Complementary and Alternative Medicine Provider Use and Expenditures by Cancer Treatment Phase

Objective: To assess the use of complementary and alternative medicine (CAM) providers and the associated expenditures by specific treatment phases among patients with cancer.

Study Design: Cross-sectional analysis of medical services utilization and expenditures during the 3 therapeutic phases of initial, continuing, and end-of-life life treatment.

Methods: Analysis of an insurance claims database that had been matched to the Washington State Surveillance, Epidemiology, and End Results cancer registry.

Results: Of 2900 registry-matched patients, 63.2% were female, the median age was 54 years, and 92.7% were of white race/ethnicity. Breast cancer was the most frequent diagnosis (52.7%), followed by prostate cancer (24.7%), lung cancer (10.1%), colon cancer (7.0%), and hematologic malignancies (5.6%). Patients using CAM providers represented 26.5%. The proportion of patients using CAM was similar during each treatment phase. All patients used some conventional care. Age, female sex, breast cancer diagnosis, and white race/ethnicity were significant predictors of CAM use. Diagnosis of a musculoskeletal problem occurred at some time during the study for 72.1% of patients. CAM provider visits represented 7.2% of total outpatient medical visits, and 85.1% of CAM visits resulted in a musculoskeletal diagnosis. Expenditures for CAM providers were 0.3%, 1.0%, and 0.1% of all expenditures during the initial, continuing, and end-of-life phases, respectively.

Conclusions: For patients with cancer, musculoskeletal issues were the most commonly listed diagnosis made by a CAM provider. Although expenditures associated with CAM are a small proportion of the total, additional studies are necessary to determine the importance that patients place on access to these services.

(Am J Manag Care. 2008;14(5):326-334)

Under a system in which complementary and alternative medicine (CAM) providers are covered by insurance, 26.5% of patients with cancer will see a licensed alternative provider during the course of their therapy.

• The proportion of patients seeing CAM providers does not significantly vary among the 3 therapeutic phases of initial, continuing, and end-of-life treatment.
• Expenditures for CAM services are a small proportion of overall expenditures.

Cancer is the second leading cause of death in the United States.¹ The American Cancer Society² estimated that in 2007 more than 1.4 million new cancer cases would be diagnosed and that more than 500,000 persons would die of this disease. Cancer treatment costs are substantial because of the direct cost of new increasingly expensive treatments³ and the enormous indirect costs associated with time spent during treatment for patients and their family members.⁴ Patient surveys have shown that some of these expenditures are for complementary and alternative medicine (CAM) providers, as more than 70% of patients with cancer will use some form of CAM after the diagnosis of cancer and at least 16% of patients with cancer visit a CAM provider.⁵ The use of CAM by patients with cancer is associated with treatment of specific symptoms,^6-11 female sex, diagnosis of breast cancer, and white race/ethnicity.¹²

Previous health services research studies have grouped conventional provider utilization and expenditures for cancer care based on intervals after diagnosis. To accomplish this, Medicare datasets have been matched to cancer registry data.^13,14 This adds diagnostic detail and mortality end points that are present in registry data to claim-based administrative data. These registry-matched cancer studies have documented healthcare utilization by treatment phase (during the initial 12 months following diagnosis, during the last year of life, and during the continuing period between these 2 phases).⁴ Utilization analysis during each phase captures a different picture of cancer care than a single cross-sectional evaluation. To our knowledge, this type of evaluation has not been performed to assess the use of CAM providers for cancer treatment.

Historically, third-party payment records have been a poor choice for studying CAM provider services because CAM care has traditionally been paid for out-of-pocket¹⁵ and because large public payers (such as Medicare) do not cover most CAM provider services. Some states have taken legislative steps to change this and to integrate CAM providers into mainstream healthcare finance.^16,17 In 1996, Washington State passed legislation requiring every category of licensed healthcare provider to be covered by private insurance. This mandated the inclusion of acupuncturists, naturopathic physicians, and massage therapists into commercial insurance products; legislative mandates in 1983 had already covered chiropractors.¹⁸ Therefore, Washington State’s mandate for CAM coverage created a large bank of insurance claims data in which CAM providers have been consistently covered since 2000. Matching enrollment and claims data from a subset of individuals who were privately insured from 2000 to 2004 to the Fred Hutchinson Cancer Research Center’s western Washington State Surveillance, Epidemiology, and End Results (SEER) cancer registry identified a cohort of patients with insurance claims and registry information. These data were used to assess the factors that predict CAM use by distinct therapeutic phases, the medical reasons for CAM use during these phases, and the proportion of expenditures resulting from CAM provider care.

METHODS

This study was approved by the institutional review boards of the University of Washington and the Fred Hutchinson Cancer Research Center. Eligible participants consisted of registry-matched patients with cancer aged 18 to 64 years who were diagnosed as having breast, colorectal, hematologic, lung, or prostate cancer from January 2000 through December 2003 and had no prior cancer diagnosis. In addition, eligibility criteria included having insurance coverage at the time of diagnosis and maintaining coverage at least 12 months after diagnosis or (in the situation of survival of <1 year) maintaining contiguous coverage from diagnosis to death. A large private provider of multiple insurance product types supplied the insurance data.

Data

Logistic regression analysis assessed the potential predictors of CAM use during each study phase. Separate regression analyses were performed for each predictor of interest because no adjustments were made for other covariates. Odds ratios were considered statistically significant at P <.05, corresponding to a 95% confidence interval (CI) not containing 1.0. No adjustments were made for multiple comparisons. All analyses were performed using commercially available statistical software (STATA version 9.2; StataCorp LP, College Station, Texas).²⁶

RESULTS

Of 900,000 persons with private insurance coverage from 2000 to 2004, 2900 were registry-matched patients with cancer who met the study criteria. The study population is summarized in Table 1. In the cohort, 93.0%, 84.8%, and 10.7% of participants had data for the initial, continuing, and end-of-life phases, respectively. Most participants were urban, female, and of white race/ethnicity. Breast cancer accounted for more than 52.7% of all cancer diagnoses, followed by prostate, lung, colorectal, and hematologic malignancies. Patients with lung cancer accounted for 58.7% of patients in the end-of-life treatment phase. The median age of all patients at diagnosis was 54 years, and almost two-thirds of participants were diagnosed as having localized cancer. Point-of-service plans, preferred provider organizations, and group policies were the predominant forms of coverage. Patients with at least 1 claim from a CAM provider accounted for 26.5% of the cumulative cohort of patients with cancer. The use of different CAM provider types was not mutually exclusive. Chiropractors were the most commonly used CAM provider. The prevalence of CAM claims was higher, although not statistically significantly so, in the continuing phase (21.8%) and in the initial phase (19.5%) compared with the end-of-life phase (17.7%). All patients used some form of conventional care.

Predictors of and Reasons for CAM UseTable 2 gives potential predictors of CAM use during each of the 3 treatment phases. The estimated odds ratio (OR) of CAM use for patients diagnosed as having breast cancer was significantly higher than that for patients diagnosed as having colorectal cancer during the initial phase (OR, 1.85; 95% CI, 1.19-2.87) and during the continuing phase (OR, 2.04; 95% CI, 1.29-3.22). The estimated OR of CAM use was not significantly different for patients with hematologic malignancies, prostate cancer, lung cancer, and colorectal cancer. No significant differences were found between the estimated OR of CAM use for patients presenting with local cancer compared with that of patients presenting with nonlocal cancer during the initial phase (OR, 1.17; 95% CI, 0.96-1.43). The estimated OR for CAM utilization was marginally lower for older patients during the initial and continuing phases. Patients having group policies had higher odds of CAM use compared with patients having individual policies during the continuing phase only (OR, 1.58; 95% CI, 1.14-2.18). Patients with an insurance product other than a preferred provider organization or a point-of-service plan had slightly higher CAM use in the continuing phase and for the aggregated phases than patients with a point-of-service plan. CAM use did not vary significantly between individuals residing in urban vs nonurban settings.

Among 895 patients receiving chemotherapy, 455 (50.8%) had a diagnosis of nausea or vomiting; 26 of these (5.7%) visited an acupuncturist (data not shown). For patients receiving chemotherapy, the estimated OR of receiving acupuncture was not significantly different for individuals with nausea or vomiting vs individuals without nausea or vomiting (OR, 1.51; 95% CI, 0.81-2.82). Approximately 3.9% of all study participants&#8217; visits to an acupuncturist were for nausea or vomiting.

Diagnostic codes for lymphedema were recorded for 240 women (15.7%) with breast cancer. Of these, 29 (12.1%) were treated by a massage therapist and 155 (64.6%) by a physical or occupational therapist. Comparing women with and without lymphedema, the estimated OR of massage therapy was 58% higher for women with lymphedema (OR, 1.58; 95% CI, 1.02-2.45). Among women with breast cancer, the OR of visiting a massage therapist was estimated to be 3.71 (95% CI, 2.78-4.94) times higher for women with lymphedema compared with women without lymphedema.

Expenditures and Use of CAM and Conventional Services

The mean per capita expenditures and the relative contribution of selected services for each treatment phase are shown in the Figure. The least expensive phase for cancer treatment was the continuing phase, which we estimated to result in $12,429 of annual expenditures. Expenditures for the initial phase were $38,587, and the most costly interval (the end-of-life phase) resulted in $115,994 per capita expenditures. Inpatient hospital and outpatient provider expenditures for conventional treatments accounted for more than 50% of all expenditures during each treatment phase. Expenditures for inpatient and hospice care were proportionately higher during the end-of-life phase than they were in the other treatment phases. Although 179 patients (57.7%) who died used hospice at the end of life, only 1.6% of end-of-life expenditures were for this service. Expenditures for CAM providers were a small portion of overall expenditures, as shown in the Figure. CAM providers accounted for 1% or less of total healthcare expenditures during all 3 treatment phases. As a proportion of outpatient provider charges only, CAM services accounted for 1.2%, 3.1%, and 0.4% of the initial, continuing, and end-of-life phases, respectively (data not shown). CAM outpatient provider expenditures were 1.5% of the total outpatient provider expenditures during the entire study period.

DISCUSSION

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