Use of advanced radiation influenced by Medicare reimbursement

Smith BD. J Natl Cancer Inst. 2011;doi:10.1093/jnci/djr100.

Issue: May 25, 2011

From 2001 to 2005, billing for intensity-modulated radiation therapy for breast cancer treatment increased 10-fold, according to an article published in the Journal of the National Cancer Institute. The cost of radiation therapy increased sharply during the study period.

Compared with conventional, 2-D- or 3-D radiation therapy, IMRT may reduce toxicity and improve cosmetic outcomes for women undergoing breast conservation therapy. However, simpler approaches to 3-D treatment may have the same benefits with lower costs; thereby causing controversy about the justification of billing Medicare for IMRT.

To determine the clinical, demographic and economic factors associated with IMRT, Benjamin D. Smith, MD, of The University of Texas MD Anderson Cancer Center, and colleagues collected data from the SEER-Medicare database on 26,163 women with localized breast cancer who had undergone surgery and radiation from 2001 to 2005.

According to the researchers, Medicare billing for IMRT increased from 0.9% of patients diagnosed in 2001 to 11.2% of those diagnosed in 2005. The average cost of radiation within the first year of diagnosis was $7,179 without IMRT and $15,230 with IMRT, according to a press release.

Billing for IMRT was more than five times higher in geographic regions with local Medicare coverage compared with regions not covered (OR=3.34; 95% CI, 2.81-3.96). In addition, billing was more frequent for patients treated in freestanding radiation centers (OR=1.36; 95% CI, 1.20-1.53) compared with those treated in hospital-based outpatient clinics (OR=0.39; 95% CI, 0.30-0.50).

In most cases, inverse planning – one of two approaches to 3-D modulation of the radiation beam profile – is a prerequisite for IMRT billing with Medicare, according to the researchers. Inverse planning is more expensive, requiring more physician and treatment planning time. However, field-in-field forward planning and inverse planning are likely to have similar outcomes, the researchers said.

"Our data suggest that with respect to breast radiation therapy, much of the variation in cost can be directly attributed to inconsistent treatment definitions and reimbursement rates authorized by Medicare and its intermediaries," they wrote.

According to an accompanying editorial by Lisa A. Kachnic, MD, of Boston University School of Medicine, and Simon N. Powell, MD, PhD, of Memorial Sloan-Kettering Cancer Center, the evidence supporting the routine use of inverse-planned IMRT for patients requiring breast-only treatment is weak. They suggest that the true value of inverse-planned IMRT will most likely be for patients with complex anatomy or those with more advanced breast cancer who require comprehensive nodal targeting. Efforts should be made to determine the group of patients most suitable for this method, they wrote.

The conclusion of the study, the editorialists wrote, "would appear to confirm the suspicion of many, both within and outside of the health care industry, that medical decision-making is too heavily influenced by reimbursement rather than medical necessity."

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