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Trends in Military Health
System Costs for Colorectal
Cancers, FY07-FY14
Michelle Kloc, PhD, MSN, RN
Diana D. Jeffery, Ph.D.
Joe Dorris, M.A.
Harry Burke, M.D., Ph.D.
Presentation for APHA Session 3300.1: “Best Practices and
Innovations in Cancer Care Delivery Models”
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Research Team


Altarum Institute
 Michelle Kloc, Ph.D., MSN, RN
[[email protected]]
 Joe Dorris, MA
Department of Defense
 Office of the Assistant Secretary of Defense (Health
Affairs), Defense Health Agency, Clinical Division
• Diana Jeffery, Ph.D.
 Uniformed Services University of the Health Sciences
• Harry Burke, MD, Ph.D.
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Presenter Disclosures
Michelle Kloc
Diana D. Jeffery, Ph.D.
Joe Dorris, M.A.
Harry Burke, M.D., Ph.D.
The following personal financial relationships with
commercial interests relevant to this presentation
existed during the past 12 months:
“No relationships to disclose”
3
Disclaimer

The opinions expressed herein are those of the authors, and
are not necessarily representative of the opinions or policies
of the Department of Defense (DOD); or the United States
Army, Navy, Marine Corps, Air Force, or Coast Guard
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Overview of Colorectal Cancers

What are Colorectal Cancers?
 A cancer of the colon or rectum, located at the digestive tract's lower
end
 Most colorectal cancers start as a non-cancerous polyp – a growth
that starts in the inner lining of the colon or rectum and grows toward
the center. Only certain types of polyps (called adenomas) can
become cancer.
 Over 95% of colon and rectal cancers are adenocarcinomas. These
are cancers that start in gland cells, like the cells that line the inside
of the colon and rectum.

Risk Factors for Colorectal Cancers





Age
History of ulcerative colitis or Crohn’s disease
Family history of colorectal cancer
Cooking meats at very high heat
Eating diets high in red or processed meats
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Colorectal Cancer Statistics

Prevalence
 Colorectal cancer is the second most common cancer
found in men and women in this country1
 Colorectal cancer is the #2 cancer killer in the US among
cancers that affect both men and women2
 Approximately 132,700 new colorectal cancers diagnosed
each year3

Direct Costs
 The mean total colon cancer cost per Medicare patient 1
year after diagnosis was $29,196.4
 Average 1-year costs for veterans who predominately used
Medicare was $39,136; for veterans who predominately
use VA was $36,146; and for dual users was $44,264. All
were statistically significantly different.5
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Objective

To examine the trends in costs for colorectal cancer patients
receiving care in the Military Health System (MHS), by age
group and gender from fiscal years (FY) 2007 – 2014
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Study Design
Study Population

Study Population
 MHS beneficiaries ages 18 to 64, residing within the United States,
were included only if they had accessed the healthcare system within
the FY.
 Included individuals were assigned to one of three groups based upon
the system of care in which their healthcare occurred:
• Direct Care (DC) – if all healthcare for a FY occurred in military
treatment facilities
• Purchased Care (PC) – if all healthcare for a FY occurred in a
civilian network facility
• Both Systems (Both) – if healthcare for a FY occurred in both
military and civilian facilities
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Study Design
Data and Analysis

Data
 Principle ICD-9 codes for claims paid by TRICARE in FY07-14 were
obtained from the MHS Master Data Repository
 Cancer diagnoses were identified using the Agency of Healthcare
Research and Quality (AHRQ) Clinical Classification Software
algorithm

 HEDIS-based measures
• A beneficiary was considered to have a cancer if they had a minimum
of:
– a) 2 outpatient visits within a FY with the same ICD-9, and/or
– b) 1 inpatient admission for a given ICD-9.
 Costs were standardized to 2014 dollars
Analysis
 Descriptive statistics and time-series linear regression models were
used to analyze the data.
 Regression models controlled for beneficiary category, sponsor Service
branch, age group, gender, comorbids, and TRICARE plan.
 Costs were standardized to 2014 dollars
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Demographic Descriptive Statistics of Colorectal
Cancer Diagnosed Individuals
Min
Min FY
Max
Max FY Average N Average %
Male
Female
3,489
3,772
FY14
FY07
3,771
4,499
FY09
FY10
3,673
4,208
48.38%
55.43%
18 to 30
31 to 44
45 to 64
129
721
6,485
FY07
FY08
FY14
760
823
6,850
FY09
FY09
FY10
397
769
6,714
5.23%
10.13%
88.45%
Active Duty
Active Duty Family Members
Retirees/Retiree Family Members
Other
Service
Air Force
Army
Coast Guard
Marines
Navy
Total
426
398
6,005
176
FY08
FY07
FY14
FY07
736
778
6,414
222
FY09
FY09
FY10
FY11
574
561
6,250
205
7.56%
7.40%
82.34%
2.70%
2,255
2,725
147
422
1,733
7,197
FY13
FY07
FY07
FY07
FY08
FY07
2,441
3,278
180
529
1,949
8,122
FY09
FY09
FY14
FY09
FY09
FY09
2,369
3,021
167
462
1,825
7,591
31.21%
39.79%
2.20%
6.09%
24.04%
100.00%
Gender
Age Group
Beneficiary Category
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Results
Trends in Colorectal Cancer Non-Pharmacy Costs
Per Person Non-Pharmacy Costs for
Colorectal Cancer, by Gender and Age
Group, Over Time
$50,000
$40,000
$30,000
$20,000
$10,000
$0
FY08
FY09
FY10
FY11
FY12
FY13
FY14
Government Paid Amounts
Government Paid Amounts
Per Person Non-Pharmacy Costs for
Colorectal Cancer, by Age Group,
Over Time
$60,000
$50,000
$40,000
$30,000
$20,000
$10,000
$0
FY07
FY08
31 to 44
45 to 64
FY10
FY11
FY12
FY13
FY14
Fiscal Year
Fiscal Year
18 to 30
FY09
Female 18 to 30
Female 31 to 44
Female 45 to 64
Male 18 to 30
Male 31 to 44
Male 45 to 64
• By FY14, non-pharmacy costs highest for ages 18-30
• Non-pharmacy costs experienced a dramatic decrease in FY09 for several
age groups
• Males ages 18 to 30 have had consistently higher non-pharmacy costs
than other gender-age groups
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Results
Trends in Colorectal Cancer Pharmacy Costs
Per Person Pharmacy Costs for
Colorectal Cancer, by Gender and Age
Group, Over Time
$4,000
$3,000
$2,000
$1,000
$0
FY07
FY08
FY09
FY10
FY11
FY12
Fiscal Year
FY13
FY14
Government Paid Amounts
Government Paid Amounts
Per Person Pharmacy Costs for
Colorectal Cancer, by Age Group,
Over Time
$7,000
$6,000
$5,000
$4,000
$3,000
$2,000
$1,000
$0
FY07
FY08
FY09
FY10
FY11
FY12
FY13
FY14
Fiscal Year
18 to 30
31 to 44
45 to 64
Female 18 to 30
Female 31 to 44
Female 45 to 64
Male 18 to 30
Male 31 to 44
Male 45 to 64
• By FY14, Pharmacy costs highest for ages 45-64, closely followed by ages 31
to 44
• Pharmacy costs have been consistently higher for males ages 18-44 than
other gender-age groups
• Pharmacy costs for males ages 18-44 have generally consistently increased
over time
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Results
Time-Series Regression: Non-Pharmacy Costs Model
DC-Only
Coef. P>|t|
Age 31 to 44
Age 45 to 64
Comorbid
Heart DX
Diabetes
COPD
Asthma
Arthritis
Back DX
Mood DX
Other Mental
DX
Female
time_female
time_31to44
time_45to64
time
_cons
1484.18 0.607
2760.96 0.273
390.58 0.702
13599.38 <0.001
283.96 0.866
-245.31 0.915
-3563.60 0.222
-2586.60 0.272
1843.86 0.241
6519.59 0.002
-329.77
-3102.64
29.56
510.87
756.18
-1199.16
22801.51
PC-Only
Coef. P>|t|
-4364.14
-9968.64
3935.92
1956.76
-3011.21
3532.93
-5616.72
-5830.35
44.15
674.31
0.369
0.029
0.000
0.036
<0.001
<0.001
<0.001
<0.001
0.952
0.498
Both Systems
Coef. P>|t| Per person non-
pharmacy costs for
20163.61 <0.001
Colorectal Cancer
10340.23 0.003
statistically
220.63 0.797
11396.42 0.000 significantly
-1115.47 0.412 decreased over time
9135.50 <0.001 for DC-Only users.
1615.47 0.494
-3250.20 0.047 Presence of
1077.32 0.390 comorbid
3339.23 0.033 diagnoses
significantly impacts
0.897 10111.67 <0.001 3730.76 0.092 costs in PC-Only and
0.081 -2108.00 0.092 -9694.92 <0.001
Both Systems.
0.926
0.374
0.118
0.021
0.000
-190.73
722.31
756.40
-960.02
26219.75
0.289
261.31
0.432 -1747.69
0.372 -884.89
0.266 -124.16
0.000 18970.62
0.400
0.021
FEMALES COSTS
0.189
0.861 WERE LOWER
0.000 THAN MALES….
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Results
Time-Series Regression: Pharmacy Costs Model
Age 31 to 44
Age 45 to 64
Comorbid
Heart DX
Diabetes
COPD
Asthma
Arthritis
Back DX
Mood DX
Other Mental DX
Female
time_female
time_31to44
time_45to64
time
_cons
DC-Only
Coef. P>|t|
2876.94
0.02
1908.07 0.116
-1418.56 <0.001
3116.94 0.018
2767.70 0.000
1448.21 0.140
1153.47 0.353
1176.94 0.240
1508.52 0.024
2745.39 0.002
798.69 0.462
396.40 0.687
-434.79 0.023
-402.00 0.105
-139.91 0.564
68.23 0.773
6848.33 0.000
PC-Only
Both Systems
Coef. P>|t|
Coef. P>|t|
1430.86 0.088 2265.69 <0.001
1166.64 0.150 1610.01 0.014
553.23 <0.001
321.23 0.029
354.61 0.026 1134.45 <0.001
861.66 <0.001
934.14 <0.001
899.77 0.000
773.99 0.011
418.86 0.063
324.44 0.423
104.53 0.498
-5.08 0.986
990.58 <0.001
391.51 0.068
1464.25 <0.001 1320.95 <0.001
1392.07 <0.001 -225.87 0.552
116.03 0.760 -532.35 0.251
-122.65 0.083
0.97 0.991
-194.20 0.222 -146.01 0.263
-225.98 0.138
-82.75 0.524
392.80 0.016
5.69 0.965
-36.29 0.967 2252.00 0.002
Per person
pharmacy costs
for Colorectal
Cancer statistically
significantly
increased over
time for PC-Only
users.
Presence of
comorbid
diagnoses
significantly
impacts
pharmacy costs
in all systems of
care.
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Results
Time-Series Regression: Total Costs Model
Age 31 to 44
Age 45 to 64
Comorbid
Heart DX
Diabetes
COPD
Asthma
Arthritis
Back DX
Mood DX
Other Mental
DX
Female
time_female
time_31to44
time_45to64
time
_cons
DC-Only
Coef.
P>|t|
4078.70
0.231
4387.51
0.140
-1023.12
0.396
16719.54 <0.001
3060.27
0.125
1177.25
0.666
-2509.91
0.466
-1463.06
0.599
3332.14
0.073
9189.28 <0.001
437.50
-4041.20
-118.05
162.28
682.18
-1132.38
29732.76
PC-Only
Coef. P>|t|
-2769.48 0.586
-8484.83 0.075
4488.08 <0.001
2312.97 0.018
-2149.05 0.006
4434.80 <0.001
-5197.24 <0.001
-5724.73 <0.001
1036.42 0.175
2140.08 0.040
Both Systems
Coef. P>|t|
22344.11 <0.001
11657.45 <0.001
540.88 0.547
12530.88 <0.001
-177.27 0.901
9909.02 <0.001
1941.17 0.432
-3254.68 0.058
1469.76 0.263
4659.00 0.005
0.885 11505.58 <0.001 3507.42 0.130
0.054 -2241.78 0.087 -10432.80 <0.001
0.755 -263.20 0.162
307.47 0.344
0.811
494.65 0.607 -1874.92 0.018
0.232
462.15 0.602 -902.83 0.201
0.065 -591.21 0.512 -156.18 0.833
0.000 26304.06 0.000 21393.37 0.000
Per person total
costs for
Colorectal Cancer
marginally
statistically
significantly
decreased over
time for DC-Only
users.
Presence of
comorbid
diagnoses
significantly
impacts PC-Only
and Both
Systems.
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Summary




Non-pharmacy costs for colorectal cancer patients
 decreased non-significantly by 1% between FY07-14.
 decreased significantly for users of DC-Only care.
 statistically significantly decreased over time for ages 31-64
compared to ages 18-30.
Total pharmacy costs (all scripts)
 increased non-significantly
 Per person costs increased significantly for PC-only users.
Total costs
 Non-significantly increased over time
 Significantly decreased for ages 31-64 compared to ages 18-30
Presence of comorbid conditions significantly impacts costs across
systems of care, in both positive and negative directions.
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Conclusions




Changes in per person costs likely relate to updates in clinical
guidelines, reimbursement criteria and pharmaceutical
treatment options for treatment of Colorectal Cancer
Updates in clinical guidelines and pharmaceutical treatment
options may have important cost implications, which may be
seen mostly clearly by age group.
Younger age groups less likely to have CRCa screening, as
the recommended age for screening is 50 years of age.
Advanced stage at diagnosis or more aggressive cancer may
explain differences in costs.
Results reflect overall trends to increase CRCa screening.
17
References
1.
2.
3.
4.
5.
SEER Cancer Statistics Factsheets: Colon and Rectum Cancer.
National Cancer Institute. Bethesda, MD,
http://seer.cancer.gov/statfacts/html/colorect.html
U.S. Cancer Statistics Working Group. United States Cancer Statistics:
1999–2012 Incidence and Mortality Web-based Report. Atlanta (GA):
Department of Health and Human Services, Centers for Disease
Control and Prevention, and National Cancer Institute; 2015.
SEER Cancer Statistics Factsheets: Colon and Rectum Cancer.
National Cancer Institute.
Luo Z, Bradley CJ, Dahman BA, et al. (2009). Colon Cancer Treatment
Costs for Medicare and Dually Eligible Beneficiaries. Health Care
Financing Review. 31(1): 35-50.
Hynes DM, Tarlov E, Lee TA, et al. (2007). VA Colon Cancer Quality
and Costs Study: Estimating Healthcare Costs for Colon Cancer. Work
done for VA. Last accessed: September 29, 2015. Obtained from:
http://www.hsrd.research.va.gov/for_researchers/cyber_seminars/archi
ves/hmcs-101712.pdf
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