The New Economics of Radiation Oncology

Radiation oncology seems to have a massive target on its collective back. The costs of all cancer treatments face increasing scrutiny. Treatment costs for the 1.6 million Americans diagnosed with cancer in 2013 will gobble at least 5 percent of healthcare spending in the U.S., Ezekiel J. Emanuel, MD, chair of the department of medical ethics and health policy at the University of Pennsylvania, wrote in a New York Times blog “A Plan to Fix Cancer Care” on March 23. Demographics presage an expanding problem; by 2030, more than 70 percent of cancer diagnoses will be made in persons eligible for Medicare.

Exacerbating the issue is the lack of a link between treatment and outcomes in some cases. A study published March 12 in Journal of the National Cancer Institute found no link between Medicare spending on advanced cancer and survival. “Most new advanced cancer therapies provide survival gains of weeks to months, and many are associated with high costs … improving the value of medical spending for advanced cancer is increasingly recognized as a priority,” wrote Gabriel A. Brooks, MD, of Dana-Farber Cancer Institute in Boston and colleagues.  

Meanwhile, the radiation oncology specialty was pegged as an absolute outlier in a perspective published Dec. 21, 2011, in the New England Journal of Medicine, which observed that the specialty was the top offender for exceeding the sustainable growth rate (SGR) target. Its excess expenditures from 2003 to 2009 as a percentage of 2002 expenditures hovered in the 300 percent range.

These figures, coupled with the looming specter of fiscal fiasco in healthcare, spiraled into the Center for Medicare and Medicaid Services’ (CMS) July 30 proposal to cut radiation oncology services 15 percent and radiation therapy payments 19 percent in the Medicare Physician Fee Schedule as of January 1. American Society for Radiation Oncology (ASTRO) Chairman Michael L. Steinberg, MD, chair of radiation oncology at the David Geffen School of Medicine at University of California, Los Angeles, has described the cuts as draconian and potentially catastrophic for patients and the specialty.

Catastrophe may have been averted in the final cuts, which totaled 7 percent for radiation oncology and 9 percent for radiation therapy. But these figures may represent a pyrrhic victory and could funnel attention away from the real issue. “Medicare cuts aren’t the issue, value is,” Steinberg asserts.

The SGR does not exist in a vacuum. The U.S. healthcare system is in the midst of a fundamental shift from a fragmented fee-for-service delivery system to one that rewards accountability, quality, safety and value. Key players have been nudged into action and developed new ideas and possible solutions. Translating these notions into practice is a work-in-progress that could offer a blueprint for healthcare stakeholders across the board.

From 2013 to 2015

Radiation oncology shouldn’t get too lost in the issue of Medicare cuts, cautions Steinberg, explaining that the funds re-allocated from radiation oncology and other specialties were used to bolster primary care initiatives. The Medicare cuts are “the right side of policy,” he says. The cuts are a near-term issue, while the transition to a value-based model is farther on the horizon.

Another point to ponder, according to Arthur L. Kellerman, MD, chair in policy analysis at RAND, is that future cuts do not need to be excised from physicians’ wallets. Annual spending on waste checked in at $750 billion in 2009, estimated the Institute of Medicine in “Best Care At Lower Cost: The Path to Continuously Learning Health Care In America,” released in September 2012. If wasteful spending can be curbed and physicians engaged to deliver the best care at the lowest cost, the transition from fee-for-service to value-based care may not be entirely painful.

Although the transition may not represent a complete fiscal wipeout for specialists, the shift will require a Herculean effort. Many proposed plans target 2015 for implementation, but the groundwork begins now.

ASTRO on March 29 announced the first step of a comprehensive payment reform effort with a proposal to revise numerous radiation oncology treatment codes to more appropriately reflect clinical practice, which includes packaging together services typically billed at the same time. For example, when precision treatment using IMRT is used to treat certain cancers, it is generally necessary to combine treatment with image guidance. This is an ideal opportunity to consolidate these two treatment codes, explains Brian D. Kavanagh, MD, MPH, from the department of radiation oncology at University of Colorado School of Medicine in Denver and head of ASTRO’s payment reform task force.

ASTRO developed the proposed revisions in response to CMS’ concerns about radiation therapy codes identified for review in the 2013 Medicare Physician Fee Schedule. The earliest the proposed codes could take effect would be January 1, 2015.

Although the code revision process is separate from the pending transition to value-based purchasing, the two should occur in parallel and may be linked, according to Kavanagh. Other essential value-based purchasing components include physician education, implementation of quality metrics and deployment of big data in decision making.

Radiation oncology stakeholders have noticed the wide variation in care models. Although some variation may be appropriate based on individual patient’s needs, in other situations more consistent and predictable ways of care may offer an effective and economical model.

Consider for example the difference between IMRT and proton beam therapy, says Emanuel. “IMRT is less expensive and, in many cases, just as effective.” Yet these differences have not halted the proliferation of proton beam treatment centers. Similarly, it is not uncommon for patients with bone metastases to receive multiple dose fractions when a single fraction is equally effective. “The price difference is pretty substantial,” he notes.  

The expected mean cost and quality-adjusted survival in months for patients receiving 8 Gy in 1 fraction and 30 Gy in 10 fractions was $998 and 7.26 months and $2,316 and 9.53 months, respectively, researchers reported in a study published in the American Journal of Clinical Oncology in August 2009.

ASTRO aims to even out variations in care delivery with a revamped accreditation program to be rolled out as soon possible. A robust accreditation program can help boost quality and consistency, says Kavanagh. Plus, accrediting practices that adhere to the highest standard of radiation oncology care could provide a link for Medicare payment to quality in radiation oncology.

However, grasping the meaning of quality and consistency is no small task. Even the gold standard of clinical research—a perfectly designed randomized clinical trial—falls short of answering these questions.

Medicare spending: No link to survival — Regional variation in advanced cancer spending. The 80 hospital referral regions are shown with colors indicating the quintile of mean regional advanced cancer spending for each region. Quintile 1 represents the highest spending and quintile 5 the lowest. There were no consistent links between spending and survival. Quintile 1 Quintile 2 Quintile 3 Quintile 4 Quintile 5 Source: March 12, Journal of the National Cancer Institute.)

Big data in modern medicine

The granddaddy of medical databases is The Society of Thoracic Surgeons STS National Database, launched in 1989 as an initiative for quality improvement and patient safety among cardiothoracic surgeons. In the last 20-plus years, the initiative has amassed a wealth of data about endpoints such as complications during hospital stays.

Now ASTRO is replicating and building on the model. The endpoints may differ, says Kavanagh, but the core principles remain constant. “We are trying to collect information about how people really practice and how that plays out by collecting evidence from a variety of sources and registries. These large-scale population-based registries offer an opportunity to look at the nuances that really affect quality.”

The STS has used its registry to compare outcomes of new surgical techniques relative to older methods. Likewise, a large, prospective prostate cancer registry could help identify features of patients who are better suited to receive treatment modalities such as stereotactic body radiation therapy (SBRT) vs. IMRT or other established methods, and vice versa.

The pilot effort will be a nationwide electronic registry focused on prostate cancer that will capture information from a range of practice configurations: academic medical centers, community hospitals and freestanding clinics. The goal is to leverage the greater statistical power derived from analyses of thousands of patients to learn about subtle differences, explains Kavanagh.

Radiation oncologists need both clinical and financial data to practice effectively in new payment and delivery models. Most physicians have no idea what they are spending, where it goes or how it compares with other physicians who care for similar patients, says Emanuel. Unknowns include imaging, treatment and hospitalization costs. With these data, radiation oncologists can begin to deliver better care at lower costs.

The other issue is that radiation oncology practices do not yet have the know-how and infrastructure to apply these data and make informed decisions. “This is one reason why we recommend that payment changes are phased in. Practices need time to adapt,” explains Emanuel.

Practices can be proactive and prep for the future by requesting data from payers and analyzing their spending. “Which spends are necessary,” he asks, offering the example of hospitalization for early stage cancer patients for symptom management as an unnecessary spend. Another is some ancillary imaging exams, Emanuel adds. 

Strategies worth a closer look

As radiation oncology practices attempt to grapple with the new economics of their specialty and of healthcare, it’s critical to understand developing trends and strategies, including appropriate use and economic innovation.

“Instead of continuing to hope that Congress will kick the SGR can down the road, specialty societies should propose self-policing to Congress and payers,” says Kellerman. If radiation oncologists can determine appropriate care and more wisely eliminate wasteful spending and inappropriate care, all stakeholders will benefit. Physicians, hospital administrators and staff should squeeze themselves based on rigorous evidence and best practices,  Kellerman urges.

ASTRO is heading in that direction and has submitted its top five items that physicians and patients should question to the American Board of Internal Medicine’s Choosing Wisely campaign, to be released this fall.

In the interim, other societies have started to address some issues of radiation oncology-related resource utilization in cases where there is overlap of patient populations. Don’t recommend more than a single fraction of palliative radiation for an uncomplicated painful bone metastasis, the American Academy of Hospice and Palliative Medicine recommended in the list of recommended strategies released in February. The Society of Thoracic Surgeons offered that patients with suspected or biopsy proven Stage I nonsmall cell lung cancer may not require brain imaging prior to definitive care in the absence of neurologic symptoms.

Related to appropriate use is value-based reimbursement. Currently, fee-for-service reimbursement incentivizes physicians to treat every patient. In some cases, the patient can be served by other options, such as watchful waiting for low-risk prostate cancer. Understanding and applying these metrics, and compensating physicians for managing care rather than treating patients, will go a long way toward curbing oncology care costs.

Another key, according to Kellerman, is encouraging innovators to focus on technologies and treatments that are inexpensive and highly effective as opposed to those that are expensive and effective. One option is coverage with evidence development, a shift that reimburses new technology at the same rate as existing treatments. If and when the new option demonstrates superiority, reimbursement increases. “If coverage with evidence development had been in place when proton beam therapy was introduced, I doubt 20 centers would have been constructed,” opines Kellerman.

Similarly, dynamic pricing may help to halt the technology arms race in radiation oncology treatment epitmized by proton beam. In this model, Medicare would pay more for diseases treated more effectively by proton therapy, such as pediatric brain cancer. Sites that use the technology to treat diseases for which proton beam has not been shown to be superior to existing treatments, such as prostate cancer, would be reimbursed at the same lower rate as existing treatment … until evidence demonstrates the superiority of proton beam.  

Although the ultimate solutions are unclear, the mandate for change is not. Practices that get on board early and embrace new strategies and change will be best-positioned for more accountable care in 2015 and beyond.