Nudge.

Top Line: Do policies to push breast cancer surgery away from low volume centers actually improve outcomes?

The Study: In 2009, New York Medicaid implemented a policy where breast cancer surgery was only reimbursed at facilities that had at least 30 breast cancer surgeries annually over a 3 year period. Thirty breast cancer surgeries seems like a modest number, so this could be seen more as a push away from the lowest volume hospitals rather than a push towards the highest volume hospitals. Of 194 hospitals registered in NY, 64 (33%) were excluded in 2010, and this increased to 84 (43%) by 2019. This study compared survival outcomes for patients treated for stage I-III breast cancer with or without Medicaid to determine if Medicaid patients benefited from the push to higher volume facilities. During the time of this policy change, there was a slight overall improvement in breast cancer mortality across the board. However, the magnitude of improvement in survival was greater among Medicaid patients. For example, 5-year breast cancer mortality among non-Medicaid patients went from 3.9% to 3.8% during the policy period. For Medicaid patients it dropped from 6.6% to 4.5%. The authors went a step further and compared these outcomes to New Jersey Medicaid. During the same time frame, 5-year breast cancer mortality dropped from 6.2% to 6.0%. An important question is whether this policy reduced access to breast cancer surgery. That did not appear to be the case as a similar proportion of Medicaid patients had surgery for breast cancer before and after the policy (86.6% v 86%). Another question is whether the quality of the surgical facilities drove the change or if the site of surgery had downstream effects on adjuvant therapy that improved outcomes.

TBL: After implementation of a NY Medicaid policy that encouraged breast cancer surgery at higher volume centers, breast cancer patients with Medicaid saw a significant drop in breast cancer mortality. | Nattinger, J Clin Oncol 2022