing doption of ASCO guidelines. The study findings need to e interpreted in light of the strengths nd limittions. The strengths were lrge study popultion, vilility of clinicl vriles, longitudinl design, nd ility to identify chemotherpy nd G- CSF prescription from clims (not suject to recll is). The study ws potentilly limited y its selection criteri. The study popultion consisted of Medicre elderly NHL ptients without inptient or ED clims in the first cycle of chemotherpy. We did not control for eligiility for G-CSF (ie, ptients who re t high risk of neutropeni). We used surrogte vriles for reimursement policies. Therefore, our findings could t est e considered n indirect evidence of the reltionship etween reimursement policies nd G-CSF choice. In ddition, our grouping of Medicre clim processors my hve ffected our findings. Despite these weknesses, our study is the first to explore Medicre reimursement policies cross different clim processors nd its ssocition with prescriing volume for ptients with cncer. While our study only mesured undled pyment policies through n indirect pproch, it lso provided some useful insights s to the ssocition etween undled pyment policies nd provision of cre for ptients with NHL. Future studies need to otin the ctul pyment policies t the clim processor level to further elucidte the reltionship etween undled pyments nd physicin prctice ptterns. Acknowledgments We cknowledge efforts of Ntionl Cncer Institute (NCI) nd the Surveillnce, Epidemiology nd End Results (SEER) Progrm tumor registries in the cretion of the SEER-Medicre dtse. Author Affilitions: From Phrmceuticl System nd Policy (XP, US), School of Phrmcy, West Virgini University, Morgntown, WV. Funding Source: Dr Smmoorthi ws prtilly supported for infrstructure from West Virgini Collortive Helth Outcomes Reserch of Therpies nd Services (WV CoHORTS) Center. Author Disclosures: The uthors (XP, US) report no reltionship or finncil interest with ny entity tht would pose conflict of interest with the suject mtter of this rticle. Authorship Informtion: Concept nd design (XP); cquisition of dt (XP); nlysis nd interprettion of dt (XP, US); drfting of the mnuscript (XP, US); criticl revision of the mnuscript for importnt intellectul content (XP, US); sttisticl nlysis (XP); nd otining funding (US). Address correspondence to: Xioyun Pn, PhD, West Virgini University, Helth Science Center North, School of Phrmcy, PO Box 9510, Morgntown, WV E-mil: xpn@hsc.wvu.edu. REFERENCES 1. Hussey P, Ridgely MS, Rosenthl M. The PROMETHEUS undled pyment experiment: slow strt shows prolems in implementing new pyment models. Helth Aff (Millwood). 2011;30(11): Miller H. From volume to vlue: etter wys to py for helth cre. Helth Aff (Millwood). 2009;28(5): Centers for Medicre & Medicid Services. Bundled pyments for cre improvement. Accessed Decemer 17, Welch WP. Bundled medicre pyment for cute nd postcute cre. Helth Aff (Millwood). 1998;17(6): Biles JS. Current issues in oncology reimursement. 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