Payment policies may be driving down utilization of key interventional radiology procedure

The use of a key interventional radiology procedure for kidney cancer has declined in recent years, with reimbursement a likely factor, according to new research published Tuesday. 

Renal cell carcinoma is the ninth most common cancer in the U.S., and its incidence has doubled over the past 50 years. Total removal of the kidney is the most common approach, though emerging IR alternatives can help preserve the organs’ function while curbing high surgical costs, experts detailed in Clinical Imaging. 

Such image-guided ablation, however, remains woefully underutilized among hospital inpatients. Across nearly 184,000 hospitalized individuals, fewer than 2% underwent the minimally invasive procedure, which uses a small incision and heat or cold to destroy the tumor. That’s compared to about 38% who received a partial nephrectomy and 60% who had the affected kidney completely removed, researchers found. 

Patients on Medicaid or Medicare were more likely to undergo the IR procedure when compared to those with private insurance (who had higher chances of nephrectomy). 

“Factors such as lower costs to the insurer could influence the trend toward increased utilization of ablation among Medicare and Medicaid patients. Ablation provides shorter procedure times and fewer postoperative hospital recovery days, thus conferring lower overall costs,” lead author Tarig S. Elhakim, MD, with the University of Pennsylvania Health System, and colleagues wrote Jan. 21. “Conversely, nephrectomy procedures are associated with higher physician reimbursement rates, which may relate to the increased procedural times. These reimbursement differences could influence referral biases based on insurance coverage, highlighting an area that policymakers and physicians should further investigate to dismantle disparities.”

Researchers gathered their data from the National Inpatient Sample spanning 2016 to 2020, using ICD-10 codes to pinpoint patients hospitalized for renal cell carcinoma. Individuals who underwent ablation tended to be older (average age of 67) compared to those who opted for partial (59) or full nephrectomy (62). Black and Latino patients also were more likely to receive the IR-based procedure than their white peers. And inpatients treated for kidney cancer in 2020 were less likely to undergo ablation when compared to those treated in 2016, the authors reported. 

Speculating on reasons for these disparities, Elhakim and colleagues noted that private insurance may cover a broader range of treatment options, allowing for easier access to surgical options at specialized centers. This despite Medicaid patients suffering disproportionately from renal cell carcinoma compared to the commercially insured. Ablation referrals typically come from urologists, and their preference for surgery—due to greater familiarity with related research, and the IR alternative’s relative novelty—may be limiting patient volumes. Advancements in outpatient ablation also may have led to declines on the inpatient side, the authors added. 

“In the U.S., the white demographic is generally more economically advantaged than racial minorities,” the study stated. “This inequity, along with the higher likelihood of nephrectomy on privately insured patients, may indicate preferential treatment patterns and referral biases toward surgical interventions for economically advantaged patients and ablation for less economically privileged groups. Additionally, limited health literacy among African American and Hispanic patients may prevent them from understanding complex medical information, including the risks and benefits of different treatment options.” 

“While the cause of these disparities could be multifactorial in nature, multimodal health policy approaches addressing access and health literacy could serve as a potential avenue for mitigating racial disparities in RCC treatment,” they added later. “Efforts to improve health literacy, enhance patient-provider and provider-provider communication, and address socioeconomic barriers are crucial to enhancing equity.”