Large Cost Variations for Radiotherapy in Medicare Patients

Roxanne Nelson

August 13, 2015

There is wide variation in Medicare reimbursement for radiation therapy in cancer care, but the reasons for these differences are largely unrelated to patient or disease factors, according to new data.

The findings come from an analysis of 55,288 patients with breast, lung, and prostate cancers who were treated with radiotherapy. The study was published online August 11 in the Journal of Oncology Practice.

"Our research suggests inefficiency in our current fee-for-service reimbursement paradigm," said lead author James Murphy, MD, assistant professor at the University of California, San Diego School of Medicine and a radiation therapist at Moores Cancer Center at UC San Diego Health.

"This current analysis didn't address the question of whether patient outcomes are improved, or not, by more healthcare spending, although that is a very relevant and difficult question to answer," Dr Murphy told Medscape Medical News.

Other studies have explored the cost variations in Medicare reimbursement. As previously reported by Medscape Medical News, in 2012, Medicare spent, on average, $15,357 per beneficiary in Miami and $6569 per beneficiary in Grand Junction, Colorado. And providers accounted for 73% of variation in post acute-care costs, such as long-term care hospitals, according to a report from the Institute of Medicine.

"Reimbursement patterns that vary by geography or hinge on individual providers suggest either suboptimal healthcare delivery or inefficient reimbursement practices," Dr Murphy and his colleagues write.

Multiple Factors Influence Cost

For their study, Dr Murphy's team identified 55,288 patients in the SEER–Medicare linked database who were diagnosed with breast, lung, or prostate cancer from 2004 to 2009. The cost of radiation therapy was estimated from Medicare reimbursements.

The median cost for a course of radiation therapy per patient was $8600 (interquartile range [IQR], $7300 to $10300) for breast cancer, $9000 (IQR, $7500 to $11,100) for lung cancer, and $18,000 (IQR, $11,300 to $25,500) for prostate cancer.

Breast and lung cancers had normal distributions for cost, but prostate cancer had a more "dispersed distribution," they note.

Across all three cancers, more than 20% of cost variability was attributable to factors unrelated to the patient. This was particularly pronounced in prostate cancer, where these factors accounted for more than 50% of variability.

The overall cost of radiation therapy itself waxed and waned during the study period. It increased from 2004 to 2007, decreased uniformly for all disease sites in 2007 and 2008, and then resumed an upward trend in 2009. The geographic region where the treatment was being administered also played a role; the cost was lowest in Hawaii and highest in Washington state.

In addition, the type and length of treatment influenced cost, with longer courses of radiation therapy, intensity-modulated radiation therapy (IMRT), stereotactic radiation therapy, and proton therapy all costing more than standard conformal radiation therapy.

For example, proton therapy in prostate cancer cost $24,400 more than standard conformal radiotherapy (P < .001) and $11,000 more than 35 daily fractions of IMRT.

The setting in which treatment is delivered also affects cost, particularly for prostate cancer. Treatment delivered in a freestanding radiation oncology clinics resulted in $11,800 more in Medicare reimbursement than treatment delivered in hospital-associated clinics (P < .001).

Because this study doesn't consider the relation between the cost of radiotherapy and quality of care, it is possible that higher-cost radiation could lead to higher-quality radiation, the researchers note. And because treatment guidelines and reimbursement codes have changed since this study was completed, these changes will undoubtedly affect cost variation.

"Medicare as a whole is starting to pivot away from fee-for-service reimbursement models," Dr Murphy explained. "I think our patients, as well as policymakers, want to see value-based reimbursement."

The study was supported by grants from the National Institute of Health. The authors have disclosed no relevant financial relationships.

J Oncol Pract. Published online August 11, 2015. Abstract

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