TY - JOUR
AU1 - Eaglehouse, Yvonne, L
AU2 - Georg, Matthew, W
AU3 - Richard,, Patrick
AU4 - Shriver, COL Craig, D
AU5 - Zhu,, Kangmin
AB - ABSTRACT Introduction Cancer is one of the leading causes of morbidity and mortality in the USA, contributing largely to US healthcare spending. Provision of services (direct or purchased) and insurance benefit type may impact cost for cancer care. As a common cause of cancer in both men and women, we aim to compare colon cancer treatment costs between insurance benefit types and care sources in the US Military Health System (MHS) to better understand whether and to what extent these system factors impact cancer care costs. Materials and Methods Department of Defense Central Cancer Registry records and MHS Data Repository administrative claims were used to identify MHS beneficiaries aged 18–64 who were diagnosed with primary colon adenocarcinoma and received treatment between 2003 and 2008. The data linkage was approved by the Institutional Review Boards of the Walter Reed National Military Medical Center, the Defense Health Agency, and the National Institutes of Health. Costs to the MHS for each claim related to cancer treatment were extracted from the linked data and adjusted to 2008 USD. We used quantile regression models to compare median cancer treatment costs between benefit types and care sources (direct, purchased, or both), adjusted for demographic, tumor, and treatment characteristics. Results The median per capita (n = 801) costs for colon cancer care were $60,321 (interquartile range $24,625, $159,729) over a median follow-up of 1.7 years. The model-estimated treatment costs were similar between benefit types. Patients using direct care had significantly lower estimated median costs [$34,145 (standard error $4,326)] than patients using purchased care [$106,395 ($10,559)] or both care sources [$82,439 ($13,330)], controlled for patient demographic, tumor, and treatment characteristics. Differences in cost by care source were noted for patients with later stage tumors and by treatment type. Relative costs were 2–3 times higher for purchased care compared to direct care for patients with late-stage tumors and for patients receiving chemotherapy or radiation treatment. Conclusions In the MHS, median cost for colon cancer treatment was lower in direct care compared to purchased care or patients using a combination of direct and purchased care. The variation in cancer treatment costs between care sources may be due to differences in treatment incentives or capabilities. Additional studies on cost differences between direct and purchased services are needed to understand how provision of care affects cancer treatment costs and to identify possible targets for cost reduction. INTRODUCTION Cancer is one of the leading causes of morbidity and mortality in the United States.1,2 The estimated economic burden of cancer care in the U.S. is $125 billion per year and this cost is projected to rise over the next several decades.3–5 The increase in costs will be due in part to incidence and prevalence trends related to an aging population. In the U.S. Military Health System (MHS) beneficiary population, approximately 7,000 new cancers are diagnosed each year.6,7 The cost for providing cancer care in the MHS is estimated to be over $1 billion per year.7 As healthcare costs continue to rise, evaluations of cancer treatment costs in a variety of health systems and patient populations will be important for informing cost maintenance or reduction strategies.8,9 The MHS provides access to medical care to over 9 million active-duty military personnel, national guards, reservists, retirees, and their family members. MHS beneficiaries have access to medical care at over 50 military hospitals and 300 ambulatory health clinics, collectively known as military treatment facilities (MTFs), and a supporting network of private practices.10 The Defense Health Agency (DHA) provides operational and administrative oversight for shared services, functions, and activities in the MHS.10 A unified medical budget appropriated to the Department of Defense (DoD) provides financial support for the DHA and MHS activities.10 The DHA allocates funding for direct medical care at MTFs based partly on the number of eligible beneficiaries in the MTF catchment area, patient volume (e.g., encounters per month), and types of services offered at the MTF. The cost to the MHS for a patient visit in direct care is determined from expenses at the MTF allocated down to the patient-encounter level. The Defense Health Agency (DHA) also allocates funds to operate TRICARE and manage payments for purchased care.10,11 Costs to the MHS for medical services rendered at private practices are determined from standard fee schedules12 and depend on the provider network status and the cost-sharing arrangements of the patient’s benefit plan. The MHS provides health insurance to eligible beneficiaries through four main benefit plans: Prime, Extra, Standard, and TRICARE for Life.10,11 Beneficiaries may pay enrollment fees, annual deductibles, co-payments and co-insurance payments based on their beneficiary status and benefit plan.13 Active-duty service members are automatically enrolled in Prime and pay no out-of-pocket costs. Other beneficiaries can elect to enroll in Prime (subject to enrollment fees) or be automatically enrolled in the Extra and Standard plans. These plans cover services rendered by authorized providers and have similar cost-sharing arrangements.10 TRICARE for Life serves as a secondary payer to Medicare for those beneficiaries who are Medicare eligible. Payments for specialty treatment (i.e., cancer) in purchased care are handled similar to an HMO (Prime) or PPO (Standard and Extra) in the private sector.10,11 MHS beneficiaries may have co-payments or co-insurance due at time of service depending on the network status of the provider and whether out-of-pocket maximums have been reached. Point-of-service fees may also be applied when specialty care is received without a referral. Although similar in structure to HMOs or PPOs, MHS beneficiaries generally have lower out-of-pocket expenses than those participating in U.S. public or private plans.13 We previously examined whether costs for breast cancer treatment in the MHS differed by benefit type and care source,14 two health services features that have seldom been considered in cancer care cost evaluations.5 In that study, we found that costs to the MHS for breast cancer treatment were similar between benefit types, but varied considerably between care sources in the MHS.14 It is important to extend this research to other tumor sites to establish whether similar patterns in cost to the MHS are found before informing health service policies. Thus, the purpose of this study was to quantify and compare cancer treatment costs to the MHS for the different care sources and benefit types in a tumor site that affects both men and women and uses different treatment modalities. As the third highest incident cancer among both men and women in the USA,15,16 representing 9% and 8% of new cancer cases respectively, colorectal cancer care contributes greatly to the $125 billion spent on cancer care in the USA each year.3 The primary treatments for colon cancer are surgery and adjuvant chemotherapy.17 This study aimed to compare costs for colon cancer care by benefit type and care source to assess whether there were patterns similar to or different from those found for breast cancer. Rectal cancer was not included as colon cancers account for approximately 70% of the patients diagnosed with colorectal cancers15 and treatment schemas differ between colon cancer and rectal cancer.18,19 Costs were compared by tumor stage and treatment types to further determine whether cost differences exist between care sources and benefit types among patient subgroups. METHODS AND MATERIALS Population and Data Sources We used linked cancer registry and administrative claims data to capture incident colon cancer diagnoses and the costs associated for colon cancer treatment, a method that has been applied to other data sources to estimate colon cancer costs.20–22 This study is a retrospective analysis of linked data from the DoD Central Cancer Registry (CCR) and MHS Data Repository (MDR) medical claims database.23,24 Information on the structure of the linked data has been published previously.25,26 Eligible patients (n = 993) were men and women aged 18–64 years with a confirmed diagnosis of a single primary colon adenocarcinoma [International Classification of Diseases – Oncology, Third Edition (ICD-O-3) topography codes C180 and C182–C189] who were ever diagnosed or treated at MTFs between 2003 and 2007. Patients diagnosed at age 65 or older were excluded since TRICARE is a secondary payer to Medicare and claims data may be incomplete for these individuals. The original data linkage project was reviewed and approved by the institutional review boards of the Walter Reed National Military Medical Center and the Defense Health Agency. Study Variables Participant demographic characteristics were obtained from CCR and included age at diagnosis, sex, race (White, Black, or other), ethnicity (Hispanic or non-Hispanic), marital status at diagnosis, active-duty status at diagnosis, and military service or sponsor branch. Comorbidities were identified from MDR records using ICD-9 codes for conditions included in the Charlson Comorbidity Index, excluding cancer.27 Cancer diagnosis date, tumor stage (I–IV, AJCC 6th edition28), tumor grade [well-differentiated (I), moderately-differentiated (II), poorly-differentiated (III), undifferentiated (IV), or unknown/undetermined], and tumor location [right-sided (ascending), transverse, left-sided (descending), or overlapping/unknown] were extracted from the CCR data for each patient. Insurance benefit status was collected from MDR records and supplemented with CCR data if values were missing. Benefit type was determined from enrollment and eligibility in the benefit plans at any point in the three months prior to and following colon cancer diagnosis. If the eligible beneficiary was not electively enrolled in Prime during the time period surrounding the cancer diagnosis, the benefit type was designated as Standard or Extra due to the automatic enrollment in these plans. The Standard and Extra plans were combined into a “non-Prime” designation due to similar payment structures and benefit coverage between the two plans.13 Patients with missing eligibility status (n = 84) and patients with other health insurance in addition to DoD-provided coverage (n = 50) were excluded. Beneficiaries with missing eligibility status were more likely to be male or age 18 to 39 compared to the study population. No significant differences were noted between those with other health insurance compared to those with DoD insurance. Information on TRICARE service region (North, South, West, or Overseas) was also captured from the data. Care source was determined from MDR administrative claims data for colon cancer treatment beginning at the date of diagnosis through the end of follow-up, death, or censoring. Care source was defined as direct, purchased, or both using a two-step process. (1) Unique claim dates were extracted to determine the number of patient visits for each treatment type (surgery, chemotherapy, radiation). Based on frequency distributions, if ≥80% of unique claim dates were for care delivered in MTFs, then patients were classified as having received direct care for that treatment type. Similarly, if ≥80% of unique claim dates were for civilian facilities, then patients were classified as having received purchased care for that treatment type. Otherwise, care source was classified as both. (2) Overall care source was determined by the proportion of treatment types received as direct care. If ≥80% of treatment types were received as direct care, then the care source was classified as direct (n = 433). If ≤20% of treatment types were received as direct care, then the care source was classified as purchased (n = 196). Otherwise, care source was classified as both (n = 172). Patients who did not have cancer treatment documented in MDR records were excluded (n = 58). Those excluded had similar demographic characteristics but were more likely to have been diagnosed with stage I tumors compared to the study population. Outcome Lifetime colon cancer treatment costs for each patient were determined from the MDR administrative claims database in the time period between cancer diagnosis and date of death, censor, or end of study on December 31, 2008, whichever occurred first. Relevant colon cancer ICD-9 diagnostic and procedure codes, Current Procedural Terminology (CPT) codes, and Healthcare Common Procedure Coding System (HCPCS) codes were used to identify related claims and episodes of care (Table I). For treatments delivered at MTFs (direct care), the MDR records contained costs for episodes of care and included institutional, professional (i.e., clinician salary), and outpatient ancillary services (e.g., laboratory, anesthesia, radiology, pharmacy). For treatments administered in private practices (purchased care), the MDR contained claim-level data for the amount paid by the MHS for each billed procedure (including radiation doses and chemotherapy drugs when applicable) but none of the associated professional or outpatient ancillary costs. In order to make MTF and private practice costs more comparable, the costs for clinician salary and outpatient ancillary services (except radiology and pharmacy when indicated) were subtracted from the MTF episode of care costs. The costs to the MHS for direct and purchased care for each code related to surgery, chemotherapy, and radiation were summed to generate a total cost to the MHS for each treatment type. All costs were adjusted for inflation to 2008 U.S. dollars (USD) using the annual average Consumer Price Index for medical care in the year of diagnosis.29 TABLE I. Medical Codes Used to Identify Colon Cancer Treatment Claims in the Military Health System Linked Data Treatment Type Coding System Codes Surgery ICD-9 Procedure 17.31–17.36, 17.39, 45.70–45.76, 45.79, 45.80–45.83, 46.01–46.04, 46.10, 46.11, 46.13, 46.20–46.23 CPT-4 44125, 44130, 44140, 44141, 44143–44147, 44150–44153, 44155–44158, 44160, 44186–44188, 44200–44213, 44227, 50810 Chemotherapy ICD-9 Diagnosis V58.1, V66.2, V67.2 ICD-9 Procedure 99.25 CPT-4 96400–96402, 96405, 96406, 96408, 96410–96417, 96420, 96422, 96423, 96425, 96440, 96445, 96450, 96520–96523, 96530, 96542, 96545, 96549, 96567, 96570, 96571 HCPCS C9205, C9418, E0779, E0780, E0781, E0783, E0786, E0791, E9331, J0640, J8520, J8521, J9060, J9062, J9190, J9200, J9206, J9263, Q0083-Q0085 Radiation Therapy ICD-9 Diagnosis V58.0, V66.1, V67.1 ICD-9 Procedure 92.21–92.29 CPT-4 32553, 49411, 55876, 61770, 76370, 76950, 76960, 77014, 77373, 77399, 77401–77404, 77406–77409, 77411–77414, 77417–77423, 77425, 77430–77432, 77761, 77762, 77776–77778, 77789, 77790, 92974 HCPCS 0082 T, 0520 F, 3318 F, 4165 F, 4181 F, 6040 F, 6045 F, A4650, C9726, C9728, D5983-D5985, G0256, G0261, S2270, S8049 Treatment Type Coding System Codes Surgery ICD-9 Procedure 17.31–17.36, 17.39, 45.70–45.76, 45.79, 45.80–45.83, 46.01–46.04, 46.10, 46.11, 46.13, 46.20–46.23 CPT-4 44125, 44130, 44140, 44141, 44143–44147, 44150–44153, 44155–44158, 44160, 44186–44188, 44200–44213, 44227, 50810 Chemotherapy ICD-9 Diagnosis V58.1, V66.2, V67.2 ICD-9 Procedure 99.25 CPT-4 96400–96402, 96405, 96406, 96408, 96410–96417, 96420, 96422, 96423, 96425, 96440, 96445, 96450, 96520–96523, 96530, 96542, 96545, 96549, 96567, 96570, 96571 HCPCS C9205, C9418, E0779, E0780, E0781, E0783, E0786, E0791, E9331, J0640, J8520, J8521, J9060, J9062, J9190, J9200, J9206, J9263, Q0083-Q0085 Radiation Therapy ICD-9 Diagnosis V58.0, V66.1, V67.1 ICD-9 Procedure 92.21–92.29 CPT-4 32553, 49411, 55876, 61770, 76370, 76950, 76960, 77014, 77373, 77399, 77401–77404, 77406–77409, 77411–77414, 77417–77423, 77425, 77430–77432, 77761, 77762, 77776–77778, 77789, 77790, 92974 HCPCS 0082 T, 0520 F, 3318 F, 4165 F, 4181 F, 6040 F, 6045 F, A4650, C9726, C9728, D5983-D5985, G0256, G0261, S2270, S8049 CPT-4, Current Procedure Terminology, 4th edition; ICD-9, International Classification of Diseases, 9th edition; HCPCS, Healthcare Common Procedure Coding System. TABLE I. Medical Codes Used to Identify Colon Cancer Treatment Claims in the Military Health System Linked Data Treatment Type Coding System Codes Surgery ICD-9 Procedure 17.31–17.36, 17.39, 45.70–45.76, 45.79, 45.80–45.83, 46.01–46.04, 46.10, 46.11, 46.13, 46.20–46.23 CPT-4 44125, 44130, 44140, 44141, 44143–44147, 44150–44153, 44155–44158, 44160, 44186–44188, 44200–44213, 44227, 50810 Chemotherapy ICD-9 Diagnosis V58.1, V66.2, V67.2 ICD-9 Procedure 99.25 CPT-4 96400–96402, 96405, 96406, 96408, 96410–96417, 96420, 96422, 96423, 96425, 96440, 96445, 96450, 96520–96523, 96530, 96542, 96545, 96549, 96567, 96570, 96571 HCPCS C9205, C9418, E0779, E0780, E0781, E0783, E0786, E0791, E9331, J0640, J8520, J8521, J9060, J9062, J9190, J9200, J9206, J9263, Q0083-Q0085 Radiation Therapy ICD-9 Diagnosis V58.0, V66.1, V67.1 ICD-9 Procedure 92.21–92.29 CPT-4 32553, 49411, 55876, 61770, 76370, 76950, 76960, 77014, 77373, 77399, 77401–77404, 77406–77409, 77411–77414, 77417–77423, 77425, 77430–77432, 77761, 77762, 77776–77778, 77789, 77790, 92974 HCPCS 0082 T, 0520 F, 3318 F, 4165 F, 4181 F, 6040 F, 6045 F, A4650, C9726, C9728, D5983-D5985, G0256, G0261, S2270, S8049 Treatment Type Coding System Codes Surgery ICD-9 Procedure 17.31–17.36, 17.39, 45.70–45.76, 45.79, 45.80–45.83, 46.01–46.04, 46.10, 46.11, 46.13, 46.20–46.23 CPT-4 44125, 44130, 44140, 44141, 44143–44147, 44150–44153, 44155–44158, 44160, 44186–44188, 44200–44213, 44227, 50810 Chemotherapy ICD-9 Diagnosis V58.1, V66.2, V67.2 ICD-9 Procedure 99.25 CPT-4 96400–96402, 96405, 96406, 96408, 96410–96417, 96420, 96422, 96423, 96425, 96440, 96445, 96450, 96520–96523, 96530, 96542, 96545, 96549, 96567, 96570, 96571 HCPCS C9205, C9418, E0779, E0780, E0781, E0783, E0786, E0791, E9331, J0640, J8520, J8521, J9060, J9062, J9190, J9200, J9206, J9263, Q0083-Q0085 Radiation Therapy ICD-9 Diagnosis V58.0, V66.1, V67.1 ICD-9 Procedure 92.21–92.29 CPT-4 32553, 49411, 55876, 61770, 76370, 76950, 76960, 77014, 77373, 77399, 77401–77404, 77406–77409, 77411–77414, 77417–77423, 77425, 77430–77432, 77761, 77762, 77776–77778, 77789, 77790, 92974 HCPCS 0082 T, 0520 F, 3318 F, 4165 F, 4181 F, 6040 F, 6045 F, A4650, C9726, C9728, D5983-D5985, G0256, G0261, S2270, S8049 CPT-4, Current Procedure Terminology, 4th edition; ICD-9, International Classification of Diseases, 9th edition; HCPCS, Healthcare Common Procedure Coding System. Analyses Demographic and tumor characteristics were examined by benefit type and care source and differences in frequency distributions were evaluated using Chi-square tests. Median colon cancer treatment costs were estimated using quantile regression with bootstrap methods for calculating standard errors.30,31 The models included the variables of interest (benefit type and care source) and adjustment for demographic, tumor, and treatment characteristics. Regression parameter estimates and 95% confidence intervals (CIs) were compared between benefit types and care sources for significant differences in median cost. The global effects of benefit type and care source on cost were evaluated in the regression model using Wald statistics. Sub-analyses were conducted by tumor stage [early-stage (I or II) or late-stage (III or IV)] and by treatment type [surgery only, chemotherapy or radiation only, or both surgery and chemotherapy/radiation] to compare colon cancer costs between benefit type and care source by these factors. Associations were considered significant at the alpha = 0.05 level with Bonferroni corrections for multiple comparisons. Analyses were conducted using SAS 9.4 (SAS Institute Inc., Cary, NC). RESULTS The sample included 801 patients diagnosed with colon cancer. The mean age at diagnosis was 51.44 (9.7) years. A majority of patients (86.0%) were enrolled in the Prime benefit type in the time period surrounding diagnosis. Colon cancer treatment was received most often in direct care (54.0%), followed by purchased care (24.5%), and both care sources (21.5%). Patient demographic (Table II) and pathologic characteristics and follow-up time from diagnosis (Table III) are presented by benefit type and care source. In regard to benefit type, differences in distribution were observed by age at diagnosis, active-duty status, and TRICARE service region. In regard to care source, differences were noted by race-ethnicity, marital status, service branch, TRICARE service region, and tumor stage, location, and grade. TABLE II. Demographic Characteristics by Benefit Type and Care Source for Patients Diagnosed with Colon Cancer in the U.S. Military Health System, 2003–2007 Benefit Type p Care Source p Prime Non-Prime Direct Purchased Both N(%) N(%) N(%) N (%) N (%) Care Source 0.163 ---  Direct 370 (53.7) 63 (56.3) 433 (100) 0 (0.0) 0 (0.0)  Purchased 176 (25.5) 20 (17.9) 0 (0.0) 196 (100) 0 (0.0)  Both 143 (20.8) 29 (25.9) 0 (0.0) 0 (0.0) 172 (100) Benefit Type --- 0.163  Prime 689 (100) 0 (0.0) 370 (85.5) 176 (89.8) 143 (83.1)  Non-Prime 0 (0.0) 112 (100) 63 (14.5) 20 (10.2) 29 (16.9) Age at Diagnosis <0.001 0.242  18–39 99 (14.4) 5 (4.5) 51 (11.8) 30 (15.3) 23 (13.4)  40–49 155 (22.5) 14 (12.5) 82 (18.9) 44 (22.5) 43 (25.0)  50–59 280 (40.6) 52 (46.4) 190 (43.9) 82 (41.8) 60 (34.9)  60–64 155 (22.5) 41 (36.6) 110 (25.4) 40 (20.4) 46 (26.7) Sex 0.398 0.681  Male 389 (56.5) 68 (60.7) 245 (56.6) 109 (55.6) 103 (59.9)  Female 300 (43.5) 44 (39.3) 188 (43.4) 87 (44.4) 69 (40.1) Race-Ethnicity 0.857 <0.001  Non-Hispanic White 411 (59.7) 64 (57.1) 257 (59.4) 122 (62.2) 96 (55.8)  Non-Hispanic Black 126 (18.3) 20 (17.9) 76 (17.6) 29 (14.8) 41 (23.8)  Non-Hispanic Other Race 62 (9.0) 9 (8.0) 39 (9.0) 14 (7.1) 18 (10.5)  Hispanic 36 (5.2) 8 (7.1) 35 (8.1) 4 (2.0) 5 (2.9)  Unknown Race or Ethnicity 54 (7.8) 11 (9.8) 26 (6.0) 27 (13.8) 12 (7.0) Marital Status 0.142 0.049  Married 561 (81.4) 86 (76.8) 344 (79.5) 155 (79.1) 148 (86.1)  Single 37 (5.4) 3 (2.7) 22 (5.1) 11 (5.6) 7 (4.1)  Other 74 (10.7) 18 (16.1) 60 (13.9) 20 (10.2) 12 (7.0)  Unknown 17 (2.5) 5 (4.5) 7 (1.6) 10 (5.1) 5 (2.9) Military Service or Sponsor Branch 0.076 <0.001  Army 262 (38.0) 29 (25.9) 166 (38.3) 71 (36.2) 54 (31.4)  Navy 157 (22.8) 36 (32.1) 101 (23.3) 38 (19.4) 54 (31.4)  Marines 27 (3.9) 7 (6.3) 19 (4.4) 2 (1.0) 13 (7.6)  Air Force 205 (29.8) 36 (32.1) 123 (28.4) 73 (37.2) 45 (26.2)  Other 33 (4.8) 4 (3.6) 22 (5.1) 10 (5.1) 5 (2.9)  Unknown 5 (0.8) 0 (0.0) 2 (0.5) 2 (1.0) 1 (0.6) Active Duty Status <0.001 0.460  Yes 150 (21.8) 3 (2.7) 79 (18.2) 41 (20.9) 22 (19.2)  No 532 (77.2) 108 (96.4) 351 (81.1) 151 (77.0) 138 (80.2)  Unknown 7 (1.0) 1 (0.9) 3 (0.7) 4 (2.0) 1 (0.6) TRICARE Service Region <0.001 <0.001  North 192 (27.9) 28 (25.0) 136 (31.4) 33 (16.8) 51 (29.7)  South 239 (34.7) 26 (23.2) 124 (28.6) 92 (46.9) 49 (28.5)  West 238 (34.5) 43 (38.4) 151 (34.9) 64 (32.7) 66 (38.4)  Overseas 20 (2.9) 15 (13.4) 22 (5.1) 7 (3.6) 6 (3.5) Comorbidities 0.893 0.417  0 501 (72.7) 81 (72.3) 320 (73.9) 139 (70.9) 123 (71.5)  1 135 (19.6) 21 (18.8) 75 (17.3) 42 (21.4) 39 (22.7)  2 or more 53 (7.8) 10 (8.9) 38 (8.8) 15 (7.7) 10 (5.8) Benefit Type p Care Source p Prime Non-Prime Direct Purchased Both N(%) N(%) N(%) N (%) N (%) Care Source 0.163 ---  Direct 370 (53.7) 63 (56.3) 433 (100) 0 (0.0) 0 (0.0)  Purchased 176 (25.5) 20 (17.9) 0 (0.0) 196 (100) 0 (0.0)  Both 143 (20.8) 29 (25.9) 0 (0.0) 0 (0.0) 172 (100) Benefit Type --- 0.163  Prime 689 (100) 0 (0.0) 370 (85.5) 176 (89.8) 143 (83.1)  Non-Prime 0 (0.0) 112 (100) 63 (14.5) 20 (10.2) 29 (16.9) Age at Diagnosis <0.001 0.242  18–39 99 (14.4) 5 (4.5) 51 (11.8) 30 (15.3) 23 (13.4)  40–49 155 (22.5) 14 (12.5) 82 (18.9) 44 (22.5) 43 (25.0)  50–59 280 (40.6) 52 (46.4) 190 (43.9) 82 (41.8) 60 (34.9)  60–64 155 (22.5) 41 (36.6) 110 (25.4) 40 (20.4) 46 (26.7) Sex 0.398 0.681  Male 389 (56.5) 68 (60.7) 245 (56.6) 109 (55.6) 103 (59.9)  Female 300 (43.5) 44 (39.3) 188 (43.4) 87 (44.4) 69 (40.1) Race-Ethnicity 0.857 <0.001  Non-Hispanic White 411 (59.7) 64 (57.1) 257 (59.4) 122 (62.2) 96 (55.8)  Non-Hispanic Black 126 (18.3) 20 (17.9) 76 (17.6) 29 (14.8) 41 (23.8)  Non-Hispanic Other Race 62 (9.0) 9 (8.0) 39 (9.0) 14 (7.1) 18 (10.5)  Hispanic 36 (5.2) 8 (7.1) 35 (8.1) 4 (2.0) 5 (2.9)  Unknown Race or Ethnicity 54 (7.8) 11 (9.8) 26 (6.0) 27 (13.8) 12 (7.0) Marital Status 0.142 0.049  Married 561 (81.4) 86 (76.8) 344 (79.5) 155 (79.1) 148 (86.1)  Single 37 (5.4) 3 (2.7) 22 (5.1) 11 (5.6) 7 (4.1)  Other 74 (10.7) 18 (16.1) 60 (13.9) 20 (10.2) 12 (7.0)  Unknown 17 (2.5) 5 (4.5) 7 (1.6) 10 (5.1) 5 (2.9) Military Service or Sponsor Branch 0.076 <0.001  Army 262 (38.0) 29 (25.9) 166 (38.3) 71 (36.2) 54 (31.4)  Navy 157 (22.8) 36 (32.1) 101 (23.3) 38 (19.4) 54 (31.4)  Marines 27 (3.9) 7 (6.3) 19 (4.4) 2 (1.0) 13 (7.6)  Air Force 205 (29.8) 36 (32.1) 123 (28.4) 73 (37.2) 45 (26.2)  Other 33 (4.8) 4 (3.6) 22 (5.1) 10 (5.1) 5 (2.9)  Unknown 5 (0.8) 0 (0.0) 2 (0.5) 2 (1.0) 1 (0.6) Active Duty Status <0.001 0.460  Yes 150 (21.8) 3 (2.7) 79 (18.2) 41 (20.9) 22 (19.2)  No 532 (77.2) 108 (96.4) 351 (81.1) 151 (77.0) 138 (80.2)  Unknown 7 (1.0) 1 (0.9) 3 (0.7) 4 (2.0) 1 (0.6) TRICARE Service Region <0.001 <0.001  North 192 (27.9) 28 (25.0) 136 (31.4) 33 (16.8) 51 (29.7)  South 239 (34.7) 26 (23.2) 124 (28.6) 92 (46.9) 49 (28.5)  West 238 (34.5) 43 (38.4) 151 (34.9) 64 (32.7) 66 (38.4)  Overseas 20 (2.9) 15 (13.4) 22 (5.1) 7 (3.6) 6 (3.5) Comorbidities 0.893 0.417  0 501 (72.7) 81 (72.3) 320 (73.9) 139 (70.9) 123 (71.5)  1 135 (19.6) 21 (18.8) 75 (17.3) 42 (21.4) 39 (22.7)  2 or more 53 (7.8) 10 (8.9) 38 (8.8) 15 (7.7) 10 (5.8) TABLE II. Demographic Characteristics by Benefit Type and Care Source for Patients Diagnosed with Colon Cancer in the U.S. Military Health System, 2003–2007 Benefit Type p Care Source p Prime Non-Prime Direct Purchased Both N(%) N(%) N(%) N (%) N (%) Care Source 0.163 ---  Direct 370 (53.7) 63 (56.3) 433 (100) 0 (0.0) 0 (0.0)  Purchased 176 (25.5) 20 (17.9) 0 (0.0) 196 (100) 0 (0.0)  Both 143 (20.8) 29 (25.9) 0 (0.0) 0 (0.0) 172 (100) Benefit Type --- 0.163  Prime 689 (100) 0 (0.0) 370 (85.5) 176 (89.8) 143 (83.1)  Non-Prime 0 (0.0) 112 (100) 63 (14.5) 20 (10.2) 29 (16.9) Age at Diagnosis <0.001 0.242  18–39 99 (14.4) 5 (4.5) 51 (11.8) 30 (15.3) 23 (13.4)  40–49 155 (22.5) 14 (12.5) 82 (18.9) 44 (22.5) 43 (25.0)  50–59 280 (40.6) 52 (46.4) 190 (43.9) 82 (41.8) 60 (34.9)  60–64 155 (22.5) 41 (36.6) 110 (25.4) 40 (20.4) 46 (26.7) Sex 0.398 0.681  Male 389 (56.5) 68 (60.7) 245 (56.6) 109 (55.6) 103 (59.9)  Female 300 (43.5) 44 (39.3) 188 (43.4) 87 (44.4) 69 (40.1) Race-Ethnicity 0.857 <0.001  Non-Hispanic White 411 (59.7) 64 (57.1) 257 (59.4) 122 (62.2) 96 (55.8)  Non-Hispanic Black 126 (18.3) 20 (17.9) 76 (17.6) 29 (14.8) 41 (23.8)  Non-Hispanic Other Race 62 (9.0) 9 (8.0) 39 (9.0) 14 (7.1) 18 (10.5)  Hispanic 36 (5.2) 8 (7.1) 35 (8.1) 4 (2.0) 5 (2.9)  Unknown Race or Ethnicity 54 (7.8) 11 (9.8) 26 (6.0) 27 (13.8) 12 (7.0) Marital Status 0.142 0.049  Married 561 (81.4) 86 (76.8) 344 (79.5) 155 (79.1) 148 (86.1)  Single 37 (5.4) 3 (2.7) 22 (5.1) 11 (5.6) 7 (4.1)  Other 74 (10.7) 18 (16.1) 60 (13.9) 20 (10.2) 12 (7.0)  Unknown 17 (2.5) 5 (4.5) 7 (1.6) 10 (5.1) 5 (2.9) Military Service or Sponsor Branch 0.076 <0.001  Army 262 (38.0) 29 (25.9) 166 (38.3) 71 (36.2) 54 (31.4)  Navy 157 (22.8) 36 (32.1) 101 (23.3) 38 (19.4) 54 (31.4)  Marines 27 (3.9) 7 (6.3) 19 (4.4) 2 (1.0) 13 (7.6)  Air Force 205 (29.8) 36 (32.1) 123 (28.4) 73 (37.2) 45 (26.2)  Other 33 (4.8) 4 (3.6) 22 (5.1) 10 (5.1) 5 (2.9)  Unknown 5 (0.8) 0 (0.0) 2 (0.5) 2 (1.0) 1 (0.6) Active Duty Status <0.001 0.460  Yes 150 (21.8) 3 (2.7) 79 (18.2) 41 (20.9) 22 (19.2)  No 532 (77.2) 108 (96.4) 351 (81.1) 151 (77.0) 138 (80.2)  Unknown 7 (1.0) 1 (0.9) 3 (0.7) 4 (2.0) 1 (0.6) TRICARE Service Region <0.001 <0.001  North 192 (27.9) 28 (25.0) 136 (31.4) 33 (16.8) 51 (29.7)  South 239 (34.7) 26 (23.2) 124 (28.6) 92 (46.9) 49 (28.5)  West 238 (34.5) 43 (38.4) 151 (34.9) 64 (32.7) 66 (38.4)  Overseas 20 (2.9) 15 (13.4) 22 (5.1) 7 (3.6) 6 (3.5) Comorbidities 0.893 0.417  0 501 (72.7) 81 (72.3) 320 (73.9) 139 (70.9) 123 (71.5)  1 135 (19.6) 21 (18.8) 75 (17.3) 42 (21.4) 39 (22.7)  2 or more 53 (7.8) 10 (8.9) 38 (8.8) 15 (7.7) 10 (5.8) Benefit Type p Care Source p Prime Non-Prime Direct Purchased Both N(%) N(%) N(%) N (%) N (%) Care Source 0.163 ---  Direct 370 (53.7) 63 (56.3) 433 (100) 0 (0.0) 0 (0.0)  Purchased 176 (25.5) 20 (17.9) 0 (0.0) 196 (100) 0 (0.0)  Both 143 (20.8) 29 (25.9) 0 (0.0) 0 (0.0) 172 (100) Benefit Type --- 0.163  Prime 689 (100) 0 (0.0) 370 (85.5) 176 (89.8) 143 (83.1)  Non-Prime 0 (0.0) 112 (100) 63 (14.5) 20 (10.2) 29 (16.9) Age at Diagnosis <0.001 0.242  18–39 99 (14.4) 5 (4.5) 51 (11.8) 30 (15.3) 23 (13.4)  40–49 155 (22.5) 14 (12.5) 82 (18.9) 44 (22.5) 43 (25.0)  50–59 280 (40.6) 52 (46.4) 190 (43.9) 82 (41.8) 60 (34.9)  60–64 155 (22.5) 41 (36.6) 110 (25.4) 40 (20.4) 46 (26.7) Sex 0.398 0.681  Male 389 (56.5) 68 (60.7) 245 (56.6) 109 (55.6) 103 (59.9)  Female 300 (43.5) 44 (39.3) 188 (43.4) 87 (44.4) 69 (40.1) Race-Ethnicity 0.857 <0.001  Non-Hispanic White 411 (59.7) 64 (57.1) 257 (59.4) 122 (62.2) 96 (55.8)  Non-Hispanic Black 126 (18.3) 20 (17.9) 76 (17.6) 29 (14.8) 41 (23.8)  Non-Hispanic Other Race 62 (9.0) 9 (8.0) 39 (9.0) 14 (7.1) 18 (10.5)  Hispanic 36 (5.2) 8 (7.1) 35 (8.1) 4 (2.0) 5 (2.9)  Unknown Race or Ethnicity 54 (7.8) 11 (9.8) 26 (6.0) 27 (13.8) 12 (7.0) Marital Status 0.142 0.049  Married 561 (81.4) 86 (76.8) 344 (79.5) 155 (79.1) 148 (86.1)  Single 37 (5.4) 3 (2.7) 22 (5.1) 11 (5.6) 7 (4.1)  Other 74 (10.7) 18 (16.1) 60 (13.9) 20 (10.2) 12 (7.0)  Unknown 17 (2.5) 5 (4.5) 7 (1.6) 10 (5.1) 5 (2.9) Military Service or Sponsor Branch 0.076 <0.001  Army 262 (38.0) 29 (25.9) 166 (38.3) 71 (36.2) 54 (31.4)  Navy 157 (22.8) 36 (32.1) 101 (23.3) 38 (19.4) 54 (31.4)  Marines 27 (3.9) 7 (6.3) 19 (4.4) 2 (1.0) 13 (7.6)  Air Force 205 (29.8) 36 (32.1) 123 (28.4) 73 (37.2) 45 (26.2)  Other 33 (4.8) 4 (3.6) 22 (5.1) 10 (5.1) 5 (2.9)  Unknown 5 (0.8) 0 (0.0) 2 (0.5) 2 (1.0) 1 (0.6) Active Duty Status <0.001 0.460  Yes 150 (21.8) 3 (2.7) 79 (18.2) 41 (20.9) 22 (19.2)  No 532 (77.2) 108 (96.4) 351 (81.1) 151 (77.0) 138 (80.2)  Unknown 7 (1.0) 1 (0.9) 3 (0.7) 4 (2.0) 1 (0.6) TRICARE Service Region <0.001 <0.001  North 192 (27.9) 28 (25.0) 136 (31.4) 33 (16.8) 51 (29.7)  South 239 (34.7) 26 (23.2) 124 (28.6) 92 (46.9) 49 (28.5)  West 238 (34.5) 43 (38.4) 151 (34.9) 64 (32.7) 66 (38.4)  Overseas 20 (2.9) 15 (13.4) 22 (5.1) 7 (3.6) 6 (3.5) Comorbidities 0.893 0.417  0 501 (72.7) 81 (72.3) 320 (73.9) 139 (70.9) 123 (71.5)  1 135 (19.6) 21 (18.8) 75 (17.3) 42 (21.4) 39 (22.7)  2 or more 53 (7.8) 10 (8.9) 38 (8.8) 15 (7.7) 10 (5.8) TABLE III. Cancer Diagnosis Information by Benefit Type and Care Source for Patients Diagnosed with Colon Cancer in the U.S. Military Health System, 2003–2007 Benefit Type p Care Source p Prime Non-Prime Direct Purchased Both N(%) N(%) N(%) N (%) N (%) Year of diagnosis 0.529 0.856  2003 145 (21.0) 28 (25.0) 96 (22.2) 45 (23.0) 32 (18.6)  2004 145 (21.0) 19 (17.0) 91 (21.0) 33 (16.8) 40 (23.3)  2005 158 (22.9) 21 (18.8) 93 (21.5) 48 (24.5) 38 (22.1)  2006 111 (16.1) 18 (16.1) 72 (16.6) 31 (15.8) 26 (15.1)  2007 130 (18.9) 26 (23.2) 81 (18.7) 39 (19.9) 36 (20.9) AJCC stage at diagnosis 0.328 <0.001  I 153 (22.2) 22 (19.6) 137 (31.6) 24 (12.2) 14 (8.1)  II 139 (20.2) 19 (17.0) 91 (21.0) 36 (18.4) 31 (18.0)  III 223 (32.4) 34 (30.4) 127 (29.3) 55 (28.1) 75 (43.6)  IV 153 (22.2) 30 (26.8) 63 (14.6) 69 (35.2) 51 (29.7)  Unknown 21 (3.1) 7 (6.3) 15 (3.5) 12 (6.1) 1 (0.6) Tumor location 0.287 0.039  Right-sided 243 (35.3) 47 (42.0) 169 (39.0) 57 (29.1) 64 (37.2)  Transverse 48 (7.0) 8 (7.1) 28 (6.5) 16 (8.2) 12 (7.0)  Left-sided 287 (41.7) 36 (32.1) 179 (41.3) 77 (39.3) 67 (39.0)  Overlapping or unknown 111 (16.1) 21 (18.8) 57 (13.2) 46 (23.5) 29 (16.9) Tumor grade 0.691 <0.001  I- Well differentiated 111 (16.1) 22 (19.6) 84 (19.4) 26 (13.3) 23 (13.4)  II- Moderately differentiated 423 (61.4) 64 (57.1) 263 (60.7) 110 (56.1) 114 (66.3)  III- Poorly differentiated 99 (14.4) 19 (17.0) 62 (14.3) 26 (13.3) 30 (17.4)  IV- Undifferentiated 4 (0.6) 1 (0.9) 0 (0.0) 3 (1.5) 2 (1.2)  Unknown 52 (7.6) 6 (5.4) 24 (5.5) 31 (15.8) 3 (1.7) Follow-up time from diagnosis 0.185 0.091  Median (IQR) years 1.8 (1.2, 2.5) 1.7 (1.1, 2.3) 1.8 (1.2, 2.5) 1.6 (1.0, 2.5) 1.7 (1.3, 2.5) Benefit Type p Care Source p Prime Non-Prime Direct Purchased Both N(%) N(%) N(%) N (%) N (%) Year of diagnosis 0.529 0.856  2003 145 (21.0) 28 (25.0) 96 (22.2) 45 (23.0) 32 (18.6)  2004 145 (21.0) 19 (17.0) 91 (21.0) 33 (16.8) 40 (23.3)  2005 158 (22.9) 21 (18.8) 93 (21.5) 48 (24.5) 38 (22.1)  2006 111 (16.1) 18 (16.1) 72 (16.6) 31 (15.8) 26 (15.1)  2007 130 (18.9) 26 (23.2) 81 (18.7) 39 (19.9) 36 (20.9) AJCC stage at diagnosis 0.328 <0.001  I 153 (22.2) 22 (19.6) 137 (31.6) 24 (12.2) 14 (8.1)  II 139 (20.2) 19 (17.0) 91 (21.0) 36 (18.4) 31 (18.0)  III 223 (32.4) 34 (30.4) 127 (29.3) 55 (28.1) 75 (43.6)  IV 153 (22.2) 30 (26.8) 63 (14.6) 69 (35.2) 51 (29.7)  Unknown 21 (3.1) 7 (6.3) 15 (3.5) 12 (6.1) 1 (0.6) Tumor location 0.287 0.039  Right-sided 243 (35.3) 47 (42.0) 169 (39.0) 57 (29.1) 64 (37.2)  Transverse 48 (7.0) 8 (7.1) 28 (6.5) 16 (8.2) 12 (7.0)  Left-sided 287 (41.7) 36 (32.1) 179 (41.3) 77 (39.3) 67 (39.0)  Overlapping or unknown 111 (16.1) 21 (18.8) 57 (13.2) 46 (23.5) 29 (16.9) Tumor grade 0.691 <0.001  I- Well differentiated 111 (16.1) 22 (19.6) 84 (19.4) 26 (13.3) 23 (13.4)  II- Moderately differentiated 423 (61.4) 64 (57.1) 263 (60.7) 110 (56.1) 114 (66.3)  III- Poorly differentiated 99 (14.4) 19 (17.0) 62 (14.3) 26 (13.3) 30 (17.4)  IV- Undifferentiated 4 (0.6) 1 (0.9) 0 (0.0) 3 (1.5) 2 (1.2)  Unknown 52 (7.6) 6 (5.4) 24 (5.5) 31 (15.8) 3 (1.7) Follow-up time from diagnosis 0.185 0.091  Median (IQR) years 1.8 (1.2, 2.5) 1.7 (1.1, 2.3) 1.8 (1.2, 2.5) 1.6 (1.0, 2.5) 1.7 (1.3, 2.5) TABLE III. Cancer Diagnosis Information by Benefit Type and Care Source for Patients Diagnosed with Colon Cancer in the U.S. Military Health System, 2003–2007 Benefit Type p Care Source p Prime Non-Prime Direct Purchased Both N(%) N(%) N(%) N (%) N (%) Year of diagnosis 0.529 0.856  2003 145 (21.0) 28 (25.0) 96 (22.2) 45 (23.0) 32 (18.6)  2004 145 (21.0) 19 (17.0) 91 (21.0) 33 (16.8) 40 (23.3)  2005 158 (22.9) 21 (18.8) 93 (21.5) 48 (24.5) 38 (22.1)  2006 111 (16.1) 18 (16.1) 72 (16.6) 31 (15.8) 26 (15.1)  2007 130 (18.9) 26 (23.2) 81 (18.7) 39 (19.9) 36 (20.9) AJCC stage at diagnosis 0.328 <0.001  I 153 (22.2) 22 (19.6) 137 (31.6) 24 (12.2) 14 (8.1)  II 139 (20.2) 19 (17.0) 91 (21.0) 36 (18.4) 31 (18.0)  III 223 (32.4) 34 (30.4) 127 (29.3) 55 (28.1) 75 (43.6)  IV 153 (22.2) 30 (26.8) 63 (14.6) 69 (35.2) 51 (29.7)  Unknown 21 (3.1) 7 (6.3) 15 (3.5) 12 (6.1) 1 (0.6) Tumor location 0.287 0.039  Right-sided 243 (35.3) 47 (42.0) 169 (39.0) 57 (29.1) 64 (37.2)  Transverse 48 (7.0) 8 (7.1) 28 (6.5) 16 (8.2) 12 (7.0)  Left-sided 287 (41.7) 36 (32.1) 179 (41.3) 77 (39.3) 67 (39.0)  Overlapping or unknown 111 (16.1) 21 (18.8) 57 (13.2) 46 (23.5) 29 (16.9) Tumor grade 0.691 <0.001  I- Well differentiated 111 (16.1) 22 (19.6) 84 (19.4) 26 (13.3) 23 (13.4)  II- Moderately differentiated 423 (61.4) 64 (57.1) 263 (60.7) 110 (56.1) 114 (66.3)  III- Poorly differentiated 99 (14.4) 19 (17.0) 62 (14.3) 26 (13.3) 30 (17.4)  IV- Undifferentiated 4 (0.6) 1 (0.9) 0 (0.0) 3 (1.5) 2 (1.2)  Unknown 52 (7.6) 6 (5.4) 24 (5.5) 31 (15.8) 3 (1.7) Follow-up time from diagnosis 0.185 0.091  Median (IQR) years 1.8 (1.2, 2.5) 1.7 (1.1, 2.3) 1.8 (1.2, 2.5) 1.6 (1.0, 2.5) 1.7 (1.3, 2.5) Benefit Type p Care Source p Prime Non-Prime Direct Purchased Both N(%) N(%) N(%) N (%) N (%) Year of diagnosis 0.529 0.856  2003 145 (21.0) 28 (25.0) 96 (22.2) 45 (23.0) 32 (18.6)  2004 145 (21.0) 19 (17.0) 91 (21.0) 33 (16.8) 40 (23.3)  2005 158 (22.9) 21 (18.8) 93 (21.5) 48 (24.5) 38 (22.1)  2006 111 (16.1) 18 (16.1) 72 (16.6) 31 (15.8) 26 (15.1)  2007 130 (18.9) 26 (23.2) 81 (18.7) 39 (19.9) 36 (20.9) AJCC stage at diagnosis 0.328 <0.001  I 153 (22.2) 22 (19.6) 137 (31.6) 24 (12.2) 14 (8.1)  II 139 (20.2) 19 (17.0) 91 (21.0) 36 (18.4) 31 (18.0)  III 223 (32.4) 34 (30.4) 127 (29.3) 55 (28.1) 75 (43.6)  IV 153 (22.2) 30 (26.8) 63 (14.6) 69 (35.2) 51 (29.7)  Unknown 21 (3.1) 7 (6.3) 15 (3.5) 12 (6.1) 1 (0.6) Tumor location 0.287 0.039  Right-sided 243 (35.3) 47 (42.0) 169 (39.0) 57 (29.1) 64 (37.2)  Transverse 48 (7.0) 8 (7.1) 28 (6.5) 16 (8.2) 12 (7.0)  Left-sided 287 (41.7) 36 (32.1) 179 (41.3) 77 (39.3) 67 (39.0)  Overlapping or unknown 111 (16.1) 21 (18.8) 57 (13.2) 46 (23.5) 29 (16.9) Tumor grade 0.691 <0.001  I- Well differentiated 111 (16.1) 22 (19.6) 84 (19.4) 26 (13.3) 23 (13.4)  II- Moderately differentiated 423 (61.4) 64 (57.1) 263 (60.7) 110 (56.1) 114 (66.3)  III- Poorly differentiated 99 (14.4) 19 (17.0) 62 (14.3) 26 (13.3) 30 (17.4)  IV- Undifferentiated 4 (0.6) 1 (0.9) 0 (0.0) 3 (1.5) 2 (1.2)  Unknown 52 (7.6) 6 (5.4) 24 (5.5) 31 (15.8) 3 (1.7) Follow-up time from diagnosis 0.185 0.091  Median (IQR) years 1.8 (1.2, 2.5) 1.7 (1.1, 2.3) 1.8 (1.2, 2.5) 1.6 (1.0, 2.5) 1.7 (1.3, 2.5) The model-estimated median cost for colon cancer treatments was $60,321 (Standard Error $3,280) per patient over a median follow-up period of 1.7 (interquartile range 1.2 to 2.5) years (Table IV). The model-estimated median costs for colon cancer treatment were similar between benefit types (Table IV) with an overall relative median cost difference of -4.9% for non-Prime compared to Prime over similar follow-up time (Fig. 1A). The model-estimated median colon cancer treatment costs were significantly different between care sources (Table IV). In total costs, direct care had the lowest median cost per patient and costs for purchased care and both care sources were 211% and 141% higher than direct care, respectively, over follow-up (Fig. 1B). TABLE IV. Quantile Regression Estimated Median Costs for Colon Cancer Treatment in the U.S. Military Health System Median Estimated Lifetime Costs (Standard Error) Total Benefit Type Care Source Prime Non-Prime Direct Purchased Both Total $60,321 $61,756 $58,748 $34,145 $106,395* $82,439* (3280) (6720) (8159) (4326) (10,559) (13,330) Stage  I/II $25,369 $24,607 $25,672 $22,568 $21,296 $42,872 (1434) (1478) (4331) (1760) (5613) (12,708)  III/IV $97,503 $104,534 $91,976 $66,986 $256,314* $183,306* (5602) (6643) (20,074) (7950) (24,570) (26,636) Treatment  Surgery $19,944 $19,742 $19,557 $20,802 $10,449* --- (511) (663) (2466) (882) (2450)  Surgery and Chemotherapy/ $100,404 $104,633 $87,738 $70,440 $245,812* $144,668*  Radiation (5933) (7444) (17,594) (6814) (23,687) (17,580) Median Estimated Lifetime Costs (Standard Error) Total Benefit Type Care Source Prime Non-Prime Direct Purchased Both Total $60,321 $61,756 $58,748 $34,145 $106,395* $82,439* (3280) (6720) (8159) (4326) (10,559) (13,330) Stage  I/II $25,369 $24,607 $25,672 $22,568 $21,296 $42,872 (1434) (1478) (4331) (1760) (5613) (12,708)  III/IV $97,503 $104,534 $91,976 $66,986 $256,314* $183,306* (5602) (6643) (20,074) (7950) (24,570) (26,636) Treatment  Surgery $19,944 $19,742 $19,557 $20,802 $10,449* --- (511) (663) (2466) (882) (2450)  Surgery and Chemotherapy/ $100,404 $104,633 $87,738 $70,440 $245,812* $144,668*  Radiation (5933) (7444) (17,594) (6814) (23,687) (17,580) Values given as 2008 USD. Costs for patients receiving chemotherapy or radiation only (n = 71) could not be estimated due to small sample sizes in benefit type and care source categories. *p < 0.05 compared to direct care. TABLE IV. Quantile Regression Estimated Median Costs for Colon Cancer Treatment in the U.S. Military Health System Median Estimated Lifetime Costs (Standard Error) Total Benefit Type Care Source Prime Non-Prime Direct Purchased Both Total $60,321 $61,756 $58,748 $34,145 $106,395* $82,439* (3280) (6720) (8159) (4326) (10,559) (13,330) Stage  I/II $25,369 $24,607 $25,672 $22,568 $21,296 $42,872 (1434) (1478) (4331) (1760) (5613) (12,708)  III/IV $97,503 $104,534 $91,976 $66,986 $256,314* $183,306* (5602) (6643) (20,074) (7950) (24,570) (26,636) Treatment  Surgery $19,944 $19,742 $19,557 $20,802 $10,449* --- (511) (663) (2466) (882) (2450)  Surgery and Chemotherapy/ $100,404 $104,633 $87,738 $70,440 $245,812* $144,668*  Radiation (5933) (7444) (17,594) (6814) (23,687) (17,580) Median Estimated Lifetime Costs (Standard Error) Total Benefit Type Care Source Prime Non-Prime Direct Purchased Both Total $60,321 $61,756 $58,748 $34,145 $106,395* $82,439* (3280) (6720) (8159) (4326) (10,559) (13,330) Stage  I/II $25,369 $24,607 $25,672 $22,568 $21,296 $42,872 (1434) (1478) (4331) (1760) (5613) (12,708)  III/IV $97,503 $104,534 $91,976 $66,986 $256,314* $183,306* (5602) (6643) (20,074) (7950) (24,570) (26,636) Treatment  Surgery $19,944 $19,742 $19,557 $20,802 $10,449* --- (511) (663) (2466) (882) (2450)  Surgery and Chemotherapy/ $100,404 $104,633 $87,738 $70,440 $245,812* $144,668*  Radiation (5933) (7444) (17,594) (6814) (23,687) (17,580) Values given as 2008 USD. Costs for patients receiving chemotherapy or radiation only (n = 71) could not be estimated due to small sample sizes in benefit type and care source categories. *p < 0.05 compared to direct care. FIGURE 1. View largeDownload slide Relative Differences# in Model-estimated^ Median Cost for Colon Cancer Care by Benefit Type (A) and Care Source (B) in the U.S. Military Health System, 2003–2007. #Relative costs differences shown are compared to Prime (A) and Direct Care (B). ^Models adjusted for age at diagnosis, sex, race-ethnicity, military service or sponsor branch, active duty status, marital status, diagnosis year, cancer stage, tumor grade, tumor location, type of treatments received, TRICARE service region at diagnosis, comorbidities, care source (A), and benefit type (B). *p < 0.05 compared to Prime (A) or Direct Care (B). FIGURE 1. View largeDownload slide Relative Differences# in Model-estimated^ Median Cost for Colon Cancer Care by Benefit Type (A) and Care Source (B) in the U.S. Military Health System, 2003–2007. #Relative costs differences shown are compared to Prime (A) and Direct Care (B). ^Models adjusted for age at diagnosis, sex, race-ethnicity, military service or sponsor branch, active duty status, marital status, diagnosis year, cancer stage, tumor grade, tumor location, type of treatments received, TRICARE service region at diagnosis, comorbidities, care source (A), and benefit type (B). *p < 0.05 compared to Prime (A) or Direct Care (B). The median per capita costs were $25,369 ($1,434) for patients with early-stage tumors (stages I and II, n = 333) during 1.9 (IQR 1.3 to 2.6) years follow-up. Median costs were $97,503 ($5,602) for patients with late-stage tumors (stages III and IV, n = 440) during 1.6 (IQR 1.1 to 2.4) years follow-up (Table IV). In stratified analyses by tumor stage, there were no significant differences in cost to the MHS between benefit types for either stage group or between care sources among patients with early-stage tumors (Table IV). Among patients with late-stage tumors, purchased care and both care sources had 282% and 173% higher costs, respectively, compared to direct care (Fig. 1B). When late-stage tumors were further evaluated by stage, the costs for purchased care were 201% higher for stage III and 525% higher for stage IV compared to direct care, respectively (data not shown). Within each stage group, follow-up time was similar between benefit types and care sources. By treatment type, patients who had surgical treatment only (n = 267) accrued median costs of $19,944 ($511) over a median of 1.8 (IQR 1.2 to 2.6) years, patients who had radiation or chemotherapy only (n = 71) accrued median costs of $54,793 (11,740) over 1.2 (IQR 0.8 to 2.2) years, and patients who had surgery and radiation or chemotherapy (n = 463) accrued median costs of $100,404 ($5,933) over 1.8 (IQR 1.2 to 2.5) years (Table IV). Treatment costs were similar between benefit types and varied by care source (Table IV). Costs for patients receiving chemotherapy/radiation only by benefit type and care source could not be estimated due to small sample sizes in respective categories. For patients who received surgery only, the relative cost was 49.8% lower for purchased care compared to direct care over a similar follow-up period (Fig. 1B). Conversely, for patients who received surgery and radiation or chemotherapy, purchased care and both care source costs were 249% and 105% higher than direct care (Fig. 1B). DISCUSSION In the US Military Health System, the cost to the MHS for colon cancer treatment was similar between benefit types but varied by care source. The similar costs between benefit types may be due to both universal access to care and similar cost-sharing arrangements between the benefit types.10,11 Regarding care source, we observed significantly lower median costs per patient in direct care compared to purchased care and both care sources. This provides some evidence that in a closed market system (i.e., DHA controls flow of resources), the costs per patient may be lower than in an open market system (purchased care). This is consistent with our previous findings in breast cancer.14 Organizational and operational features of the MHS may contribute to some of the observed differences in median cost by care source.10,14 The variation in cost between and within care sources may also imply the possibility of over/under billing between facilities or the effects of other unmeasured institutional factors such as facility size, academic affiliation, and service availability. However, the large relative cost differences observed herein also suggests that factors such as treatment and profit incentives or care capabilities may contribute to cost variation. In the MHS, there is incentive to keep costs low while ensuring quality patient care. The DoD purchasing requirements regulate whether a device or medication can be stocked at MTFs based on compliance with the Trade Agreements Act (TAA) of 197932 and specify that low-cost alternatives should be used when available.33 While both MTFs and civilian facilities are likely to utilize generic medical devices or medications over name-brands, reimbursement and profit incentives may influence treatment selection in civilian facilities34–37 which may increase cancer treatment costs in purchased care. In our data, we found 3-fold higher costs per patient for chemotherapy or radiation treatment in purchased care relative to direct care. We found similar results in patients with breast cancer14 despite including both genders and different treatment modalities in the current study. This reveals a potential means to reduce cancer treatment costs in the larger healthcare landscape by disincentivizing use of higher-cost procedures or agents without demonstrated cost-efficiency or cost-effectiveness. Further research comparing care sources in the use of specific treatment agents with more patients will help add understanding to our results. Smaller military hospitals and clinics in the MHS may not have the resources to provide recommended chemotherapy treatment or radiation as second-line therapy or palliative care for colon cancer.18 Patients requiring these treatments or those who live outside the MTF catchment area are therefore referred to the private sector for care. The broad capability to deliver specialty services and the demand for these services in purchased care may result in different billing and fee schedules that reflect the professional staffing and operating costs required to maintain a specialty center.38,39 It is also possible that patients with referrals for purchased care may have received a greater volume of chemotherapy or received more combination therapy (e.g., chemotherapy using multiple agents simultaneously) or second-line radiation therapy to treat aggressive or late-stage disease18 and thus had higher associated costs. This was demonstrated in our data such that patients classified as using direct care had fewer encounters for surgery compared to purchased care and fewer encounters for chemotherapy compared to purchased care and both care sources (data not shown). The higher likelihood of referral to purchased care for second-line or palliative treatment and the higher volume of treatment in purchased care may inflate overall median costs for purchased care compared to direct care. However, we adjusted for tumor and treatment variables in our analysis to minimize this. In this study, we compared costs between insurance benefit types and care sources among adults aged 18–64 years in an equal-access healthcare system, adding to previous economic evaluations of colon cancer care.3,22,40–45 Given the potential implications of our research, there are several limitations to be addressed. First, although the cost information from direct and purchased care was extracted from the claims data and consolidated using deliberate processes, there are inherent differences in the way cost is recorded between the care sources and thus the costs may not be completely comparable. Nevertheless, this might not account for the large differences in cost between care sources. Second, benefit type was determined in the 3 months prior to and after the cancer diagnosis date. It is possible that benefit eligibility and plan election changed outside this window, potentially introducing a misclassification of Prime or non-Prime status. Third, linked data were available for 2003 to 2008 for assessing treatment and associated costs. Thus, the estimated lifetime cost to the MHS per patient for colon cancer treatment could be higher when considering costs occurring beyond the time period of the data. Also, given the years of available data, our findings may be limited in their implications for today’s dynamic healthcare landscape. Nevertheless, the relative cost differences observed between direct and purchased care may provide insight for cost studies and provision of care in the current market. Next, as with other administrative data, errors are possible in coding and completeness of the cost information. Lastly, the cancer registry data only included patients who ever received care at an MTF, thus information on patients receiving medical care exclusively in the private sector were not included. Likewise, the claims data represent patients receiving care in the MHS. Therefore, the findings from this study are specific to the MHS and may not be generalizable to other health systems or patient populations. CONCLUSION The costs to the MHS for colon cancer care were similar by insurance benefit type but were lower for patients receiving direct care at MTFs compared to patients receiving purchased care in the private sector or patients using both care sources. Cost variation between care sources may be due to differences in treatment incentives or capabilities. Further research on direct administration of cancer care compared to purchased services is needed to determine whether and to what extent cancer care costs to a health system may be reduced. Additional investigations that evaluate the value of care, i.e., the association between cost and clinical outcomes, are also needed to understand the importance of differences in cost for cancer care both within the MHS and in other health systems. Together, this research can inform development of cost reduction strategies while maintaining quality care. ACKNOWLEDGMENTS The authors thank the following institutes for their contributions to the original data linkage project: ICF Macro, Kennell and Associates, Inc., the Defense Health Agency, the Joint Pathology Center and former Armed Forces Institute of Pathology, and the National Cancer Institute. FUNDING This project was supported by the Murtha Cancer Center Research Program of the Uniformed Services University of the Health Sciences and Walter Reed National Military Medical Center under the auspices of the Henry M. Jackson Foundation for the Advancement of Military Medicine. PREVIOUS PRESENTATION The contents of this manuscript have been presented as an oral presentation at the 2018 Military Health System Research Symposium, hosted by the United States Army Medical Research and Materiel Command at the Gaylord Palms Convention Center in Kissimmee, Florida on August 22, 2018. REFERENCES 1 Siegel RL , Miller KD , Jemal A : Cancer statistics, 2019 . CA: Cancer J Clin 2019 ; 69 ( 1 ): 7 – 34 . Google Scholar Crossref Search ADS PubMed 2 Johnson NB , Hayes LD , Brown K , et al. : CDC national health report: leading causes of morbidity and mortality and associated behavioral risk and protective factors – United States, 2005–2013 . 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TI - Costs for Colon Cancer Treatment Comparing Benefit Types and Care Sources in the US Military Health System
JF - Military Medicine
DO - 10.1093/milmed/usz065
DA - 2019-04-03
UR - https://www.deepdyve.com/lp/oxford-university-press/costs-for-colon-cancer-treatment-comparing-benefit-types-and-care-5SdEdlZS3a
SP - 1
VL - Advance Article
IS - 
DP - DeepDyve
ER -