Prostate Cancer Self Referals

Austin Frakt with a chart on the increase in self-refering for Prostate Cancer IMRT treatments among Medicaid patients:

Some other facts from the GAO report:

  • Providers are not required to disclose that they self-refer.
  • IMRT is one of the more costly prostate cancer treatment options, but not clearly superior.
  • Other work has documented that physicians play a large role in determination of a patient’s prostate cancer treatment approach.
  • Other work has also suggests financial incentives may influence treatment decisions.
  • Differences between self-referring and non-self-referring providers shown above could not be explained by differences in age, geographic location, or health.

Prostate IMRT Services Performed by self-refering and non-self-refering

It looks like Stark Law has a restriction against self-refering for Medicare & Medicaid patients, but it looks like there are plenty of loopholes in the law. Clearly the law is failing in its intent, and I would hope that any future rewrites would include all patients in a self-referal restriction.

Oregon Medicaid Study: Need More Power

If you missed it last week, a two year follow up from the Oregon Medicaid experiment was published and caused a bit of a stir as the study concluded any health gains from Medicaid were statistically insignificant. The only problem is, there doesn’t appear to be enough participants in the study to measure any individual health gains for a specific condition (baring any large effects).

Kevin Drum:

Let’s do the math. In the Oregon study, 5.1 percent of the people in the control group had elevated GH [glycated hemoglobin, aka A1C, or colloquially, blood sugar] levels. Now let’s take a look at the treatment group. It started out with about 6,000 people who were offered Medicaid. Of that, 1,500 actually signed up. If you figure that 5.1 percent of them started out with elevated GH levels, that’s about 80 people. A 20 percent reduction would be 16 people.

So here’s the question: if the researchers ended up finding the result they hoped for (i.e., a reduction of 16 people with elevated GH levels), is there any chance that this result would be statistically significant? […] The answer is almost certainly no. It’s just too small a number.

Austin Frakt:

I plugged these numbers into Stata’s sample size calculation program (sampsi) to do a power calculation for the difference between two proportions. I found that the probability of this result occurring under the null hypothesis that Medicaid would have no effect on GH levels is 0.35. The null cannot be rejected. We knew this from the paper, and, hence, all the hubbub. (Never mind that we also cannot reject a much larger effect. The authors cover this in their discussion.)

The standard level of statistical significance is rejecting the null with 0.95 probability. Assuming the same baseline 5.1% elevated GH rate and a 20% reduction under Medicaid, what sample size would we need to achieve a 0.95 level of significance? Plugging and chugging, I get about 30,000 for the control group and a 7,500 treatment (Medicaid) group. (I’ve fixed the Medicaid take-up rate at 25%, as found in the study.) This is a factor of five bigger than the researchers had.

You should read the entirety of both Frakt and Dunn’s posts. Frakt also has a follow up post to the one I have quoted with some technical explanation to his power calculation.

PS: Matt Yglesias has a post on the experiment needed to determine the effectiveness of Medicaid. He also notes that Florida and Texas missed out on this opportunity when they completely rejected all Medicaid expansion.