Notes from the ACCC 38th Annual National Meeting: Cost, Benefit and Trends in Radiation Technology

A study published in the April 18 issue of the Journal of the American Medical Association found that proton therapy, commonly used although it’s the most expensive way to treat prostate cancer today, didn’t really work any better than intensity-modulated radiation therapy (IMRT), a less expensive form of radiation treatment for men with early-stage prostate cancer. So, “Why would you use proton therapy if you can utilize cheaper modalities to treat the disease?” asked Najeeb Mohideen, MD, Radiation Oncology Associates, Northwest Community Hospital, Arlington Heights, IL, at the recently held ACCC Annual Meeting in Baltimore, MD.

A cost-benefit analysis of newer, high-priced radiation technologies was explored by an expert panel who, in addition to Dr. Mohideen, consisted of William Holden, vice president of cancer services, Christiana Care Health System, Helen F. Graham Cancer Center, Newark, DE; Andre Konski, MD, professor and chair, department of radiation oncology, Wayne State University School of Medicine, and Barbara Ann Karmanos Cancer Center, Detroit, MI; and was moderated by Cliff Goodman, PhD, of The Lewin Group.

Despite proton therapy’s high price tag, Dr. Mohideen did acknowledge that it might be the best option in some cases, such as when treating pediatric cancers. According to statistics, Dr. Mohideen offered that radiation technology made up only 2% of Medicare’s total spend of $83.3 billion in 2010, but that the more expensive radiation technologies were nonetheless on the rise. As an example of the increased utilization, a recent national survey of over 1,600 radiation oncologists found that 65% offered stereotactic body radiotherapy (SBRT) in 2012 whereas only a few cancer centers offered the same technology in 2005. “We’ve seen tremendous advances with high technologies like SBRT,” Dr. Mohideen said, calling the technology a game-changer as far as treating medically inoperable, early-stage lung cancer patients.

But, he emphasized that the clinical evidence needed to support these different radiation technologies is still an area of deficiency. Several reasons cited for that deficiency are that current studies are focused on too small of a patient population or that reports are taken from primarily claims-based Medicare data.

Less is More
Dr. Konski pointed out that the loss in annual dollars for a cancer center treating prostate cancer patients with a full course of radiation therapy compared to a more hypofractionated course based on current Medicare reimbursement rates and two different types of radiation therapy—either IMRT and SBRT—is staggering. In the case of SBRT, the reimbursement resulted in either a loss of $254,000 in revenue for the year (based on technical fees alone) if one patient was treated weekly based on 5 courses of SBRT, or a loss of $325,000 annually if that same patient received only 26 treatments overall or a more hypofractionated treatment regimen.

Dr. Konski also compared the cost effectiveness of treating pancreatic cancer with gemcitabine alone or with a combination of different radiation therapies and produced the following results: A cancer center would lose $12,800 in revenue per patient if that patient were treated with fewer fractions using gemcitabine and SBRT (at a cost of $56,700) versus gemcitabine and IMRT (at a cost of $69,500)—the standard therapy for pancreatic cancer. Great for the provider, Dr. Konski said, but not so good for the revenue stream of a cancer center.

Saving Money With Cyberknife
William Holden discussed the strategy that Graham Cancer Center used to get the go-ahead for the purchase and utilization of the CyberKnife®—a huge $4.7 million capital investment for the institution. “A big part of the strategy was to develop a strong relationship with Blue Cross of Delaware and show that the cost-benefit ratio of treating cancer patients with Cyberknife was cost-effective when done as an outpatient procedure, with no readmissions,” he said. Treating pancreatic patients, for example, was cut by 50% from $80,000; cranial cases showed similar cost-benefit although the cost was not cut in half. Graham is now able to get authorization for patients for Cyberknife treatment from Blue Cross in a single day.

Holden’s advice to cancer centers planning similar start-ups is to “justify your return on investment to financial management and find a champion with the clinical expertise and credibility to push the process through.” Patients benefit from Cyberknife as well, he said, especially in terms of time-savings. For example, lung cancer patients ineligible for surgery who moved to Cyberknife went from having 29 treatments to 5 fractions as outpatients; and prostate cancer patients experienced 5 days of Cyberknife rather than 29 or 30 external beam treatments.

Future Trends
According to Dr. Konski, in contrast to the lost revenue due to the trend towards more hypofractionations, the cost of the newer technology will only increase, Medicare reimbursement rates will remain stagnant or decrease, and cancer centers can’t generally make up the dollars lost in volume since there’s so much competition. And more comparative effectiveness research is sorely needed to accumulate better data on patient outcomes and the cost-benefit of these newer and pricier radiation technologies. “Any payment reform coming down the pike will be looking for excellent quality and excellent outcomes at lower cost,” Dr. Mohideen said.

by Nancy Ciancaglini

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