Changes Over Time for Radiation Oncology Reimbursement for Specific Treatment Courses

Purpose/Objective(s)

Radiation oncology (RO) has seen declines in Medicare reimbursement (MCR) and will see an additional $300 million projected decline if the RO Alternative Payment Model (RO-APM) is implemented. To our knowledge there are no contemporary studies analyzing changes in MCR over time for common RO treatment courses. Understanding how reimbursement for RO courses has changed over time will provide a baseline comparison for the RO-APM, as MCR under RO-APM is episode-based. Our study aims to quantify changes in MCR for common photon RT treatment courses from 2010 to 2020. We hypothesize that the declines will be highest for IMRT treatment courses.

Materials/Methods

CMS Physician/Supplier Procedure Summary databases were used to obtain reimbursement for all RO procedures in 2010, 2015, and 2020 for free-standing facilities. Average reimbursement (AR) per billing instance was calculated for each Healthcare Common Procedure Coding System code using 2020-adjusted dollars. For each RT course, a RO billing expert selected the codes associated with that course along with the billing frequency of each code. For each year, the billing frequency of each code for a given treatment was multiplied by the AR per code and the results summed. AR for 15 common RO courses were analyzed: head and neck (HN), breast (B), prostate (P), lung (L), and palliative (Pa)(Table).

Results

AR decreased for all 15 courses from 2010 to 2020. From 2015 to 2020, the only course that increased in AR was palliative 2D 30 Gy/10 (0.4% increase). IMRT courses saw the largest AR decline from 2010 to 2020. The AR for a 37-fx prostate bed IMRT plan averaged $32.1K in 2010, $23K in 2015 (-28%), and $19.7K in 2020 (-39%). The AR for a 5-fx IMRT accelerated partial breast irradiation (APBI) averaged $6.9K in 2010, $5.2K in 2015 (-25%) and $4.2K in 2020 (-39%).

Conclusion

We report significant declines in MCR from 2010 – 2020 for common RO courses with the largest declines for IMRT. Hypofractionated regimens were not spared severe cuts, discouraging its broader adoption. Policymakers should consider the significant cuts to MCR that have already occurred when considering further cuts, and the negative impact of such cuts on quality and access to care.