Costs for Breast Cancer Care in the Military Health System: An Analysis by Benefit Type and Care Source

Costs for Breast Cancer Care in the Military Health System: An Analysis by Benefit Type and Care... Abstract Introduction Breast cancer care imposes a significant financial burden to U.S. healthcare systems. Health services factors, such as insurance benefit type and care source, may impact costs to the health system. Beneficiaries in the U.S. Military Health System (MHS) have universal healthcare coverage and access to a network of military facilities (direct care) and private practices (purchased care). This study aims to quantify and compare breast cancer care costs to the MHS by insurance benefit type and care source. Materials and Methods We conducted a retrospective analysis of data linked between the MHS data repository administrative claims and central cancer registry databases. The institutional review boards of the Walter Reed National Military Medical Center, the Defense Health Agency, and the National Institutes of Health Office of Human Subjects Research reviewed and approved the data linkage. We used the linked data to identify records for women aged 40–64 yr who were diagnosed with breast cancer between 2003 and 2007 and to extract information on insurance benefit type, care source, and cost to the MHS for breast cancer treatment. We estimated per capita costs for breast cancer care by benefit type and care source in 2008 USD using generalized linear models, adjusted for demographic, pathologic, and treatment characteristics. Results The average per capita (n = 2,666) total cost for breast cancer care was $66,300 [standard error (SE) $9,200] over 3.31 (1.48) years of follow-up. Total costs were similar between benefit types, but varied by care source. The average per capita cost was $34,500 ($3,000) for direct care (n = 924), $96,800 ($4,800) for purchased care (n = 622), and $60,700 ($3,900) for both care sources (n = 1,120), respectively. Care source differences remained by tumor stage and for chemotherapy, radiation, and hormone therapy treatment types. Conclusions Per capita costs to the MHS for breast cancer care were similar by benefit type and lower for direct care compared with purchased care. Further research is needed in breast and other tumor sites to determine patterns and determinants of cancer care costs between benefit types and care sources within the MHS. Introduction As the U.S. population ages, the number of cancer diagnoses and survivors is expected to increase.1 With this increase, the costs for cancer care are also expected to rise.2,3 Direct costs of cancer care in the USA were approximately $125 billion in 2010, with 13% of costs attributable to breast cancer, the largest contribution of any single cancer site.3 Evaluating breast cancer costs in a variety of patient populations and health care settings has potential to inform practice and policy aimed at reducing breast cancer care costs. Costs associated with cancer-specific diagnostic and treatment services have been estimated from public and private insurer’s administrative claims data.4,5 These cost estimates generally reflect the amount the insurer pays to service providers as a percentage of allowable costs. The amount paid may vary by benefit plan, as plans can offer different cost-sharing arrangements, service coverage, and financial incentives for selecting certain providers over others.6 Care source can also factor into costs, as institutions may have different resource allocation methods or fee and billing schedules depending on organizational structure and the services provided within that facility.6 Currently, there is limited research examining cancer costs between benefit plans and care sources in the USA.2 Breast cancer diagnosis and treatment costs have been reported in U.S. Medicare and private insurance patient populations.7–16 These evaluations have demonstrated substantial cost variability and the need for further examination of breast cancer care costs in multiple health care settings. To the authors’ knowledge, breast cancer care costs have not been evaluated by insurance benefit type and care source within the U.S. Military Health System (MHS). The MHS provides access to medical care to nearly 10 million active-duty personnel, national guards, reservists, retirees, and their families through a network of military hospitals and clinics [military treatment facilities (MTFs)] and approved civilian providers.17–19 Medical insurance is provided for beneficiaries and managed through TRICARE. The four main benefit plans include Prime, Extra, Standard, and TRICARE for Life.17,18 Beneficiaries may pay enrollment fees, annual deductibles, and co-payments based on their sponsor status (active-duty, retired, etc.), military rank, and the plan selected. Active-duty service members are automatically enrolled in Prime and their family members are eligible to enroll at no cost. Other beneficiaries can elect to enroll in Prime, subject to enrollment fees and co-payments for authorized providers. Prime has no annual deductible unless enrollees use the point-of-service option, which is when routine or urgent care is received outside the MHS network without a referral. Eligible beneficiaries who have not enrolled in Prime are automatically entitled to Standard and Extra. These plans have no enrollment fees and cover services rendered by authorized providers after co-payments and deductibles are met. TRICARE for Life serves as a secondary payer to Medicare for those beneficiaries who are eligible and enrolled in Medicare Part A and Part B. Beneficiaries in the MHS can receive care in MTFs or in civilian facilities. MTFs receive funding from the Department of Defense (DoD) in order to provide medical care directly to beneficiaries and maintain administrative functions.18 Costs for medical care received in the MTFs (direct care) are based on how individual MTF resources are allocated down to the clinic, patient, and encounter level. TRICARE manages payments for services received in civilian facilities (purchased care) after taking into account payments by other insurers (e.g., Medicare) and cost-sharing by the patient.17,18 The DoD fee schedule20 determines the maximum amount TRICARE pays for purchased services. The purpose of this study was to quantify and compare the breast cancer care costs to the MHS for the different benefit plans and care sources within the MHS. We further evaluated costs by treatment type and tumor stage. Quantifying breast cancer care costs and determining whether these costs are different by benefit type and care source in a universal coverage system will provide information for developing strategies to optimize and reduce cost. Methods Population and Data Sources This study is a retrospective analysis of linked data from the DoD Central Cancer Registry (CCR) and MHS Data Repository (MDR) medical claims database. Information on the database structures have been published previously.21,22 We identified breast cancer cases in the registry using International Classification of Diseases – Oncology, Third Edition (ICD-O-3) topography codes C50.0-C50.6 and C50.8-C50.9. Women aged 40–64 yr with histologically confirmed primary breast cancer who were ever diagnosed or treated at MTFs between 2003 and 2007 (n = 2,982) were eligible. Age 40 yr was selected to reflect the starting age for annual screening mammography per TRICARE’s payment policy.17 We excluded women diagnosed at age 65 or older since TRICARE is a secondary payer to Medicare and claims data may be incomplete for these individuals. The institutional review boards of the Walter Reed National Military Medical Center, the Defense Health Agency, and the National Institutes of Health Office of Human Subjects Research review and approved the data linkage project. Study Variables We collected patient demographic, comorbidity, and cancer information from the linked data. CCR variables included age at diagnosis, race, ethnicity, marital status at diagnosis, active-duty status at diagnosis, and military service or sponsor branch. We identified comorbidities in MDR records using ICD-9 diagnostic codes for conditions included in the Charlson Comorbidity Index.23 We extracted cancer diagnosis date, tumor stage (AJCC 6th edition), tumor grade, and estrogen (ER) and progesterone (PR) hormone receptor status from the CCR data. The MDR records contained information on insurance benefit status and we supplemented with CCR data if values were missing. Benefit type was determined from eligibility and enrollment in the TRICARE plans at any point in the three months prior to and following breast cancer diagnosis. If the eligible beneficiary was not electively enrolled in Prime during this period, the benefit type was designated as non-Prime. The non-Prime plans represented mostly Standard and Extra, which we combined due to automatic enrollment in these plan types for eligible beneficiaries and similar cost-sharing arrangements. Women with unknown benefit type (n = 56) and women with other health insurance in addition to TRICARE (n = 258) were excluded due to the possibility of missing or incomplete data. Care source was determined from MDR administrative claims data for breast cancer treatment beginning at the diagnosis date through the end of follow-up, death, or censoring. We defined care source as direct, purchased, or both using a two-step process. (1) For each treatment type (mastectomy, breast conserving surgery, reconstructive surgery, chemotherapy, radiation therapy, hormone therapy), unique claim dates were extracted and counted as patient visits. Based on frequency distributions, if ≥90% of visits were for care delivered in MTFs, then patients were classified as using direct care for that treatment type. Similarly, if ≥90% of visits were in civilian facilities, then patients were classified as using purchased care for that treatment type. Otherwise, treatment care source was classified as both. (2) Overall care source was determined by the proportion of treatment types received as direct or purchased care. If ≥80% of treatment types were received as direct care, then the care source was classified as direct. If ≥80% of treatment types were received as purchased care, then the care source was classified as purchased. Otherwise, overall care source was classified as both. Cases who did not have cancer treatment documented in MDR records (n = 29) were classified based on where they received non-cancer medical care in the three months prior to and three months following diagnosis using similar cut-points (e.g., ≥80% visits at MTFs for direct care). Cases who did not have MDR cancer treatment records and who had missing information on where non-cancer medical care was sought were excluded (n = 2). Study Outcome Costs for incident breast cancer care were determined from the MDR administrative claims database in the time period between the diagnosis date and date of death, censor, or study end on December 31, 2008. Relevant breast cancer ICD-9 diagnostic and treatment procedures codes, Current Procedural Terminology (CPT) codes, and Healthcare Common Procedure Coding System (HCPCS) codes were used to identify related claims and episodes of care for surgery, chemotherapy, radiation therapy, and hormone therapy (Table I).7,13,24–26 Direct care costs extracted from the MDR claims represented episodes of care and included institutional, professional (i.e., clinician salary), and ancillary services (e.g., laboratory, anesthesia, radiology, pharmacy). Purchased care costs extracted from the MDR claims represented claim-level data for each billed procedure (including radiation doses and chemotherapy drugs) and did not include professional or ancillary services. In order to make direct and purchased costs more comparable, the cost for clinician salary and ancillary services (except radiology and pharmacy when indicated) was subtracted from the direct costs. The costs to the MTF at the encounter level for direct care and amount paid by TRICARE for purchased care 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 (CPI) for medical care in the year of diagnosis.27 For analyses, the cost for each treatment type was capped at the 99th percentile in order to minimize the influence of extreme values.9,28–30 Then, costs for individual treatment types were summed to produce total breast cancer care costs per patient. Table I. Medical Codes Used to Identify Breast Cancer Treatment Claims in the Military Health System Linked Data Treatment Type  Coding System  Codes  Mastectomy  ICD-9 Procedure  85.41–85.48, 85.34, 85.36  CPT-4  19180, 19182, 19200, 19220, 19240, 19303, 19304, 19305, 19306, 19307  Breast conserving surgery  ICD-9 Procedure  85.20–85.25  CPT-4  19160, 19162, 19301, 19302, 19120, 19125, 19126  Reconstructive surgery  ICD-9 Procedure  857, 85.33, 85.35, 85.53, 85.54, 85.84, 85.85, 85.87, 85.93, 85.95, 85.70–85.76, 85.79  CPT-4  19340, 19342, 19350, 19357, 19361, 19364, 19366, 19367, 19368, 19369, 19380  HCPCS  L8000, L8001, L8010, L8015, L8020, L8030, L8035, L8039, L8600, C1789, S2066, S2068  Chemotherapy  ICD-9 Diagnosis  V58.1, V58.11, V66.2, V67.2  ICD-9 Procedure  00.10, 99.25  CPT-4  96400–96495, 95990, 95991, 99555  HCPCS  Q0083-Q0085, Q2017, Q2024, C8953-C8955, G0355, G0357-G0362, G9021-G9032, J7150, J8520, J8521, J9000-J9999, S0088, S0115, S0016, S0172, S0176, S0178, S0182, S5019, S5020, S9329-S9331, S9425  Radiation therapy  ICD-9 Diagnosis  V58.0, V66.1, V67.1  ICD-9 Procedure  92.21–92.29  CPT-4  76000, 76370, 76950, 76965, 77014, 77263, 77280, 77295, 77305, 77310, 77315, 77321, 77326–77328, 77285, 77290, 77401–77423, 77425, 77470, 77520, 77522, 77523, 77750, 77781, 77782, 77799  HCPCS  0073 T, 0082 T, 0197 T, G0173, G0174, G0178, G0242, G0243, G0251, G0340  Hormone therapy  ICD-9 Diagnosis  V07.52  ICD-9 Procedure  65.51–65.54  CPT-4  4179 F, 58940  HCPCS  S0156, S0170, S0179, S0187, S9560, G8381, J1950, J3315, J3487, J3488, J9202, J9217-J9219, J9264, J9265, J9355, J9395  Treatment Type  Coding System  Codes  Mastectomy  ICD-9 Procedure  85.41–85.48, 85.34, 85.36  CPT-4  19180, 19182, 19200, 19220, 19240, 19303, 19304, 19305, 19306, 19307  Breast conserving surgery  ICD-9 Procedure  85.20–85.25  CPT-4  19160, 19162, 19301, 19302, 19120, 19125, 19126  Reconstructive surgery  ICD-9 Procedure  857, 85.33, 85.35, 85.53, 85.54, 85.84, 85.85, 85.87, 85.93, 85.95, 85.70–85.76, 85.79  CPT-4  19340, 19342, 19350, 19357, 19361, 19364, 19366, 19367, 19368, 19369, 19380  HCPCS  L8000, L8001, L8010, L8015, L8020, L8030, L8035, L8039, L8600, C1789, S2066, S2068  Chemotherapy  ICD-9 Diagnosis  V58.1, V58.11, V66.2, V67.2  ICD-9 Procedure  00.10, 99.25  CPT-4  96400–96495, 95990, 95991, 99555  HCPCS  Q0083-Q0085, Q2017, Q2024, C8953-C8955, G0355, G0357-G0362, G9021-G9032, J7150, J8520, J8521, J9000-J9999, S0088, S0115, S0016, S0172, S0176, S0178, S0182, S5019, S5020, S9329-S9331, S9425  Radiation therapy  ICD-9 Diagnosis  V58.0, V66.1, V67.1  ICD-9 Procedure  92.21–92.29  CPT-4  76000, 76370, 76950, 76965, 77014, 77263, 77280, 77295, 77305, 77310, 77315, 77321, 77326–77328, 77285, 77290, 77401–77423, 77425, 77470, 77520, 77522, 77523, 77750, 77781, 77782, 77799  HCPCS  0073 T, 0082 T, 0197 T, G0173, G0174, G0178, G0242, G0243, G0251, G0340  Hormone therapy  ICD-9 Diagnosis  V07.52  ICD-9 Procedure  65.51–65.54  CPT-4  4179 F, 58940  HCPCS  S0156, S0170, S0179, S0187, S9560, G8381, J1950, J3315, J3487, J3488, J9202, J9217-J9219, J9264, J9265, J9355, J9395  CPT-4, Current Procedure Terminology, fourth edition; ICD-9, International Classification of Diseases, ninth edition; HCPCS, Healthcare Common Procedure Coding System. Table I. Medical Codes Used to Identify Breast Cancer Treatment Claims in the Military Health System Linked Data Treatment Type  Coding System  Codes  Mastectomy  ICD-9 Procedure  85.41–85.48, 85.34, 85.36  CPT-4  19180, 19182, 19200, 19220, 19240, 19303, 19304, 19305, 19306, 19307  Breast conserving surgery  ICD-9 Procedure  85.20–85.25  CPT-4  19160, 19162, 19301, 19302, 19120, 19125, 19126  Reconstructive surgery  ICD-9 Procedure  857, 85.33, 85.35, 85.53, 85.54, 85.84, 85.85, 85.87, 85.93, 85.95, 85.70–85.76, 85.79  CPT-4  19340, 19342, 19350, 19357, 19361, 19364, 19366, 19367, 19368, 19369, 19380  HCPCS  L8000, L8001, L8010, L8015, L8020, L8030, L8035, L8039, L8600, C1789, S2066, S2068  Chemotherapy  ICD-9 Diagnosis  V58.1, V58.11, V66.2, V67.2  ICD-9 Procedure  00.10, 99.25  CPT-4  96400–96495, 95990, 95991, 99555  HCPCS  Q0083-Q0085, Q2017, Q2024, C8953-C8955, G0355, G0357-G0362, G9021-G9032, J7150, J8520, J8521, J9000-J9999, S0088, S0115, S0016, S0172, S0176, S0178, S0182, S5019, S5020, S9329-S9331, S9425  Radiation therapy  ICD-9 Diagnosis  V58.0, V66.1, V67.1  ICD-9 Procedure  92.21–92.29  CPT-4  76000, 76370, 76950, 76965, 77014, 77263, 77280, 77295, 77305, 77310, 77315, 77321, 77326–77328, 77285, 77290, 77401–77423, 77425, 77470, 77520, 77522, 77523, 77750, 77781, 77782, 77799  HCPCS  0073 T, 0082 T, 0197 T, G0173, G0174, G0178, G0242, G0243, G0251, G0340  Hormone therapy  ICD-9 Diagnosis  V07.52  ICD-9 Procedure  65.51–65.54  CPT-4  4179 F, 58940  HCPCS  S0156, S0170, S0179, S0187, S9560, G8381, J1950, J3315, J3487, J3488, J9202, J9217-J9219, J9264, J9265, J9355, J9395  Treatment Type  Coding System  Codes  Mastectomy  ICD-9 Procedure  85.41–85.48, 85.34, 85.36  CPT-4  19180, 19182, 19200, 19220, 19240, 19303, 19304, 19305, 19306, 19307  Breast conserving surgery  ICD-9 Procedure  85.20–85.25  CPT-4  19160, 19162, 19301, 19302, 19120, 19125, 19126  Reconstructive surgery  ICD-9 Procedure  857, 85.33, 85.35, 85.53, 85.54, 85.84, 85.85, 85.87, 85.93, 85.95, 85.70–85.76, 85.79  CPT-4  19340, 19342, 19350, 19357, 19361, 19364, 19366, 19367, 19368, 19369, 19380  HCPCS  L8000, L8001, L8010, L8015, L8020, L8030, L8035, L8039, L8600, C1789, S2066, S2068  Chemotherapy  ICD-9 Diagnosis  V58.1, V58.11, V66.2, V67.2  ICD-9 Procedure  00.10, 99.25  CPT-4  96400–96495, 95990, 95991, 99555  HCPCS  Q0083-Q0085, Q2017, Q2024, C8953-C8955, G0355, G0357-G0362, G9021-G9032, J7150, J8520, J8521, J9000-J9999, S0088, S0115, S0016, S0172, S0176, S0178, S0182, S5019, S5020, S9329-S9331, S9425  Radiation therapy  ICD-9 Diagnosis  V58.0, V66.1, V67.1  ICD-9 Procedure  92.21–92.29  CPT-4  76000, 76370, 76950, 76965, 77014, 77263, 77280, 77295, 77305, 77310, 77315, 77321, 77326–77328, 77285, 77290, 77401–77423, 77425, 77470, 77520, 77522, 77523, 77750, 77781, 77782, 77799  HCPCS  0073 T, 0082 T, 0197 T, G0173, G0174, G0178, G0242, G0243, G0251, G0340  Hormone therapy  ICD-9 Diagnosis  V07.52  ICD-9 Procedure  65.51–65.54  CPT-4  4179 F, 58940  HCPCS  S0156, S0170, S0179, S0187, S9560, G8381, J1950, J3315, J3487, J3488, J9202, J9217-J9219, J9264, J9265, J9355, J9395  CPT-4, Current Procedure Terminology, fourth edition; ICD-9, International Classification of Diseases, ninth edition; HCPCS, Healthcare Common Procedure Coding System. Analyses First, we presented demographic and tumor characteristics by benefit type and care source and evaluated distributions by Chi-square tests. Then, we estimated mean cost and associated standard errors (SE) for cancer care per capita using generalized linear models (GLMs) for ill-conditioned data,31,32 adjusted for demographic, tumor, and treatment characteristics. The GLMs applied a least-squares linear regression method to generate the estimated means. Model-estimated costs were derived from regression parameter estimates for each benefit type and care source for total care, individual treatment types, and tumor stage. Costs for hormone therapy were restricted to those with ER+ or PR+ tumors. We evaluated statistically significant differences in estimated cost between benefit types and care sources in the GLMs by comparing least-squares means and SEs at an alpha = 0.05, with Bonferroni corrections for multiple comparisons when appropriate. Analyses were conducted using SAS 9.4 (SAS Institute Inc., Cary, NC, USA). RESULTS The analyses included 2,666 women with breast cancer. The average follow-up time was 3.31 (SD 1.48) years. Table II includes demographic information by benefit type and care source. Women with Prime benefit type had a lower age at diagnosis and were more likely to be non-Hispanic white or active duty at diagnosis than women with non-Prime benefit types. Women who used direct care were less likely to be non-Hispanic white, less likely to be married, and more likely to be sponsored by the Navy than those using purchased or both care sources. Table II. Selected Demographics and Comorbidities by Benefit Type and Care Source for Women Diagnosed with Breast Cancer in the U.S. Military Health System, 2003–2007   Benefit Type  Breast Cancer Care Source  Prime  Non-Prime    Direct  Purchased  Both    N = 2,412  N = 256    N = 924  N = 622  N = 1,120    N  %  N  %  p  N  %  N  %  N  %  p  Age at diagnosis          0.015              0.506   40–49  981  40.7  83  32.4    387  41.9  249  40.0  426  38.0     50–59  923  38.3  103  40.2    342  37.0  242  38.9  442  39.5     60–64  508  21.1  70  27.3    195  21.1  131  21.1  252  22.5    Race-ethnicity          0.006              <0.001   Non-Hispanic White  1,421  58.9  128  50.0    521  56.4  392  63.0  635  56.7     Non-Hispanic Black  388  16.1  45  17.6    149  16.1  73  11.7  210  18.8     Non-Hispanic Other  269  11.2  41  16.0    136  14.7  44  7.1  130  11.6     Hispanic  145  6.0  11  4.3    57  6.2  28  4.5  71  6.3     Unknown  189  7.8  31  12.1    61  6.6  85  13.7  74  6.6    Marital status          0.080              0.033   Married  2,072  85.9  207  80.9    771  83.4  535  86.0  972  86.8     Single  57  2.4  7  2.7    35  3.8  12  1.9  17  1.5     Other  228  9.5  37  14.5    95  10.3  64  10.3  105  9.4     Unknown  55  2.3  5  2.0    23  2.5  11  1.8  26  2.3    Military sponsor          0.192              <0.001   Army  875  36.3  84  32.8    296  32.0  206  33.1  456  40.7     Navy  466  19.3  63  24.6    247  26.7  83  13.3  198  17.7     Marines  113  4.7  8  3.1    36  3.9  32  5.1  53  4.7     Air Force  761  31.6  74  28.9    254  27.5  255  41.0  326  29.1     Other  180  7.5  25  9.8    82  8.9  43  6.9  80  7.1     Unknown  17  0.7  2  0.8    9  1.0  3  0.5  7  0.6    Active duty status          0.037              0.005   Yes  139  5.8  5  2.0    69  7.5  27  4.3  48  4.3     No  2,254  93.5  249  97.3    844  91.3  592  95.2  1,065  95.1     Unknown  19  0.8  2  0.8    11  1.2  3  0.5  7  0.6    Diagnosis year          0.003              0.090   2003  473  19.6  64  25.0    160  17.3  126  20.3  251  22.4     2004  500  20.7  34  13.3    200  21.7  127  20.4  206  18.4     2005  524  21.7  45  17.6    188  20.4  132  21.2  249  22.2     2006  439  18.2  47  18.4    186  20.1  114  18.3  186  16.6     2007  476  19.7  66  25.8    190  20.6  123  19.8  228  20.4    Comorbidities          0.360              0.055   0  1,778  73.7  185  72.3    688  74.5  480  77.2  795  71.0     1  466  19.3  47  18.4    165  17.9  97  15.6  235  21.0     2+  168  7.0  24  9.4    71  7.7  45  7.2  90  8.0      Benefit Type  Breast Cancer Care Source  Prime  Non-Prime    Direct  Purchased  Both    N = 2,412  N = 256    N = 924  N = 622  N = 1,120    N  %  N  %  p  N  %  N  %  N  %  p  Age at diagnosis          0.015              0.506   40–49  981  40.7  83  32.4    387  41.9  249  40.0  426  38.0     50–59  923  38.3  103  40.2    342  37.0  242  38.9  442  39.5     60–64  508  21.1  70  27.3    195  21.1  131  21.1  252  22.5    Race-ethnicity          0.006              <0.001   Non-Hispanic White  1,421  58.9  128  50.0    521  56.4  392  63.0  635  56.7     Non-Hispanic Black  388  16.1  45  17.6    149  16.1  73  11.7  210  18.8     Non-Hispanic Other  269  11.2  41  16.0    136  14.7  44  7.1  130  11.6     Hispanic  145  6.0  11  4.3    57  6.2  28  4.5  71  6.3     Unknown  189  7.8  31  12.1    61  6.6  85  13.7  74  6.6    Marital status          0.080              0.033   Married  2,072  85.9  207  80.9    771  83.4  535  86.0  972  86.8     Single  57  2.4  7  2.7    35  3.8  12  1.9  17  1.5     Other  228  9.5  37  14.5    95  10.3  64  10.3  105  9.4     Unknown  55  2.3  5  2.0    23  2.5  11  1.8  26  2.3    Military sponsor          0.192              <0.001   Army  875  36.3  84  32.8    296  32.0  206  33.1  456  40.7     Navy  466  19.3  63  24.6    247  26.7  83  13.3  198  17.7     Marines  113  4.7  8  3.1    36  3.9  32  5.1  53  4.7     Air Force  761  31.6  74  28.9    254  27.5  255  41.0  326  29.1     Other  180  7.5  25  9.8    82  8.9  43  6.9  80  7.1     Unknown  17  0.7  2  0.8    9  1.0  3  0.5  7  0.6    Active duty status          0.037              0.005   Yes  139  5.8  5  2.0    69  7.5  27  4.3  48  4.3     No  2,254  93.5  249  97.3    844  91.3  592  95.2  1,065  95.1     Unknown  19  0.8  2  0.8    11  1.2  3  0.5  7  0.6    Diagnosis year          0.003              0.090   2003  473  19.6  64  25.0    160  17.3  126  20.3  251  22.4     2004  500  20.7  34  13.3    200  21.7  127  20.4  206  18.4     2005  524  21.7  45  17.6    188  20.4  132  21.2  249  22.2     2006  439  18.2  47  18.4    186  20.1  114  18.3  186  16.6     2007  476  19.7  66  25.8    190  20.6  123  19.8  228  20.4    Comorbidities          0.360              0.055   0  1,778  73.7  185  72.3    688  74.5  480  77.2  795  71.0     1  466  19.3  47  18.4    165  17.9  97  15.6  235  21.0     2+  168  7.0  24  9.4    71  7.7  45  7.2  90  8.0    Table II. Selected Demographics and Comorbidities by Benefit Type and Care Source for Women Diagnosed with Breast Cancer in the U.S. Military Health System, 2003–2007   Benefit Type  Breast Cancer Care Source  Prime  Non-Prime    Direct  Purchased  Both    N = 2,412  N = 256    N = 924  N = 622  N = 1,120    N  %  N  %  p  N  %  N  %  N  %  p  Age at diagnosis          0.015              0.506   40–49  981  40.7  83  32.4    387  41.9  249  40.0  426  38.0     50–59  923  38.3  103  40.2    342  37.0  242  38.9  442  39.5     60–64  508  21.1  70  27.3    195  21.1  131  21.1  252  22.5    Race-ethnicity          0.006              <0.001   Non-Hispanic White  1,421  58.9  128  50.0    521  56.4  392  63.0  635  56.7     Non-Hispanic Black  388  16.1  45  17.6    149  16.1  73  11.7  210  18.8     Non-Hispanic Other  269  11.2  41  16.0    136  14.7  44  7.1  130  11.6     Hispanic  145  6.0  11  4.3    57  6.2  28  4.5  71  6.3     Unknown  189  7.8  31  12.1    61  6.6  85  13.7  74  6.6    Marital status          0.080              0.033   Married  2,072  85.9  207  80.9    771  83.4  535  86.0  972  86.8     Single  57  2.4  7  2.7    35  3.8  12  1.9  17  1.5     Other  228  9.5  37  14.5    95  10.3  64  10.3  105  9.4     Unknown  55  2.3  5  2.0    23  2.5  11  1.8  26  2.3    Military sponsor          0.192              <0.001   Army  875  36.3  84  32.8    296  32.0  206  33.1  456  40.7     Navy  466  19.3  63  24.6    247  26.7  83  13.3  198  17.7     Marines  113  4.7  8  3.1    36  3.9  32  5.1  53  4.7     Air Force  761  31.6  74  28.9    254  27.5  255  41.0  326  29.1     Other  180  7.5  25  9.8    82  8.9  43  6.9  80  7.1     Unknown  17  0.7  2  0.8    9  1.0  3  0.5  7  0.6    Active duty status          0.037              0.005   Yes  139  5.8  5  2.0    69  7.5  27  4.3  48  4.3     No  2,254  93.5  249  97.3    844  91.3  592  95.2  1,065  95.1     Unknown  19  0.8  2  0.8    11  1.2  3  0.5  7  0.6    Diagnosis year          0.003              0.090   2003  473  19.6  64  25.0    160  17.3  126  20.3  251  22.4     2004  500  20.7  34  13.3    200  21.7  127  20.4  206  18.4     2005  524  21.7  45  17.6    188  20.4  132  21.2  249  22.2     2006  439  18.2  47  18.4    186  20.1  114  18.3  186  16.6     2007  476  19.7  66  25.8    190  20.6  123  19.8  228  20.4    Comorbidities          0.360              0.055   0  1,778  73.7  185  72.3    688  74.5  480  77.2  795  71.0     1  466  19.3  47  18.4    165  17.9  97  15.6  235  21.0     2+  168  7.0  24  9.4    71  7.7  45  7.2  90  8.0      Benefit Type  Breast Cancer Care Source  Prime  Non-Prime    Direct  Purchased  Both    N = 2,412  N = 256    N = 924  N = 622  N = 1,120    N  %  N  %  p  N  %  N  %  N  %  p  Age at diagnosis          0.015              0.506   40–49  981  40.7  83  32.4    387  41.9  249  40.0  426  38.0     50–59  923  38.3  103  40.2    342  37.0  242  38.9  442  39.5     60–64  508  21.1  70  27.3    195  21.1  131  21.1  252  22.5    Race-ethnicity          0.006              <0.001   Non-Hispanic White  1,421  58.9  128  50.0    521  56.4  392  63.0  635  56.7     Non-Hispanic Black  388  16.1  45  17.6    149  16.1  73  11.7  210  18.8     Non-Hispanic Other  269  11.2  41  16.0    136  14.7  44  7.1  130  11.6     Hispanic  145  6.0  11  4.3    57  6.2  28  4.5  71  6.3     Unknown  189  7.8  31  12.1    61  6.6  85  13.7  74  6.6    Marital status          0.080              0.033   Married  2,072  85.9  207  80.9    771  83.4  535  86.0  972  86.8     Single  57  2.4  7  2.7    35  3.8  12  1.9  17  1.5     Other  228  9.5  37  14.5    95  10.3  64  10.3  105  9.4     Unknown  55  2.3  5  2.0    23  2.5  11  1.8  26  2.3    Military sponsor          0.192              <0.001   Army  875  36.3  84  32.8    296  32.0  206  33.1  456  40.7     Navy  466  19.3  63  24.6    247  26.7  83  13.3  198  17.7     Marines  113  4.7  8  3.1    36  3.9  32  5.1  53  4.7     Air Force  761  31.6  74  28.9    254  27.5  255  41.0  326  29.1     Other  180  7.5  25  9.8    82  8.9  43  6.9  80  7.1     Unknown  17  0.7  2  0.8    9  1.0  3  0.5  7  0.6    Active duty status          0.037              0.005   Yes  139  5.8  5  2.0    69  7.5  27  4.3  48  4.3     No  2,254  93.5  249  97.3    844  91.3  592  95.2  1,065  95.1     Unknown  19  0.8  2  0.8    11  1.2  3  0.5  7  0.6    Diagnosis year          0.003              0.090   2003  473  19.6  64  25.0    160  17.3  126  20.3  251  22.4     2004  500  20.7  34  13.3    200  21.7  127  20.4  206  18.4     2005  524  21.7  45  17.6    188  20.4  132  21.2  249  22.2     2006  439  18.2  47  18.4    186  20.1  114  18.3  186  16.6     2007  476  19.7  66  25.8    190  20.6  123  19.8  228  20.4    Comorbidities          0.360              0.055   0  1,778  73.7  185  72.3    688  74.5  480  77.2  795  71.0     1  466  19.3  47  18.4    165  17.9  97  15.6  235  21.0     2+  168  7.0  24  9.4    71  7.7  45  7.2  90  8.0    Pathologic diagnosis and treatment characteristics by benefit type and care source are shown in Table III. Women with Prime were more likely to be diagnosed as Stage I or II and were more likely to have surgery, chemotherapy, or radiation therapy than women with non-Prime benefit type. Women who used direct care were more likely be diagnosed as Stage I or Grade I or II and were less likely to have chemotherapy, radiation therapy, or hormone therapy than those using purchased care or both care sources. Patients using both care sources were more likely to have surgery than the other two groups. Table III. Tumor and Treatment Characteristics by Benefit Type and Care Source for Women Diagnosed with Breast Cancer in the U.S. Military Health System, 2003–2007   Benefit Type  Breast Cancer Care Source  Prime  Non-Prime    Direct  Purchased  Both    N = 2,412  N = 256    N = 924  N = 622  N = 1,120    N  %  N  %  p  N  %  N  %  N  %  p  Stage          0.002              <0.001   Stage I  1,131  46.9  108  42.2    468  50.7  257  41.3  513  45.8     Stage II  852  35.3  85  33.2    304  32.9  219  35.2  413  36.9     Stage III  310  12.9  36  14.1    109  11.8  87  14.0  150  13.4     Stage IV  67  2.8  18  7.0    32  3.5  26  4.2  27  2.4     Unknown  52  2.2  9  3.5    11  1.2  33  5.3  17  1.5    Grade          0.643              0.003   Grade I  494  20.5  46  18.0    202  21.9  103  16.6  235  21.0     Grade II  895  37.1  99  38.7    355  38.4  223  35.9  416  37.1     Grade III  790  32.8  81  31.6    291  31.5  209  33.6  370  33.0     Grade IV  25  1.0  2  0.8    11  1.2  9  1.5  7  0.6     Unknown  208  8.6  28  10.9    65  7.0  78  12.5  92  8.2    Receptor Status          0.301              0.003   ER+/PR+  1,382  57.3  143  55.9    545  59.0  338  54.3  641  57.2     ER−/PR+  26  1.1  4  1.6    12  1.3  4  0.6  14  1.3     ER+/PR−  230  9.5  24  9.4    86  9.3  56  9.0  111  9.9     ER−/PR−  555  23.0  52  20.3    219  23.7  139  22.4  249  22.2     Unknown  219  9.1  33  12.9    62  6.7  85  13.7  105  9.4    Chemotherapy          0.007              <0.001   Yes  1,662  69.0  154  60.6    580  62.8  464  74.7  772  69.1     No  747  31.0  100  39.4    344  37.2  157  25.2  346  30.9    Hormone Therapya          0.033              <0.001   Yes  714  43.6  60  35.1    163  23.4  284  71.4  327  42.7     No  924  56.4  111  64.9    480  74.7  114  28.6  439  57.3    Radiation Therapy          <0.001              <0.001   Yes  1,831  75.9  163  63.9    744  80.5  469  75.4  781  69.7     No  580  24.1  92  36.1    180  19.5  153  24.6  339  30.3    Surgery (any)          <0.001              <0.001   Yes  2,317  96.1  227  88.7    859  93.0  587  94.5  1,098  98.0     No  95  3.9  29  11.3    65  7.0  35  5.6  22  2.0      Benefit Type  Breast Cancer Care Source  Prime  Non-Prime    Direct  Purchased  Both    N = 2,412  N = 256    N = 924  N = 622  N = 1,120    N  %  N  %  p  N  %  N  %  N  %  p  Stage          0.002              <0.001   Stage I  1,131  46.9  108  42.2    468  50.7  257  41.3  513  45.8     Stage II  852  35.3  85  33.2    304  32.9  219  35.2  413  36.9     Stage III  310  12.9  36  14.1    109  11.8  87  14.0  150  13.4     Stage IV  67  2.8  18  7.0    32  3.5  26  4.2  27  2.4     Unknown  52  2.2  9  3.5    11  1.2  33  5.3  17  1.5    Grade          0.643              0.003   Grade I  494  20.5  46  18.0    202  21.9  103  16.6  235  21.0     Grade II  895  37.1  99  38.7    355  38.4  223  35.9  416  37.1     Grade III  790  32.8  81  31.6    291  31.5  209  33.6  370  33.0     Grade IV  25  1.0  2  0.8    11  1.2  9  1.5  7  0.6     Unknown  208  8.6  28  10.9    65  7.0  78  12.5  92  8.2    Receptor Status          0.301              0.003   ER+/PR+  1,382  57.3  143  55.9    545  59.0  338  54.3  641  57.2     ER−/PR+  26  1.1  4  1.6    12  1.3  4  0.6  14  1.3     ER+/PR−  230  9.5  24  9.4    86  9.3  56  9.0  111  9.9     ER−/PR−  555  23.0  52  20.3    219  23.7  139  22.4  249  22.2     Unknown  219  9.1  33  12.9    62  6.7  85  13.7  105  9.4    Chemotherapy          0.007              <0.001   Yes  1,662  69.0  154  60.6    580  62.8  464  74.7  772  69.1     No  747  31.0  100  39.4    344  37.2  157  25.2  346  30.9    Hormone Therapya          0.033              <0.001   Yes  714  43.6  60  35.1    163  23.4  284  71.4  327  42.7     No  924  56.4  111  64.9    480  74.7  114  28.6  439  57.3    Radiation Therapy          <0.001              <0.001   Yes  1,831  75.9  163  63.9    744  80.5  469  75.4  781  69.7     No  580  24.1  92  36.1    180  19.5  153  24.6  339  30.3    Surgery (any)          <0.001              <0.001   Yes  2,317  96.1  227  88.7    859  93.0  587  94.5  1,098  98.0     No  95  3.9  29  11.3    65  7.0  35  5.6  22  2.0    aIndividuals with ER−/PR− and unknown receptor status tumors excluded. Table III. Tumor and Treatment Characteristics by Benefit Type and Care Source for Women Diagnosed with Breast Cancer in the U.S. Military Health System, 2003–2007   Benefit Type  Breast Cancer Care Source  Prime  Non-Prime    Direct  Purchased  Both    N = 2,412  N = 256    N = 924  N = 622  N = 1,120    N  %  N  %  p  N  %  N  %  N  %  p  Stage          0.002              <0.001   Stage I  1,131  46.9  108  42.2    468  50.7  257  41.3  513  45.8     Stage II  852  35.3  85  33.2    304  32.9  219  35.2  413  36.9     Stage III  310  12.9  36  14.1    109  11.8  87  14.0  150  13.4     Stage IV  67  2.8  18  7.0    32  3.5  26  4.2  27  2.4     Unknown  52  2.2  9  3.5    11  1.2  33  5.3  17  1.5    Grade          0.643              0.003   Grade I  494  20.5  46  18.0    202  21.9  103  16.6  235  21.0     Grade II  895  37.1  99  38.7    355  38.4  223  35.9  416  37.1     Grade III  790  32.8  81  31.6    291  31.5  209  33.6  370  33.0     Grade IV  25  1.0  2  0.8    11  1.2  9  1.5  7  0.6     Unknown  208  8.6  28  10.9    65  7.0  78  12.5  92  8.2    Receptor Status          0.301              0.003   ER+/PR+  1,382  57.3  143  55.9    545  59.0  338  54.3  641  57.2     ER−/PR+  26  1.1  4  1.6    12  1.3  4  0.6  14  1.3     ER+/PR−  230  9.5  24  9.4    86  9.3  56  9.0  111  9.9     ER−/PR−  555  23.0  52  20.3    219  23.7  139  22.4  249  22.2     Unknown  219  9.1  33  12.9    62  6.7  85  13.7  105  9.4    Chemotherapy          0.007              <0.001   Yes  1,662  69.0  154  60.6    580  62.8  464  74.7  772  69.1     No  747  31.0  100  39.4    344  37.2  157  25.2  346  30.9    Hormone Therapya          0.033              <0.001   Yes  714  43.6  60  35.1    163  23.4  284  71.4  327  42.7     No  924  56.4  111  64.9    480  74.7  114  28.6  439  57.3    Radiation Therapy          <0.001              <0.001   Yes  1,831  75.9  163  63.9    744  80.5  469  75.4  781  69.7     No  580  24.1  92  36.1    180  19.5  153  24.6  339  30.3    Surgery (any)          <0.001              <0.001   Yes  2,317  96.1  227  88.7    859  93.0  587  94.5  1,098  98.0     No  95  3.9  29  11.3    65  7.0  35  5.6  22  2.0      Benefit Type  Breast Cancer Care Source  Prime  Non-Prime    Direct  Purchased  Both    N = 2,412  N = 256    N = 924  N = 622  N = 1,120    N  %  N  %  p  N  %  N  %  N  %  p  Stage          0.002              <0.001   Stage I  1,131  46.9  108  42.2    468  50.7  257  41.3  513  45.8     Stage II  852  35.3  85  33.2    304  32.9  219  35.2  413  36.9     Stage III  310  12.9  36  14.1    109  11.8  87  14.0  150  13.4     Stage IV  67  2.8  18  7.0    32  3.5  26  4.2  27  2.4     Unknown  52  2.2  9  3.5    11  1.2  33  5.3  17  1.5    Grade          0.643              0.003   Grade I  494  20.5  46  18.0    202  21.9  103  16.6  235  21.0     Grade II  895  37.1  99  38.7    355  38.4  223  35.9  416  37.1     Grade III  790  32.8  81  31.6    291  31.5  209  33.6  370  33.0     Grade IV  25  1.0  2  0.8    11  1.2  9  1.5  7  0.6     Unknown  208  8.6  28  10.9    65  7.0  78  12.5  92  8.2    Receptor Status          0.301              0.003   ER+/PR+  1,382  57.3  143  55.9    545  59.0  338  54.3  641  57.2     ER−/PR+  26  1.1  4  1.6    12  1.3  4  0.6  14  1.3     ER+/PR−  230  9.5  24  9.4    86  9.3  56  9.0  111  9.9     ER−/PR−  555  23.0  52  20.3    219  23.7  139  22.4  249  22.2     Unknown  219  9.1  33  12.9    62  6.7  85  13.7  105  9.4    Chemotherapy          0.007              <0.001   Yes  1,662  69.0  154  60.6    580  62.8  464  74.7  772  69.1     No  747  31.0  100  39.4    344  37.2  157  25.2  346  30.9    Hormone Therapya          0.033              <0.001   Yes  714  43.6  60  35.1    163  23.4  284  71.4  327  42.7     No  924  56.4  111  64.9    480  74.7  114  28.6  439  57.3    Radiation Therapy          <0.001              <0.001   Yes  1,831  75.9  163  63.9    744  80.5  469  75.4  781  69.7     No  580  24.1  92  36.1    180  19.5  153  24.6  339  30.3    Surgery (any)          <0.001              <0.001   Yes  2,317  96.1  227  88.7    859  93.0  587  94.5  1,098  98.0     No  95  3.9  29  11.3    65  7.0  35  5.6  22  2.0    aIndividuals with ER−/PR− and unknown receptor status tumors excluded. The estimated mean per capita cost for breast cancer care was $66,300 (SE $9,170). The greatest per capita cost was observed for treatment with radiation therapy [$35,050 ($5,900); n = 1,994], followed by chemotherapy [$30,990 ($6,360); n = 1,816], inpatient surgery [$16,770 ($2,170); n = 1,219], hormone therapy [$13,230 ($7,140); n = 774], and outpatient surgery [$4,220 ($540); n = 2,371]. The model-estimated total cost for breast cancer care and cost for treatment type-specific care were not statistically different between beneficiaries with Prime and non-Prime plans when adjusted for other factors (Fig. 1). Figure 1. View largeDownload slide Model-estimated mean costsa,b by treatment and benefit type for female breast cancer care in the U.S. Military Health System, 2003–2007. aCosts adjusted to 2008 U.S. dollars (USD). bMeans adjusted for race, age at diagnosis, year of diagnosis, active duty status at diagnosis, military service/sponsor branch, marital status at diagnosis, tumor stage, tumor grade, hormone receptor status, number of comorbidities, type of treatment received (except for treatment of interest), and care source. +Only those with hormone receptor positive (ER+ and/or PR+) tumors are included in hormone therapy cost p-diff > 0.05 for all comparisons between Prime and non-Prime. Figure 1. View largeDownload slide Model-estimated mean costsa,b by treatment and benefit type for female breast cancer care in the U.S. Military Health System, 2003–2007. aCosts adjusted to 2008 U.S. dollars (USD). bMeans adjusted for race, age at diagnosis, year of diagnosis, active duty status at diagnosis, military service/sponsor branch, marital status at diagnosis, tumor stage, tumor grade, hormone receptor status, number of comorbidities, type of treatment received (except for treatment of interest), and care source. +Only those with hormone receptor positive (ER+ and/or PR+) tumors are included in hormone therapy cost p-diff > 0.05 for all comparisons between Prime and non-Prime. Cost for breast cancer care significantly differed between care sources (Fig. 2). The estimated mean total cost per capita was $34,490 ($2,980) for direct care, $96,840 ($4,820) for purchased care, and $60,740 ($3,890) for both care sources. When evaluated by treatment type, per capita costs for direct care were significantly higher than purchased care for inpatient surgery, and significantly lower than purchased care for outpatient surgery, chemotherapy, radiation therapy, or hormone therapy treatment. Figure 2. View largeDownload slide Model-estimated mean costsa,b by treatment and care source for female breast cancer care in the U.S. Military Health System, 2003–2007. aCosts adjusted to 2008 U.S. dollars (USD). bMeans adjusted for race, age at diagnosis, year of diagnosis, active duty status at diagnosis, military service/sponsor branch, marital status at diagnosis, tumor stage, tumor grade, hormone receptor status, number of comorbidities, type of treatment received (except for treatment of interest), and benefit type. +Only those with hormone receptor positive (ER+ and/or PR+) tumors included. *p < 0.01 for all comparisons; ^p < 0.01 for comparison between direct and purchased care; #p < 0.01 for comparison between direct and both care; %p < 0.01 for comparison between purchased and both care. N < 10 for both care sources for chemotherapy and hormone therapy treatment types and reliable mean estimates could not be generated. Figure 2. View largeDownload slide Model-estimated mean costsa,b by treatment and care source for female breast cancer care in the U.S. Military Health System, 2003–2007. aCosts adjusted to 2008 U.S. dollars (USD). bMeans adjusted for race, age at diagnosis, year of diagnosis, active duty status at diagnosis, military service/sponsor branch, marital status at diagnosis, tumor stage, tumor grade, hormone receptor status, number of comorbidities, type of treatment received (except for treatment of interest), and benefit type. +Only those with hormone receptor positive (ER+ and/or PR+) tumors included. *p < 0.01 for all comparisons; ^p < 0.01 for comparison between direct and purchased care; #p < 0.01 for comparison between direct and both care; %p < 0.01 for comparison between purchased and both care. N < 10 for both care sources for chemotherapy and hormone therapy treatment types and reliable mean estimates could not be generated. Per capita breast cancer care costs increased with tumor stage (p-trend < 0.001; Fig. 3). In general, the trend of increased cost with tumor stage was observed when evaluated by benefit type and care source. For each tumor stage, there were no significant differences in estimated cost by benefit type. The differences in cost between care sources within each tumor stage were similar to those observed in the entire sample such that direct care had the lowest associated mean per capita costs. Figure 3. View largeDownload slide Model-estimated mean costsa,b by tumor stage for each benefit type and care source for female breast cancer care in the U.S. Military Health System, 2003–2007. aCosts adjusted to 2008 U.S. dollars (USD). bMeans adjusted for race, age at diagnosis, year of diagnosis, active duty status at diagnosis, military service/sponsor branch, marital status at diagnosis, tumor grade, hormone receptor status, number of comorbidities, breast cancer care source, and benefit type. p-diff > 0.05 for comparisons between Prime and non-Prime within each tumor stage. *p < 0.01 for direct compared with purchased care for Stage I–IV; ^p < 0.01 for direct compared with both for Stage I–III; #p < 0.01 for purchased compared with both for Stage I–IV. N < 35 for stage IV for non-Prime, direct care, purchased care, and both care and mean estimates may not be reliable for these strata. Figure 3. View largeDownload slide Model-estimated mean costsa,b by tumor stage for each benefit type and care source for female breast cancer care in the U.S. Military Health System, 2003–2007. aCosts adjusted to 2008 U.S. dollars (USD). bMeans adjusted for race, age at diagnosis, year of diagnosis, active duty status at diagnosis, military service/sponsor branch, marital status at diagnosis, tumor grade, hormone receptor status, number of comorbidities, breast cancer care source, and benefit type. p-diff > 0.05 for comparisons between Prime and non-Prime within each tumor stage. *p < 0.01 for direct compared with purchased care for Stage I–IV; ^p < 0.01 for direct compared with both for Stage I–III; #p < 0.01 for purchased compared with both for Stage I–IV. N < 35 for stage IV for non-Prime, direct care, purchased care, and both care and mean estimates may not be reliable for these strata. DISCUSSION Breast cancer poses a significant financial burden to healthcare systems in the USA. The average model-estimated cost for breast cancer treatment within the MHS was $66,300 per patient. This estimate is in line with breast cancer-related costs reported in other public and privately insured U.S. populations that were derived using a number of methods.7,9,14,15 We found that estimated per capita costs were similar between benefit types. However, estimated costs between care sources were significantly different, such that direct care had the lowest associated per capita cost compared with purchased care and both care sources. Our results indicate that organizational or institutional factors that differ between care sources may contribute to cost variations for breast cancer treatment in the MHS. The estimated per capita breast cancer costs to the MHS were similar between benefit plans, when controlled for other factors. In the MHS, costs allocated to patient encounters in direct care are determined without regard to benefit type. For purchased care, TRICARE pays remaining costs after cost-sharing agreements have been met. Costs paid by TRICARE may not differ between Prime and non-Prime plans due to similar maximum annual out-of-pocket charges18,33 and the high likelihood that out-of-pocket maximums are reached regardless of plan for costly specialty treatments (i.e., cancer therapy). A lower cost in direct care might be related to pay structure. At the organization level, MTFs operate with annual funding from the DoD. The amount granted to each MTF is allocated down to the patient-encounter level. In purchased care, operational support may come from multiple public and private sources and facilities receive reimbursement for patient services through insurance claims. It is also possible that civilian facilities and providers might be motivated to treat patients for profit.34–36 The combination of one primary source of funding and less motivation for profit in direct care is one possible explanation for lower costs in direct compared with purchased care. In addition, many facility features that we were unable to measure and account for in the analyses may contribute to cost differences between direct and purchased care, such as capacity, staffing, patient volume, affiliations or designations, clinic specialties, and services offered.6,37 Costs were estimated for each treatment type and tumor stage and compared between the benefit types and care sources. Chemo- and radiation therapies had the greatest per capita costs and estimated costs increased with tumor stage. This is consistent with previous evaluations7,9,15,38–40 and reflects the use of systemic therapy to treat late-stage tumors.41 Comparing costs between care sources, the estimated costs for direct care were lower than purchased care for each treatment type, with the one exception of inpatient surgery, and for each tumor stage. Possible reasons for this difference could be that reimbursement structures or incentives from pharmaceutical representatives may motivate physicians to prescribe certain therapeutic agents over others.36,42,43 This may be more likely in purchased care and thus contribute to higher systemic therapy costs in purchased care. Also, patients with more complicated or advanced cancers may have been referred for systemic therapy through purchased care when capabilities at MTFs were reached, artificially inflating the purchased care costs. The treatment algorithms, types of agents available, doses, delivery schedules, and combination therapies used for treatment can also impact cost. Variation in these components may be more likely in purchased care, where a number of hospital networks are represented, leading to greater cost variability. Additional information on services offered and treatment options and availability within direct and purchased care are needed to further evaluate treatment cost differences by care source. This study was based on MHS data and, therefore, the findings are specific to the DoD and MHS. However, the study has built upon the previous literature in several meaningful ways. First, we used administrative claims data and ICD-9, CPT, and HCPCS codes to identify costs specific to breast cancer treatments and care, adding to previous cost estimates that were calculated using a case-control approach.4,9,13,15,16,39,40 Second, the consolidation of cancer registry and administrative claims data permitted patient-level characteristics to be included and adjusted for in the analyses. Third, our study captured a patient population younger than age 65, filling a gap in the literature regarding breast cancer costs in this age group. Despite these contributions, our study had some limitations. First and foremost, although the data from different care sources were consolidated according to deliberated procedures, the estimated costs might not be completely comparable between direct and purchased care and therefore cost comparisons should be interpreted cautiously. This is due to the described differences between direct and purchased care in the way resources are allocated to facilities, in how fees for services are determined or incentivized, and in how cost information is recorded in administrative data. Second, benefit type was determined from records within the 3 mo prior to and after the diagnosis date. Members’ benefit eligibility and plan elections might have changed out of this time window, potentially introducing misclassification of Prime or non-Prime status. Third, the registry data only included patients who ever received care in an MTF. Thus, patients who were never diagnosed or treated at an MTF would not have been captured in the data and limits the generalizability of our results. Next, like with other administrative data sets, coding errors and data incompleteness are possible. Therefore, cancer care costs might not be completely accurate. CONCLUSIONS Per capita breast cancer care costs within the MHS were similar by insurance benefit type and were lower for direct care compared with purchased care. Further research is needed in breast and other tumor sites to determine patterns and determinants of cancer care costs between benefit types and care sources within the MHS. This research can provide insight on strategies for reducing cancer care costs to the medical system. Additionally, it is important to consider the “value of care”, i.e., whether a higher cost is related to a better clinical outcome, when assessing costs for cancer care. To fully understand the impact of differences in cost for breast cancer treatment, the associations between cost and clinical outcomes should be evaluated in the future. Funding This project was supported by the John P. Murtha Cancer Center of the Uniformed Services University and Walter Reed National Military Medical Center under the auspices of the Henry M. Jackson Foundation for the Advancement of Military Medicine. Acknowledgements 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. References 1 National Cancer Institute. Office of Cancer Survivorship: Statistics. 2016. cancercontrol.cancer.gov/ocs/statistics; accessed June 20, 2017. 2 Yabroff KR, Lund J, Kepka D, et al.  : Economic burden of cancer in the United States: estimates, projections, and future research. Cancer Epidemiol, Biomarkers Prev  2011; 20( 10): 2006– 14. doi:10.1158/1055-9965.epi-11-0650. Google Scholar CrossRef Search ADS   3 Mariotto AB, Yabroff KR, Shao Y, et al.  : Projections of the cost of cancer care in the United States: 2010–2020. J Natl Cancer Inst  2011; 103( 2): 117– 28. 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Health Aff (Millwood)  2015; 34( 4): 592– 600. Google Scholar CrossRef Search ADS PubMed  13 Boero IJ, Paravati AJ, Triplett DP, et al.  : The impact of radiotherapy costs on clinical outcomes in breast cancer. Radiother Oncol  2015; 117( 2): 393– 9. Google Scholar CrossRef Search ADS PubMed  14 Hassett MJ, Neville BA, Weeks JC: The relationship between quality, spending and outcomes among women with breast cancer. J Natl Cancer Inst  2014; 106: 10. Google Scholar CrossRef Search ADS   15 Fu AZ, Jhaveri M: Healthcare cost attributable to recently-diagnosed breast cancer in a privately-insured population in the United States. J Med Econ  2012; 15( 4): 688– 94. doi:10.3111/13696998.2012.673524. Google Scholar CrossRef Search ADS PubMed  16 Barron JJ, Quimbo R, Nikam PT, et al.  : Assessing the economic burden of breast cancer in a US managed care population. Breast Cancer Res Treat  2008; 109( 2): 367– 77. doi:10.1007/s10549-007-9650-4. Google Scholar CrossRef Search ADS PubMed  17 Defense Health Agency. TRICARE. 2016. www.tricare.mil. 18 Jansen DJ. Military Medical Care: Questions and Answers. Congressional Research Service, editor. 2014. http://fas.org/sgp/crs/misc/RL33537.pdf. 19 National Health Statistics Group. National health expenditures by type of service and source of funds: calendar years 1960 to 2015. In: U.S. Centers for Medicare & Medicaid Services Office of the Actuary, editor. www.cms.gov/research-statistics-data-and-systems/statistics-trends-and-reports/nationalhealthexpenddata/2016. 20 Military Health System and Defense Health Agency. Rates and Reimbursement. 2017. health.mil/military-health-topics/business-support/rates-and-reimbursement; accessed April 5, 2017. 21 Enewold L, McGlynn KA, Zahm SH, et al.  : Surveillance mammography among female Department of Defense beneficiaries: a study by race and ethnicity. Cancer  2013; 119( 19): 3531– 8. doi:10.1002/cncr.28242. 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February 25, 2014. https://health.mil/Reference-Center/Reports. 34 Woolhandler S, Himmelstein DU: Costs of care and administration at for-profit and other hospitals in the United States. N Engl J Med  1997; 336( 11): 769– 74. doi:10.1056/nejm199703133361106. Google Scholar CrossRef Search ADS PubMed  35 Sen S, Soulos PR, Herrin J, et al.  : For-profit hospital ownership status and use of brachytherapy after breast-conserving surgery. Surgery  2014; 155( 5): 776– 88. doi:10.1016/j.surg.2013.12.009. Google Scholar CrossRef Search ADS PubMed  36 Epstein AJ, Johnson SJ: Physician response to financial incentives when choosing drugs to treat breast cancer. Int J Health Care Finance Econ  2012; 12( 4): 285– 302. doi:10.1007/s10754-012-9117-y. Google Scholar CrossRef Search ADS PubMed  37 Fuchs VR.: The basic forces influencing costs of medical care. In: Essays in the Economics of Health and Medical Care , pp 39– 50. Edited by Fuchs VR. Cambridge, MA, National Bureau of Economic Research, 1972. 38 Sail KR, Franzini L, Lairson DR, et al.  : Clinical and economic outcomes associated with adjuvant chemotherapy in elderly patients with early stage operable breast cancer. Value in health: the journal of the International Society for Pharmacoeconomics and Outcomes. Research  2012; 15( 1): 72– 80. doi:10.1016/j.jval.2011.10.004. 39 Mittmann N, Porter JM, Rangrej J, et al.  : Health system costs for stage-specific breast cancer: a population-based approach. Curr Oncol  2014; 21( 6): 281– 93. doi:10.3747/co.21.2143. Google Scholar CrossRef Search ADS PubMed  40 Broekx S, Den Hond E, Torfs R, et al.  : The costs of breast cancer prior to and following diagnosis. European J Health Econ  2011; 12( 4): 311– 7. doi:10.1007/s10198-010-0237-3. Google Scholar CrossRef Search ADS   41 NCCN Clinical Practice Guidelines in Oncology: Breast Cancer [database on the Internet] 2017. Accessed 42 Jacobson M, O’Malley AJ, Earle CC, et al.  : Does reimbursement influence chemotherapy treatment for cancer patients? Health Aff (Millwood)  2006; 25( 2): 437– 43. Google Scholar CrossRef Search ADS PubMed  43 Hornbrook MC, Malin J, Weeks JC, et al.  : Did changes in drug reimbursement after the medicare modernization act affect chemotherapy prescribing? J Clin Oncol  2014; 32( 36): 4042– 9. doi:10.1200/jco.2013.52.6780. Google Scholar CrossRef Search ADS PubMed  Author notes The contents of this publication are the sole responsibility of the authors and do not necessarily reflect the views, assertions, opinions or policies of the Uniformed Services University of the Health Sciences (USUHS), the Department of Defense (DoD), or the Departments of the Army, Navy, or Air Force. Mention of trade names, commercial products, or organizations does not imply endorsement by the U.S. Government. © Association of Military Surgeons of the United States 2018. All rights reserved. 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Costs for Breast Cancer Care in the Military Health System: An Analysis by Benefit Type and Care Source

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© Association of Military Surgeons of the United States 2018. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.
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Abstract

Abstract Introduction Breast cancer care imposes a significant financial burden to U.S. healthcare systems. Health services factors, such as insurance benefit type and care source, may impact costs to the health system. Beneficiaries in the U.S. Military Health System (MHS) have universal healthcare coverage and access to a network of military facilities (direct care) and private practices (purchased care). This study aims to quantify and compare breast cancer care costs to the MHS by insurance benefit type and care source. Materials and Methods We conducted a retrospective analysis of data linked between the MHS data repository administrative claims and central cancer registry databases. The institutional review boards of the Walter Reed National Military Medical Center, the Defense Health Agency, and the National Institutes of Health Office of Human Subjects Research reviewed and approved the data linkage. We used the linked data to identify records for women aged 40–64 yr who were diagnosed with breast cancer between 2003 and 2007 and to extract information on insurance benefit type, care source, and cost to the MHS for breast cancer treatment. We estimated per capita costs for breast cancer care by benefit type and care source in 2008 USD using generalized linear models, adjusted for demographic, pathologic, and treatment characteristics. Results The average per capita (n = 2,666) total cost for breast cancer care was $66,300 [standard error (SE) $9,200] over 3.31 (1.48) years of follow-up. Total costs were similar between benefit types, but varied by care source. The average per capita cost was $34,500 ($3,000) for direct care (n = 924), $96,800 ($4,800) for purchased care (n = 622), and $60,700 ($3,900) for both care sources (n = 1,120), respectively. Care source differences remained by tumor stage and for chemotherapy, radiation, and hormone therapy treatment types. Conclusions Per capita costs to the MHS for breast cancer care were similar by benefit type and lower for direct care compared with purchased care. Further research is needed in breast and other tumor sites to determine patterns and determinants of cancer care costs between benefit types and care sources within the MHS. Introduction As the U.S. population ages, the number of cancer diagnoses and survivors is expected to increase.1 With this increase, the costs for cancer care are also expected to rise.2,3 Direct costs of cancer care in the USA were approximately $125 billion in 2010, with 13% of costs attributable to breast cancer, the largest contribution of any single cancer site.3 Evaluating breast cancer costs in a variety of patient populations and health care settings has potential to inform practice and policy aimed at reducing breast cancer care costs. Costs associated with cancer-specific diagnostic and treatment services have been estimated from public and private insurer’s administrative claims data.4,5 These cost estimates generally reflect the amount the insurer pays to service providers as a percentage of allowable costs. The amount paid may vary by benefit plan, as plans can offer different cost-sharing arrangements, service coverage, and financial incentives for selecting certain providers over others.6 Care source can also factor into costs, as institutions may have different resource allocation methods or fee and billing schedules depending on organizational structure and the services provided within that facility.6 Currently, there is limited research examining cancer costs between benefit plans and care sources in the USA.2 Breast cancer diagnosis and treatment costs have been reported in U.S. Medicare and private insurance patient populations.7–16 These evaluations have demonstrated substantial cost variability and the need for further examination of breast cancer care costs in multiple health care settings. To the authors’ knowledge, breast cancer care costs have not been evaluated by insurance benefit type and care source within the U.S. Military Health System (MHS). The MHS provides access to medical care to nearly 10 million active-duty personnel, national guards, reservists, retirees, and their families through a network of military hospitals and clinics [military treatment facilities (MTFs)] and approved civilian providers.17–19 Medical insurance is provided for beneficiaries and managed through TRICARE. The four main benefit plans include Prime, Extra, Standard, and TRICARE for Life.17,18 Beneficiaries may pay enrollment fees, annual deductibles, and co-payments based on their sponsor status (active-duty, retired, etc.), military rank, and the plan selected. Active-duty service members are automatically enrolled in Prime and their family members are eligible to enroll at no cost. Other beneficiaries can elect to enroll in Prime, subject to enrollment fees and co-payments for authorized providers. Prime has no annual deductible unless enrollees use the point-of-service option, which is when routine or urgent care is received outside the MHS network without a referral. Eligible beneficiaries who have not enrolled in Prime are automatically entitled to Standard and Extra. These plans have no enrollment fees and cover services rendered by authorized providers after co-payments and deductibles are met. TRICARE for Life serves as a secondary payer to Medicare for those beneficiaries who are eligible and enrolled in Medicare Part A and Part B. Beneficiaries in the MHS can receive care in MTFs or in civilian facilities. MTFs receive funding from the Department of Defense (DoD) in order to provide medical care directly to beneficiaries and maintain administrative functions.18 Costs for medical care received in the MTFs (direct care) are based on how individual MTF resources are allocated down to the clinic, patient, and encounter level. TRICARE manages payments for services received in civilian facilities (purchased care) after taking into account payments by other insurers (e.g., Medicare) and cost-sharing by the patient.17,18 The DoD fee schedule20 determines the maximum amount TRICARE pays for purchased services. The purpose of this study was to quantify and compare the breast cancer care costs to the MHS for the different benefit plans and care sources within the MHS. We further evaluated costs by treatment type and tumor stage. Quantifying breast cancer care costs and determining whether these costs are different by benefit type and care source in a universal coverage system will provide information for developing strategies to optimize and reduce cost. Methods Population and Data Sources This study is a retrospective analysis of linked data from the DoD Central Cancer Registry (CCR) and MHS Data Repository (MDR) medical claims database. Information on the database structures have been published previously.21,22 We identified breast cancer cases in the registry using International Classification of Diseases – Oncology, Third Edition (ICD-O-3) topography codes C50.0-C50.6 and C50.8-C50.9. Women aged 40–64 yr with histologically confirmed primary breast cancer who were ever diagnosed or treated at MTFs between 2003 and 2007 (n = 2,982) were eligible. Age 40 yr was selected to reflect the starting age for annual screening mammography per TRICARE’s payment policy.17 We excluded women diagnosed at age 65 or older since TRICARE is a secondary payer to Medicare and claims data may be incomplete for these individuals. The institutional review boards of the Walter Reed National Military Medical Center, the Defense Health Agency, and the National Institutes of Health Office of Human Subjects Research review and approved the data linkage project. Study Variables We collected patient demographic, comorbidity, and cancer information from the linked data. CCR variables included age at diagnosis, race, ethnicity, marital status at diagnosis, active-duty status at diagnosis, and military service or sponsor branch. We identified comorbidities in MDR records using ICD-9 diagnostic codes for conditions included in the Charlson Comorbidity Index.23 We extracted cancer diagnosis date, tumor stage (AJCC 6th edition), tumor grade, and estrogen (ER) and progesterone (PR) hormone receptor status from the CCR data. The MDR records contained information on insurance benefit status and we supplemented with CCR data if values were missing. Benefit type was determined from eligibility and enrollment in the TRICARE plans at any point in the three months prior to and following breast cancer diagnosis. If the eligible beneficiary was not electively enrolled in Prime during this period, the benefit type was designated as non-Prime. The non-Prime plans represented mostly Standard and Extra, which we combined due to automatic enrollment in these plan types for eligible beneficiaries and similar cost-sharing arrangements. Women with unknown benefit type (n = 56) and women with other health insurance in addition to TRICARE (n = 258) were excluded due to the possibility of missing or incomplete data. Care source was determined from MDR administrative claims data for breast cancer treatment beginning at the diagnosis date through the end of follow-up, death, or censoring. We defined care source as direct, purchased, or both using a two-step process. (1) For each treatment type (mastectomy, breast conserving surgery, reconstructive surgery, chemotherapy, radiation therapy, hormone therapy), unique claim dates were extracted and counted as patient visits. Based on frequency distributions, if ≥90% of visits were for care delivered in MTFs, then patients were classified as using direct care for that treatment type. Similarly, if ≥90% of visits were in civilian facilities, then patients were classified as using purchased care for that treatment type. Otherwise, treatment care source was classified as both. (2) Overall care source was determined by the proportion of treatment types received as direct or purchased care. If ≥80% of treatment types were received as direct care, then the care source was classified as direct. If ≥80% of treatment types were received as purchased care, then the care source was classified as purchased. Otherwise, overall care source was classified as both. Cases who did not have cancer treatment documented in MDR records (n = 29) were classified based on where they received non-cancer medical care in the three months prior to and three months following diagnosis using similar cut-points (e.g., ≥80% visits at MTFs for direct care). Cases who did not have MDR cancer treatment records and who had missing information on where non-cancer medical care was sought were excluded (n = 2). Study Outcome Costs for incident breast cancer care were determined from the MDR administrative claims database in the time period between the diagnosis date and date of death, censor, or study end on December 31, 2008. Relevant breast cancer ICD-9 diagnostic and treatment procedures codes, Current Procedural Terminology (CPT) codes, and Healthcare Common Procedure Coding System (HCPCS) codes were used to identify related claims and episodes of care for surgery, chemotherapy, radiation therapy, and hormone therapy (Table I).7,13,24–26 Direct care costs extracted from the MDR claims represented episodes of care and included institutional, professional (i.e., clinician salary), and ancillary services (e.g., laboratory, anesthesia, radiology, pharmacy). Purchased care costs extracted from the MDR claims represented claim-level data for each billed procedure (including radiation doses and chemotherapy drugs) and did not include professional or ancillary services. In order to make direct and purchased costs more comparable, the cost for clinician salary and ancillary services (except radiology and pharmacy when indicated) was subtracted from the direct costs. The costs to the MTF at the encounter level for direct care and amount paid by TRICARE for purchased care 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 (CPI) for medical care in the year of diagnosis.27 For analyses, the cost for each treatment type was capped at the 99th percentile in order to minimize the influence of extreme values.9,28–30 Then, costs for individual treatment types were summed to produce total breast cancer care costs per patient. Table I. Medical Codes Used to Identify Breast Cancer Treatment Claims in the Military Health System Linked Data Treatment Type  Coding System  Codes  Mastectomy  ICD-9 Procedure  85.41–85.48, 85.34, 85.36  CPT-4  19180, 19182, 19200, 19220, 19240, 19303, 19304, 19305, 19306, 19307  Breast conserving surgery  ICD-9 Procedure  85.20–85.25  CPT-4  19160, 19162, 19301, 19302, 19120, 19125, 19126  Reconstructive surgery  ICD-9 Procedure  857, 85.33, 85.35, 85.53, 85.54, 85.84, 85.85, 85.87, 85.93, 85.95, 85.70–85.76, 85.79  CPT-4  19340, 19342, 19350, 19357, 19361, 19364, 19366, 19367, 19368, 19369, 19380  HCPCS  L8000, L8001, L8010, L8015, L8020, L8030, L8035, L8039, L8600, C1789, S2066, S2068  Chemotherapy  ICD-9 Diagnosis  V58.1, V58.11, V66.2, V67.2  ICD-9 Procedure  00.10, 99.25  CPT-4  96400–96495, 95990, 95991, 99555  HCPCS  Q0083-Q0085, Q2017, Q2024, C8953-C8955, G0355, G0357-G0362, G9021-G9032, J7150, J8520, J8521, J9000-J9999, S0088, S0115, S0016, S0172, S0176, S0178, S0182, S5019, S5020, S9329-S9331, S9425  Radiation therapy  ICD-9 Diagnosis  V58.0, V66.1, V67.1  ICD-9 Procedure  92.21–92.29  CPT-4  76000, 76370, 76950, 76965, 77014, 77263, 77280, 77295, 77305, 77310, 77315, 77321, 77326–77328, 77285, 77290, 77401–77423, 77425, 77470, 77520, 77522, 77523, 77750, 77781, 77782, 77799  HCPCS  0073 T, 0082 T, 0197 T, G0173, G0174, G0178, G0242, G0243, G0251, G0340  Hormone therapy  ICD-9 Diagnosis  V07.52  ICD-9 Procedure  65.51–65.54  CPT-4  4179 F, 58940  HCPCS  S0156, S0170, S0179, S0187, S9560, G8381, J1950, J3315, J3487, J3488, J9202, J9217-J9219, J9264, J9265, J9355, J9395  Treatment Type  Coding System  Codes  Mastectomy  ICD-9 Procedure  85.41–85.48, 85.34, 85.36  CPT-4  19180, 19182, 19200, 19220, 19240, 19303, 19304, 19305, 19306, 19307  Breast conserving surgery  ICD-9 Procedure  85.20–85.25  CPT-4  19160, 19162, 19301, 19302, 19120, 19125, 19126  Reconstructive surgery  ICD-9 Procedure  857, 85.33, 85.35, 85.53, 85.54, 85.84, 85.85, 85.87, 85.93, 85.95, 85.70–85.76, 85.79  CPT-4  19340, 19342, 19350, 19357, 19361, 19364, 19366, 19367, 19368, 19369, 19380  HCPCS  L8000, L8001, L8010, L8015, L8020, L8030, L8035, L8039, L8600, C1789, S2066, S2068  Chemotherapy  ICD-9 Diagnosis  V58.1, V58.11, V66.2, V67.2  ICD-9 Procedure  00.10, 99.25  CPT-4  96400–96495, 95990, 95991, 99555  HCPCS  Q0083-Q0085, Q2017, Q2024, C8953-C8955, G0355, G0357-G0362, G9021-G9032, J7150, J8520, J8521, J9000-J9999, S0088, S0115, S0016, S0172, S0176, S0178, S0182, S5019, S5020, S9329-S9331, S9425  Radiation therapy  ICD-9 Diagnosis  V58.0, V66.1, V67.1  ICD-9 Procedure  92.21–92.29  CPT-4  76000, 76370, 76950, 76965, 77014, 77263, 77280, 77295, 77305, 77310, 77315, 77321, 77326–77328, 77285, 77290, 77401–77423, 77425, 77470, 77520, 77522, 77523, 77750, 77781, 77782, 77799  HCPCS  0073 T, 0082 T, 0197 T, G0173, G0174, G0178, G0242, G0243, G0251, G0340  Hormone therapy  ICD-9 Diagnosis  V07.52  ICD-9 Procedure  65.51–65.54  CPT-4  4179 F, 58940  HCPCS  S0156, S0170, S0179, S0187, S9560, G8381, J1950, J3315, J3487, J3488, J9202, J9217-J9219, J9264, J9265, J9355, J9395  CPT-4, Current Procedure Terminology, fourth edition; ICD-9, International Classification of Diseases, ninth edition; HCPCS, Healthcare Common Procedure Coding System. Table I. Medical Codes Used to Identify Breast Cancer Treatment Claims in the Military Health System Linked Data Treatment Type  Coding System  Codes  Mastectomy  ICD-9 Procedure  85.41–85.48, 85.34, 85.36  CPT-4  19180, 19182, 19200, 19220, 19240, 19303, 19304, 19305, 19306, 19307  Breast conserving surgery  ICD-9 Procedure  85.20–85.25  CPT-4  19160, 19162, 19301, 19302, 19120, 19125, 19126  Reconstructive surgery  ICD-9 Procedure  857, 85.33, 85.35, 85.53, 85.54, 85.84, 85.85, 85.87, 85.93, 85.95, 85.70–85.76, 85.79  CPT-4  19340, 19342, 19350, 19357, 19361, 19364, 19366, 19367, 19368, 19369, 19380  HCPCS  L8000, L8001, L8010, L8015, L8020, L8030, L8035, L8039, L8600, C1789, S2066, S2068  Chemotherapy  ICD-9 Diagnosis  V58.1, V58.11, V66.2, V67.2  ICD-9 Procedure  00.10, 99.25  CPT-4  96400–96495, 95990, 95991, 99555  HCPCS  Q0083-Q0085, Q2017, Q2024, C8953-C8955, G0355, G0357-G0362, G9021-G9032, J7150, J8520, J8521, J9000-J9999, S0088, S0115, S0016, S0172, S0176, S0178, S0182, S5019, S5020, S9329-S9331, S9425  Radiation therapy  ICD-9 Diagnosis  V58.0, V66.1, V67.1  ICD-9 Procedure  92.21–92.29  CPT-4  76000, 76370, 76950, 76965, 77014, 77263, 77280, 77295, 77305, 77310, 77315, 77321, 77326–77328, 77285, 77290, 77401–77423, 77425, 77470, 77520, 77522, 77523, 77750, 77781, 77782, 77799  HCPCS  0073 T, 0082 T, 0197 T, G0173, G0174, G0178, G0242, G0243, G0251, G0340  Hormone therapy  ICD-9 Diagnosis  V07.52  ICD-9 Procedure  65.51–65.54  CPT-4  4179 F, 58940  HCPCS  S0156, S0170, S0179, S0187, S9560, G8381, J1950, J3315, J3487, J3488, J9202, J9217-J9219, J9264, J9265, J9355, J9395  Treatment Type  Coding System  Codes  Mastectomy  ICD-9 Procedure  85.41–85.48, 85.34, 85.36  CPT-4  19180, 19182, 19200, 19220, 19240, 19303, 19304, 19305, 19306, 19307  Breast conserving surgery  ICD-9 Procedure  85.20–85.25  CPT-4  19160, 19162, 19301, 19302, 19120, 19125, 19126  Reconstructive surgery  ICD-9 Procedure  857, 85.33, 85.35, 85.53, 85.54, 85.84, 85.85, 85.87, 85.93, 85.95, 85.70–85.76, 85.79  CPT-4  19340, 19342, 19350, 19357, 19361, 19364, 19366, 19367, 19368, 19369, 19380  HCPCS  L8000, L8001, L8010, L8015, L8020, L8030, L8035, L8039, L8600, C1789, S2066, S2068  Chemotherapy  ICD-9 Diagnosis  V58.1, V58.11, V66.2, V67.2  ICD-9 Procedure  00.10, 99.25  CPT-4  96400–96495, 95990, 95991, 99555  HCPCS  Q0083-Q0085, Q2017, Q2024, C8953-C8955, G0355, G0357-G0362, G9021-G9032, J7150, J8520, J8521, J9000-J9999, S0088, S0115, S0016, S0172, S0176, S0178, S0182, S5019, S5020, S9329-S9331, S9425  Radiation therapy  ICD-9 Diagnosis  V58.0, V66.1, V67.1  ICD-9 Procedure  92.21–92.29  CPT-4  76000, 76370, 76950, 76965, 77014, 77263, 77280, 77295, 77305, 77310, 77315, 77321, 77326–77328, 77285, 77290, 77401–77423, 77425, 77470, 77520, 77522, 77523, 77750, 77781, 77782, 77799  HCPCS  0073 T, 0082 T, 0197 T, G0173, G0174, G0178, G0242, G0243, G0251, G0340  Hormone therapy  ICD-9 Diagnosis  V07.52  ICD-9 Procedure  65.51–65.54  CPT-4  4179 F, 58940  HCPCS  S0156, S0170, S0179, S0187, S9560, G8381, J1950, J3315, J3487, J3488, J9202, J9217-J9219, J9264, J9265, J9355, J9395  CPT-4, Current Procedure Terminology, fourth edition; ICD-9, International Classification of Diseases, ninth edition; HCPCS, Healthcare Common Procedure Coding System. Analyses First, we presented demographic and tumor characteristics by benefit type and care source and evaluated distributions by Chi-square tests. Then, we estimated mean cost and associated standard errors (SE) for cancer care per capita using generalized linear models (GLMs) for ill-conditioned data,31,32 adjusted for demographic, tumor, and treatment characteristics. The GLMs applied a least-squares linear regression method to generate the estimated means. Model-estimated costs were derived from regression parameter estimates for each benefit type and care source for total care, individual treatment types, and tumor stage. Costs for hormone therapy were restricted to those with ER+ or PR+ tumors. We evaluated statistically significant differences in estimated cost between benefit types and care sources in the GLMs by comparing least-squares means and SEs at an alpha = 0.05, with Bonferroni corrections for multiple comparisons when appropriate. Analyses were conducted using SAS 9.4 (SAS Institute Inc., Cary, NC, USA). RESULTS The analyses included 2,666 women with breast cancer. The average follow-up time was 3.31 (SD 1.48) years. Table II includes demographic information by benefit type and care source. Women with Prime benefit type had a lower age at diagnosis and were more likely to be non-Hispanic white or active duty at diagnosis than women with non-Prime benefit types. Women who used direct care were less likely to be non-Hispanic white, less likely to be married, and more likely to be sponsored by the Navy than those using purchased or both care sources. Table II. Selected Demographics and Comorbidities by Benefit Type and Care Source for Women Diagnosed with Breast Cancer in the U.S. Military Health System, 2003–2007   Benefit Type  Breast Cancer Care Source  Prime  Non-Prime    Direct  Purchased  Both    N = 2,412  N = 256    N = 924  N = 622  N = 1,120    N  %  N  %  p  N  %  N  %  N  %  p  Age at diagnosis          0.015              0.506   40–49  981  40.7  83  32.4    387  41.9  249  40.0  426  38.0     50–59  923  38.3  103  40.2    342  37.0  242  38.9  442  39.5     60–64  508  21.1  70  27.3    195  21.1  131  21.1  252  22.5    Race-ethnicity          0.006              <0.001   Non-Hispanic White  1,421  58.9  128  50.0    521  56.4  392  63.0  635  56.7     Non-Hispanic Black  388  16.1  45  17.6    149  16.1  73  11.7  210  18.8     Non-Hispanic Other  269  11.2  41  16.0    136  14.7  44  7.1  130  11.6     Hispanic  145  6.0  11  4.3    57  6.2  28  4.5  71  6.3     Unknown  189  7.8  31  12.1    61  6.6  85  13.7  74  6.6    Marital status          0.080              0.033   Married  2,072  85.9  207  80.9    771  83.4  535  86.0  972  86.8     Single  57  2.4  7  2.7    35  3.8  12  1.9  17  1.5     Other  228  9.5  37  14.5    95  10.3  64  10.3  105  9.4     Unknown  55  2.3  5  2.0    23  2.5  11  1.8  26  2.3    Military sponsor          0.192              <0.001   Army  875  36.3  84  32.8    296  32.0  206  33.1  456  40.7     Navy  466  19.3  63  24.6    247  26.7  83  13.3  198  17.7     Marines  113  4.7  8  3.1    36  3.9  32  5.1  53  4.7     Air Force  761  31.6  74  28.9    254  27.5  255  41.0  326  29.1     Other  180  7.5  25  9.8    82  8.9  43  6.9  80  7.1     Unknown  17  0.7  2  0.8    9  1.0  3  0.5  7  0.6    Active duty status          0.037              0.005   Yes  139  5.8  5  2.0    69  7.5  27  4.3  48  4.3     No  2,254  93.5  249  97.3    844  91.3  592  95.2  1,065  95.1     Unknown  19  0.8  2  0.8    11  1.2  3  0.5  7  0.6    Diagnosis year          0.003              0.090   2003  473  19.6  64  25.0    160  17.3  126  20.3  251  22.4     2004  500  20.7  34  13.3    200  21.7  127  20.4  206  18.4     2005  524  21.7  45  17.6    188  20.4  132  21.2  249  22.2     2006  439  18.2  47  18.4    186  20.1  114  18.3  186  16.6     2007  476  19.7  66  25.8    190  20.6  123  19.8  228  20.4    Comorbidities          0.360              0.055   0  1,778  73.7  185  72.3    688  74.5  480  77.2  795  71.0     1  466  19.3  47  18.4    165  17.9  97  15.6  235  21.0     2+  168  7.0  24  9.4    71  7.7  45  7.2  90  8.0      Benefit Type  Breast Cancer Care Source  Prime  Non-Prime    Direct  Purchased  Both    N = 2,412  N = 256    N = 924  N = 622  N = 1,120    N  %  N  %  p  N  %  N  %  N  %  p  Age at diagnosis          0.015              0.506   40–49  981  40.7  83  32.4    387  41.9  249  40.0  426  38.0     50–59  923  38.3  103  40.2    342  37.0  242  38.9  442  39.5     60–64  508  21.1  70  27.3    195  21.1  131  21.1  252  22.5    Race-ethnicity          0.006              <0.001   Non-Hispanic White  1,421  58.9  128  50.0    521  56.4  392  63.0  635  56.7     Non-Hispanic Black  388  16.1  45  17.6    149  16.1  73  11.7  210  18.8     Non-Hispanic Other  269  11.2  41  16.0    136  14.7  44  7.1  130  11.6     Hispanic  145  6.0  11  4.3    57  6.2  28  4.5  71  6.3     Unknown  189  7.8  31  12.1    61  6.6  85  13.7  74  6.6    Marital status          0.080              0.033   Married  2,072  85.9  207  80.9    771  83.4  535  86.0  972  86.8     Single  57  2.4  7  2.7    35  3.8  12  1.9  17  1.5     Other  228  9.5  37  14.5    95  10.3  64  10.3  105  9.4     Unknown  55  2.3  5  2.0    23  2.5  11  1.8  26  2.3    Military sponsor          0.192              <0.001   Army  875  36.3  84  32.8    296  32.0  206  33.1  456  40.7     Navy  466  19.3  63  24.6    247  26.7  83  13.3  198  17.7     Marines  113  4.7  8  3.1    36  3.9  32  5.1  53  4.7     Air Force  761  31.6  74  28.9    254  27.5  255  41.0  326  29.1     Other  180  7.5  25  9.8    82  8.9  43  6.9  80  7.1     Unknown  17  0.7  2  0.8    9  1.0  3  0.5  7  0.6    Active duty status          0.037              0.005   Yes  139  5.8  5  2.0    69  7.5  27  4.3  48  4.3     No  2,254  93.5  249  97.3    844  91.3  592  95.2  1,065  95.1     Unknown  19  0.8  2  0.8    11  1.2  3  0.5  7  0.6    Diagnosis year          0.003              0.090   2003  473  19.6  64  25.0    160  17.3  126  20.3  251  22.4     2004  500  20.7  34  13.3    200  21.7  127  20.4  206  18.4     2005  524  21.7  45  17.6    188  20.4  132  21.2  249  22.2     2006  439  18.2  47  18.4    186  20.1  114  18.3  186  16.6     2007  476  19.7  66  25.8    190  20.6  123  19.8  228  20.4    Comorbidities          0.360              0.055   0  1,778  73.7  185  72.3    688  74.5  480  77.2  795  71.0     1  466  19.3  47  18.4    165  17.9  97  15.6  235  21.0     2+  168  7.0  24  9.4    71  7.7  45  7.2  90  8.0    Table II. Selected Demographics and Comorbidities by Benefit Type and Care Source for Women Diagnosed with Breast Cancer in the U.S. Military Health System, 2003–2007   Benefit Type  Breast Cancer Care Source  Prime  Non-Prime    Direct  Purchased  Both    N = 2,412  N = 256    N = 924  N = 622  N = 1,120    N  %  N  %  p  N  %  N  %  N  %  p  Age at diagnosis          0.015              0.506   40–49  981  40.7  83  32.4    387  41.9  249  40.0  426  38.0     50–59  923  38.3  103  40.2    342  37.0  242  38.9  442  39.5     60–64  508  21.1  70  27.3    195  21.1  131  21.1  252  22.5    Race-ethnicity          0.006              <0.001   Non-Hispanic White  1,421  58.9  128  50.0    521  56.4  392  63.0  635  56.7     Non-Hispanic Black  388  16.1  45  17.6    149  16.1  73  11.7  210  18.8     Non-Hispanic Other  269  11.2  41  16.0    136  14.7  44  7.1  130  11.6     Hispanic  145  6.0  11  4.3    57  6.2  28  4.5  71  6.3     Unknown  189  7.8  31  12.1    61  6.6  85  13.7  74  6.6    Marital status          0.080              0.033   Married  2,072  85.9  207  80.9    771  83.4  535  86.0  972  86.8     Single  57  2.4  7  2.7    35  3.8  12  1.9  17  1.5     Other  228  9.5  37  14.5    95  10.3  64  10.3  105  9.4     Unknown  55  2.3  5  2.0    23  2.5  11  1.8  26  2.3    Military sponsor          0.192              <0.001   Army  875  36.3  84  32.8    296  32.0  206  33.1  456  40.7     Navy  466  19.3  63  24.6    247  26.7  83  13.3  198  17.7     Marines  113  4.7  8  3.1    36  3.9  32  5.1  53  4.7     Air Force  761  31.6  74  28.9    254  27.5  255  41.0  326  29.1     Other  180  7.5  25  9.8    82  8.9  43  6.9  80  7.1     Unknown  17  0.7  2  0.8    9  1.0  3  0.5  7  0.6    Active duty status          0.037              0.005   Yes  139  5.8  5  2.0    69  7.5  27  4.3  48  4.3     No  2,254  93.5  249  97.3    844  91.3  592  95.2  1,065  95.1     Unknown  19  0.8  2  0.8    11  1.2  3  0.5  7  0.6    Diagnosis year          0.003              0.090   2003  473  19.6  64  25.0    160  17.3  126  20.3  251  22.4     2004  500  20.7  34  13.3    200  21.7  127  20.4  206  18.4     2005  524  21.7  45  17.6    188  20.4  132  21.2  249  22.2     2006  439  18.2  47  18.4    186  20.1  114  18.3  186  16.6     2007  476  19.7  66  25.8    190  20.6  123  19.8  228  20.4    Comorbidities          0.360              0.055   0  1,778  73.7  185  72.3    688  74.5  480  77.2  795  71.0     1  466  19.3  47  18.4    165  17.9  97  15.6  235  21.0     2+  168  7.0  24  9.4    71  7.7  45  7.2  90  8.0      Benefit Type  Breast Cancer Care Source  Prime  Non-Prime    Direct  Purchased  Both    N = 2,412  N = 256    N = 924  N = 622  N = 1,120    N  %  N  %  p  N  %  N  %  N  %  p  Age at diagnosis          0.015              0.506   40–49  981  40.7  83  32.4    387  41.9  249  40.0  426  38.0     50–59  923  38.3  103  40.2    342  37.0  242  38.9  442  39.5     60–64  508  21.1  70  27.3    195  21.1  131  21.1  252  22.5    Race-ethnicity          0.006              <0.001   Non-Hispanic White  1,421  58.9  128  50.0    521  56.4  392  63.0  635  56.7     Non-Hispanic Black  388  16.1  45  17.6    149  16.1  73  11.7  210  18.8     Non-Hispanic Other  269  11.2  41  16.0    136  14.7  44  7.1  130  11.6     Hispanic  145  6.0  11  4.3    57  6.2  28  4.5  71  6.3     Unknown  189  7.8  31  12.1    61  6.6  85  13.7  74  6.6    Marital status          0.080              0.033   Married  2,072  85.9  207  80.9    771  83.4  535  86.0  972  86.8     Single  57  2.4  7  2.7    35  3.8  12  1.9  17  1.5     Other  228  9.5  37  14.5    95  10.3  64  10.3  105  9.4     Unknown  55  2.3  5  2.0    23  2.5  11  1.8  26  2.3    Military sponsor          0.192              <0.001   Army  875  36.3  84  32.8    296  32.0  206  33.1  456  40.7     Navy  466  19.3  63  24.6    247  26.7  83  13.3  198  17.7     Marines  113  4.7  8  3.1    36  3.9  32  5.1  53  4.7     Air Force  761  31.6  74  28.9    254  27.5  255  41.0  326  29.1     Other  180  7.5  25  9.8    82  8.9  43  6.9  80  7.1     Unknown  17  0.7  2  0.8    9  1.0  3  0.5  7  0.6    Active duty status          0.037              0.005   Yes  139  5.8  5  2.0    69  7.5  27  4.3  48  4.3     No  2,254  93.5  249  97.3    844  91.3  592  95.2  1,065  95.1     Unknown  19  0.8  2  0.8    11  1.2  3  0.5  7  0.6    Diagnosis year          0.003              0.090   2003  473  19.6  64  25.0    160  17.3  126  20.3  251  22.4     2004  500  20.7  34  13.3    200  21.7  127  20.4  206  18.4     2005  524  21.7  45  17.6    188  20.4  132  21.2  249  22.2     2006  439  18.2  47  18.4    186  20.1  114  18.3  186  16.6     2007  476  19.7  66  25.8    190  20.6  123  19.8  228  20.4    Comorbidities          0.360              0.055   0  1,778  73.7  185  72.3    688  74.5  480  77.2  795  71.0     1  466  19.3  47  18.4    165  17.9  97  15.6  235  21.0     2+  168  7.0  24  9.4    71  7.7  45  7.2  90  8.0    Pathologic diagnosis and treatment characteristics by benefit type and care source are shown in Table III. Women with Prime were more likely to be diagnosed as Stage I or II and were more likely to have surgery, chemotherapy, or radiation therapy than women with non-Prime benefit type. Women who used direct care were more likely be diagnosed as Stage I or Grade I or II and were less likely to have chemotherapy, radiation therapy, or hormone therapy than those using purchased care or both care sources. Patients using both care sources were more likely to have surgery than the other two groups. Table III. Tumor and Treatment Characteristics by Benefit Type and Care Source for Women Diagnosed with Breast Cancer in the U.S. Military Health System, 2003–2007   Benefit Type  Breast Cancer Care Source  Prime  Non-Prime    Direct  Purchased  Both    N = 2,412  N = 256    N = 924  N = 622  N = 1,120    N  %  N  %  p  N  %  N  %  N  %  p  Stage          0.002              <0.001   Stage I  1,131  46.9  108  42.2    468  50.7  257  41.3  513  45.8     Stage II  852  35.3  85  33.2    304  32.9  219  35.2  413  36.9     Stage III  310  12.9  36  14.1    109  11.8  87  14.0  150  13.4     Stage IV  67  2.8  18  7.0    32  3.5  26  4.2  27  2.4     Unknown  52  2.2  9  3.5    11  1.2  33  5.3  17  1.5    Grade          0.643              0.003   Grade I  494  20.5  46  18.0    202  21.9  103  16.6  235  21.0     Grade II  895  37.1  99  38.7    355  38.4  223  35.9  416  37.1     Grade III  790  32.8  81  31.6    291  31.5  209  33.6  370  33.0     Grade IV  25  1.0  2  0.8    11  1.2  9  1.5  7  0.6     Unknown  208  8.6  28  10.9    65  7.0  78  12.5  92  8.2    Receptor Status          0.301              0.003   ER+/PR+  1,382  57.3  143  55.9    545  59.0  338  54.3  641  57.2     ER−/PR+  26  1.1  4  1.6    12  1.3  4  0.6  14  1.3     ER+/PR−  230  9.5  24  9.4    86  9.3  56  9.0  111  9.9     ER−/PR−  555  23.0  52  20.3    219  23.7  139  22.4  249  22.2     Unknown  219  9.1  33  12.9    62  6.7  85  13.7  105  9.4    Chemotherapy          0.007              <0.001   Yes  1,662  69.0  154  60.6    580  62.8  464  74.7  772  69.1     No  747  31.0  100  39.4    344  37.2  157  25.2  346  30.9    Hormone Therapya          0.033              <0.001   Yes  714  43.6  60  35.1    163  23.4  284  71.4  327  42.7     No  924  56.4  111  64.9    480  74.7  114  28.6  439  57.3    Radiation Therapy          <0.001              <0.001   Yes  1,831  75.9  163  63.9    744  80.5  469  75.4  781  69.7     No  580  24.1  92  36.1    180  19.5  153  24.6  339  30.3    Surgery (any)          <0.001              <0.001   Yes  2,317  96.1  227  88.7    859  93.0  587  94.5  1,098  98.0     No  95  3.9  29  11.3    65  7.0  35  5.6  22  2.0      Benefit Type  Breast Cancer Care Source  Prime  Non-Prime    Direct  Purchased  Both    N = 2,412  N = 256    N = 924  N = 622  N = 1,120    N  %  N  %  p  N  %  N  %  N  %  p  Stage          0.002              <0.001   Stage I  1,131  46.9  108  42.2    468  50.7  257  41.3  513  45.8     Stage II  852  35.3  85  33.2    304  32.9  219  35.2  413  36.9     Stage III  310  12.9  36  14.1    109  11.8  87  14.0  150  13.4     Stage IV  67  2.8  18  7.0    32  3.5  26  4.2  27  2.4     Unknown  52  2.2  9  3.5    11  1.2  33  5.3  17  1.5    Grade          0.643              0.003   Grade I  494  20.5  46  18.0    202  21.9  103  16.6  235  21.0     Grade II  895  37.1  99  38.7    355  38.4  223  35.9  416  37.1     Grade III  790  32.8  81  31.6    291  31.5  209  33.6  370  33.0     Grade IV  25  1.0  2  0.8    11  1.2  9  1.5  7  0.6     Unknown  208  8.6  28  10.9    65  7.0  78  12.5  92  8.2    Receptor Status          0.301              0.003   ER+/PR+  1,382  57.3  143  55.9    545  59.0  338  54.3  641  57.2     ER−/PR+  26  1.1  4  1.6    12  1.3  4  0.6  14  1.3     ER+/PR−  230  9.5  24  9.4    86  9.3  56  9.0  111  9.9     ER−/PR−  555  23.0  52  20.3    219  23.7  139  22.4  249  22.2     Unknown  219  9.1  33  12.9    62  6.7  85  13.7  105  9.4    Chemotherapy          0.007              <0.001   Yes  1,662  69.0  154  60.6    580  62.8  464  74.7  772  69.1     No  747  31.0  100  39.4    344  37.2  157  25.2  346  30.9    Hormone Therapya          0.033              <0.001   Yes  714  43.6  60  35.1    163  23.4  284  71.4  327  42.7     No  924  56.4  111  64.9    480  74.7  114  28.6  439  57.3    Radiation Therapy          <0.001              <0.001   Yes  1,831  75.9  163  63.9    744  80.5  469  75.4  781  69.7     No  580  24.1  92  36.1    180  19.5  153  24.6  339  30.3    Surgery (any)          <0.001              <0.001   Yes  2,317  96.1  227  88.7    859  93.0  587  94.5  1,098  98.0     No  95  3.9  29  11.3    65  7.0  35  5.6  22  2.0    aIndividuals with ER−/PR− and unknown receptor status tumors excluded. Table III. Tumor and Treatment Characteristics by Benefit Type and Care Source for Women Diagnosed with Breast Cancer in the U.S. Military Health System, 2003–2007   Benefit Type  Breast Cancer Care Source  Prime  Non-Prime    Direct  Purchased  Both    N = 2,412  N = 256    N = 924  N = 622  N = 1,120    N  %  N  %  p  N  %  N  %  N  %  p  Stage          0.002              <0.001   Stage I  1,131  46.9  108  42.2    468  50.7  257  41.3  513  45.8     Stage II  852  35.3  85  33.2    304  32.9  219  35.2  413  36.9     Stage III  310  12.9  36  14.1    109  11.8  87  14.0  150  13.4     Stage IV  67  2.8  18  7.0    32  3.5  26  4.2  27  2.4     Unknown  52  2.2  9  3.5    11  1.2  33  5.3  17  1.5    Grade          0.643              0.003   Grade I  494  20.5  46  18.0    202  21.9  103  16.6  235  21.0     Grade II  895  37.1  99  38.7    355  38.4  223  35.9  416  37.1     Grade III  790  32.8  81  31.6    291  31.5  209  33.6  370  33.0     Grade IV  25  1.0  2  0.8    11  1.2  9  1.5  7  0.6     Unknown  208  8.6  28  10.9    65  7.0  78  12.5  92  8.2    Receptor Status          0.301              0.003   ER+/PR+  1,382  57.3  143  55.9    545  59.0  338  54.3  641  57.2     ER−/PR+  26  1.1  4  1.6    12  1.3  4  0.6  14  1.3     ER+/PR−  230  9.5  24  9.4    86  9.3  56  9.0  111  9.9     ER−/PR−  555  23.0  52  20.3    219  23.7  139  22.4  249  22.2     Unknown  219  9.1  33  12.9    62  6.7  85  13.7  105  9.4    Chemotherapy          0.007              <0.001   Yes  1,662  69.0  154  60.6    580  62.8  464  74.7  772  69.1     No  747  31.0  100  39.4    344  37.2  157  25.2  346  30.9    Hormone Therapya          0.033              <0.001   Yes  714  43.6  60  35.1    163  23.4  284  71.4  327  42.7     No  924  56.4  111  64.9    480  74.7  114  28.6  439  57.3    Radiation Therapy          <0.001              <0.001   Yes  1,831  75.9  163  63.9    744  80.5  469  75.4  781  69.7     No  580  24.1  92  36.1    180  19.5  153  24.6  339  30.3    Surgery (any)          <0.001              <0.001   Yes  2,317  96.1  227  88.7    859  93.0  587  94.5  1,098  98.0     No  95  3.9  29  11.3    65  7.0  35  5.6  22  2.0      Benefit Type  Breast Cancer Care Source  Prime  Non-Prime    Direct  Purchased  Both    N = 2,412  N = 256    N = 924  N = 622  N = 1,120    N  %  N  %  p  N  %  N  %  N  %  p  Stage          0.002              <0.001   Stage I  1,131  46.9  108  42.2    468  50.7  257  41.3  513  45.8     Stage II  852  35.3  85  33.2    304  32.9  219  35.2  413  36.9     Stage III  310  12.9  36  14.1    109  11.8  87  14.0  150  13.4     Stage IV  67  2.8  18  7.0    32  3.5  26  4.2  27  2.4     Unknown  52  2.2  9  3.5    11  1.2  33  5.3  17  1.5    Grade          0.643              0.003   Grade I  494  20.5  46  18.0    202  21.9  103  16.6  235  21.0     Grade II  895  37.1  99  38.7    355  38.4  223  35.9  416  37.1     Grade III  790  32.8  81  31.6    291  31.5  209  33.6  370  33.0     Grade IV  25  1.0  2  0.8    11  1.2  9  1.5  7  0.6     Unknown  208  8.6  28  10.9    65  7.0  78  12.5  92  8.2    Receptor Status          0.301              0.003   ER+/PR+  1,382  57.3  143  55.9    545  59.0  338  54.3  641  57.2     ER−/PR+  26  1.1  4  1.6    12  1.3  4  0.6  14  1.3     ER+/PR−  230  9.5  24  9.4    86  9.3  56  9.0  111  9.9     ER−/PR−  555  23.0  52  20.3    219  23.7  139  22.4  249  22.2     Unknown  219  9.1  33  12.9    62  6.7  85  13.7  105  9.4    Chemotherapy          0.007              <0.001   Yes  1,662  69.0  154  60.6    580  62.8  464  74.7  772  69.1     No  747  31.0  100  39.4    344  37.2  157  25.2  346  30.9    Hormone Therapya          0.033              <0.001   Yes  714  43.6  60  35.1    163  23.4  284  71.4  327  42.7     No  924  56.4  111  64.9    480  74.7  114  28.6  439  57.3    Radiation Therapy          <0.001              <0.001   Yes  1,831  75.9  163  63.9    744  80.5  469  75.4  781  69.7     No  580  24.1  92  36.1    180  19.5  153  24.6  339  30.3    Surgery (any)          <0.001              <0.001   Yes  2,317  96.1  227  88.7    859  93.0  587  94.5  1,098  98.0     No  95  3.9  29  11.3    65  7.0  35  5.6  22  2.0    aIndividuals with ER−/PR− and unknown receptor status tumors excluded. The estimated mean per capita cost for breast cancer care was $66,300 (SE $9,170). The greatest per capita cost was observed for treatment with radiation therapy [$35,050 ($5,900); n = 1,994], followed by chemotherapy [$30,990 ($6,360); n = 1,816], inpatient surgery [$16,770 ($2,170); n = 1,219], hormone therapy [$13,230 ($7,140); n = 774], and outpatient surgery [$4,220 ($540); n = 2,371]. The model-estimated total cost for breast cancer care and cost for treatment type-specific care were not statistically different between beneficiaries with Prime and non-Prime plans when adjusted for other factors (Fig. 1). Figure 1. View largeDownload slide Model-estimated mean costsa,b by treatment and benefit type for female breast cancer care in the U.S. Military Health System, 2003–2007. aCosts adjusted to 2008 U.S. dollars (USD). bMeans adjusted for race, age at diagnosis, year of diagnosis, active duty status at diagnosis, military service/sponsor branch, marital status at diagnosis, tumor stage, tumor grade, hormone receptor status, number of comorbidities, type of treatment received (except for treatment of interest), and care source. +Only those with hormone receptor positive (ER+ and/or PR+) tumors are included in hormone therapy cost p-diff > 0.05 for all comparisons between Prime and non-Prime. Figure 1. View largeDownload slide Model-estimated mean costsa,b by treatment and benefit type for female breast cancer care in the U.S. Military Health System, 2003–2007. aCosts adjusted to 2008 U.S. dollars (USD). bMeans adjusted for race, age at diagnosis, year of diagnosis, active duty status at diagnosis, military service/sponsor branch, marital status at diagnosis, tumor stage, tumor grade, hormone receptor status, number of comorbidities, type of treatment received (except for treatment of interest), and care source. +Only those with hormone receptor positive (ER+ and/or PR+) tumors are included in hormone therapy cost p-diff > 0.05 for all comparisons between Prime and non-Prime. Cost for breast cancer care significantly differed between care sources (Fig. 2). The estimated mean total cost per capita was $34,490 ($2,980) for direct care, $96,840 ($4,820) for purchased care, and $60,740 ($3,890) for both care sources. When evaluated by treatment type, per capita costs for direct care were significantly higher than purchased care for inpatient surgery, and significantly lower than purchased care for outpatient surgery, chemotherapy, radiation therapy, or hormone therapy treatment. Figure 2. View largeDownload slide Model-estimated mean costsa,b by treatment and care source for female breast cancer care in the U.S. Military Health System, 2003–2007. aCosts adjusted to 2008 U.S. dollars (USD). bMeans adjusted for race, age at diagnosis, year of diagnosis, active duty status at diagnosis, military service/sponsor branch, marital status at diagnosis, tumor stage, tumor grade, hormone receptor status, number of comorbidities, type of treatment received (except for treatment of interest), and benefit type. +Only those with hormone receptor positive (ER+ and/or PR+) tumors included. *p < 0.01 for all comparisons; ^p < 0.01 for comparison between direct and purchased care; #p < 0.01 for comparison between direct and both care; %p < 0.01 for comparison between purchased and both care. N < 10 for both care sources for chemotherapy and hormone therapy treatment types and reliable mean estimates could not be generated. Figure 2. View largeDownload slide Model-estimated mean costsa,b by treatment and care source for female breast cancer care in the U.S. Military Health System, 2003–2007. aCosts adjusted to 2008 U.S. dollars (USD). bMeans adjusted for race, age at diagnosis, year of diagnosis, active duty status at diagnosis, military service/sponsor branch, marital status at diagnosis, tumor stage, tumor grade, hormone receptor status, number of comorbidities, type of treatment received (except for treatment of interest), and benefit type. +Only those with hormone receptor positive (ER+ and/or PR+) tumors included. *p < 0.01 for all comparisons; ^p < 0.01 for comparison between direct and purchased care; #p < 0.01 for comparison between direct and both care; %p < 0.01 for comparison between purchased and both care. N < 10 for both care sources for chemotherapy and hormone therapy treatment types and reliable mean estimates could not be generated. Per capita breast cancer care costs increased with tumor stage (p-trend < 0.001; Fig. 3). In general, the trend of increased cost with tumor stage was observed when evaluated by benefit type and care source. For each tumor stage, there were no significant differences in estimated cost by benefit type. The differences in cost between care sources within each tumor stage were similar to those observed in the entire sample such that direct care had the lowest associated mean per capita costs. Figure 3. View largeDownload slide Model-estimated mean costsa,b by tumor stage for each benefit type and care source for female breast cancer care in the U.S. Military Health System, 2003–2007. aCosts adjusted to 2008 U.S. dollars (USD). bMeans adjusted for race, age at diagnosis, year of diagnosis, active duty status at diagnosis, military service/sponsor branch, marital status at diagnosis, tumor grade, hormone receptor status, number of comorbidities, breast cancer care source, and benefit type. p-diff > 0.05 for comparisons between Prime and non-Prime within each tumor stage. *p < 0.01 for direct compared with purchased care for Stage I–IV; ^p < 0.01 for direct compared with both for Stage I–III; #p < 0.01 for purchased compared with both for Stage I–IV. N < 35 for stage IV for non-Prime, direct care, purchased care, and both care and mean estimates may not be reliable for these strata. Figure 3. View largeDownload slide Model-estimated mean costsa,b by tumor stage for each benefit type and care source for female breast cancer care in the U.S. Military Health System, 2003–2007. aCosts adjusted to 2008 U.S. dollars (USD). bMeans adjusted for race, age at diagnosis, year of diagnosis, active duty status at diagnosis, military service/sponsor branch, marital status at diagnosis, tumor grade, hormone receptor status, number of comorbidities, breast cancer care source, and benefit type. p-diff > 0.05 for comparisons between Prime and non-Prime within each tumor stage. *p < 0.01 for direct compared with purchased care for Stage I–IV; ^p < 0.01 for direct compared with both for Stage I–III; #p < 0.01 for purchased compared with both for Stage I–IV. N < 35 for stage IV for non-Prime, direct care, purchased care, and both care and mean estimates may not be reliable for these strata. DISCUSSION Breast cancer poses a significant financial burden to healthcare systems in the USA. The average model-estimated cost for breast cancer treatment within the MHS was $66,300 per patient. This estimate is in line with breast cancer-related costs reported in other public and privately insured U.S. populations that were derived using a number of methods.7,9,14,15 We found that estimated per capita costs were similar between benefit types. However, estimated costs between care sources were significantly different, such that direct care had the lowest associated per capita cost compared with purchased care and both care sources. Our results indicate that organizational or institutional factors that differ between care sources may contribute to cost variations for breast cancer treatment in the MHS. The estimated per capita breast cancer costs to the MHS were similar between benefit plans, when controlled for other factors. In the MHS, costs allocated to patient encounters in direct care are determined without regard to benefit type. For purchased care, TRICARE pays remaining costs after cost-sharing agreements have been met. Costs paid by TRICARE may not differ between Prime and non-Prime plans due to similar maximum annual out-of-pocket charges18,33 and the high likelihood that out-of-pocket maximums are reached regardless of plan for costly specialty treatments (i.e., cancer therapy). A lower cost in direct care might be related to pay structure. At the organization level, MTFs operate with annual funding from the DoD. The amount granted to each MTF is allocated down to the patient-encounter level. In purchased care, operational support may come from multiple public and private sources and facilities receive reimbursement for patient services through insurance claims. It is also possible that civilian facilities and providers might be motivated to treat patients for profit.34–36 The combination of one primary source of funding and less motivation for profit in direct care is one possible explanation for lower costs in direct compared with purchased care. In addition, many facility features that we were unable to measure and account for in the analyses may contribute to cost differences between direct and purchased care, such as capacity, staffing, patient volume, affiliations or designations, clinic specialties, and services offered.6,37 Costs were estimated for each treatment type and tumor stage and compared between the benefit types and care sources. Chemo- and radiation therapies had the greatest per capita costs and estimated costs increased with tumor stage. This is consistent with previous evaluations7,9,15,38–40 and reflects the use of systemic therapy to treat late-stage tumors.41 Comparing costs between care sources, the estimated costs for direct care were lower than purchased care for each treatment type, with the one exception of inpatient surgery, and for each tumor stage. Possible reasons for this difference could be that reimbursement structures or incentives from pharmaceutical representatives may motivate physicians to prescribe certain therapeutic agents over others.36,42,43 This may be more likely in purchased care and thus contribute to higher systemic therapy costs in purchased care. Also, patients with more complicated or advanced cancers may have been referred for systemic therapy through purchased care when capabilities at MTFs were reached, artificially inflating the purchased care costs. The treatment algorithms, types of agents available, doses, delivery schedules, and combination therapies used for treatment can also impact cost. Variation in these components may be more likely in purchased care, where a number of hospital networks are represented, leading to greater cost variability. Additional information on services offered and treatment options and availability within direct and purchased care are needed to further evaluate treatment cost differences by care source. This study was based on MHS data and, therefore, the findings are specific to the DoD and MHS. However, the study has built upon the previous literature in several meaningful ways. First, we used administrative claims data and ICD-9, CPT, and HCPCS codes to identify costs specific to breast cancer treatments and care, adding to previous cost estimates that were calculated using a case-control approach.4,9,13,15,16,39,40 Second, the consolidation of cancer registry and administrative claims data permitted patient-level characteristics to be included and adjusted for in the analyses. Third, our study captured a patient population younger than age 65, filling a gap in the literature regarding breast cancer costs in this age group. Despite these contributions, our study had some limitations. First and foremost, although the data from different care sources were consolidated according to deliberated procedures, the estimated costs might not be completely comparable between direct and purchased care and therefore cost comparisons should be interpreted cautiously. This is due to the described differences between direct and purchased care in the way resources are allocated to facilities, in how fees for services are determined or incentivized, and in how cost information is recorded in administrative data. Second, benefit type was determined from records within the 3 mo prior to and after the diagnosis date. Members’ benefit eligibility and plan elections might have changed out of this time window, potentially introducing misclassification of Prime or non-Prime status. Third, the registry data only included patients who ever received care in an MTF. Thus, patients who were never diagnosed or treated at an MTF would not have been captured in the data and limits the generalizability of our results. Next, like with other administrative data sets, coding errors and data incompleteness are possible. Therefore, cancer care costs might not be completely accurate. CONCLUSIONS Per capita breast cancer care costs within the MHS were similar by insurance benefit type and were lower for direct care compared with purchased care. Further research is needed in breast and other tumor sites to determine patterns and determinants of cancer care costs between benefit types and care sources within the MHS. This research can provide insight on strategies for reducing cancer care costs to the medical system. Additionally, it is important to consider the “value of care”, i.e., whether a higher cost is related to a better clinical outcome, when assessing costs for cancer care. To fully understand the impact of differences in cost for breast cancer treatment, the associations between cost and clinical outcomes should be evaluated in the future. Funding This project was supported by the John P. Murtha Cancer Center of the Uniformed Services University and Walter Reed National Military Medical Center under the auspices of the Henry M. Jackson Foundation for the Advancement of Military Medicine. Acknowledgements 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. References 1 National Cancer Institute. Office of Cancer Survivorship: Statistics. 2016. cancercontrol.cancer.gov/ocs/statistics; accessed June 20, 2017. 2 Yabroff KR, Lund J, Kepka D, et al.  : Economic burden of cancer in the United States: estimates, projections, and future research. Cancer Epidemiol, Biomarkers Prev  2011; 20( 10): 2006– 14. doi:10.1158/1055-9965.epi-11-0650. Google Scholar CrossRef Search ADS   3 Mariotto AB, Yabroff KR, Shao Y, et al.  : Projections of the cost of cancer care in the United States: 2010–2020. J Natl Cancer Inst  2011; 103( 2): 117– 28. 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For permissions, please e-mail: journals.permissions@oup.com. This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/about_us/legal/notices)

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Military MedicineOxford University Press

Published: Apr 11, 2018

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