Medicare Reimbursement Policies and Practice Settings Impact Access to Advanced Radiation for Breast Cancer Patients

Newswise — HOUSTON – Billing for intensity modulated radiation therapy (IMRT) for the treatment of breast cancer increased more than ten-fold from 2001-2005, thus contributing to a 33 percent increase in the cost of breast radiation, according to a new report from The University of Texas MD Anderson Cancer Center.

According to the report, Medicare coverage for IMRT for breast cancer varied across the 16 geographical regions researchers examined in the United States, with local coverage determinations favorable to breast IMRT in some regions and unfavorable to breast IMRT in other regions.

The authors note that the data illustrated that the current Medicare reimbursement system is structured to either control cost, as in regions with unfavorable coverage for breast IMRT, or to promote quality, as in regions that allow billing IMRT charges for patients with breast cancer.

Researchers also found that the type of treatment facility – whether a free-standing radiation center or a hospital clinic – was among the key factors influencing the adoption of IMRT.

The study, published in the April 29, 2011, issue of The Journal of the National Cancer Institute, examined the clinical, demographic and economic factors associated with the adoption of IMRT, a more costly therapy compared with standard radiation treatment methods.

IMRT is a type of three-dimensional radiation therapy that matches the radiation beam to the size and shape of a tumor using sophisticated treatment planning systems. Compared with standard therapy, IMRT enables radiation oncologists to deliver a more uniform dose of radiation to the breast, resulting in fewer side effects, such as scarring and burning of the skin. Doses to critical structures such as the heart and lungs may also be reduced.

“This study offers a timely snapshot of how one advanced cancer treatment is being adopted across the United States, and the factors that are driving that adoption,” said Benjamin D. Smith, M.D., an assistant professor in the Department of Radiation Oncology at MD Anderson and lead author on the study. “Our analysis demonstrates a real need for novel reimbursement strategies that simultaneously incentivize the implementation of such clinically important treatments while still promoting cost-effectiveness. This balanced approach will benefit patient access nationwide.”

In the study, researchers reviewed Medicare records for 26,163 women aged 66 years or older with nonmetastatic breast cancer treated with surgery and radiation therapy between 2001-2005 to compare the demographic, health services, tumor and treatment characteristics. A claim for IMRT was present in 1,567 patients and increased from 0.9 percent of patients diagnosed in 2001 to 11.2 percent of patients diagnosed in 2005.

The mean cost of radiation therapy within the first year of diagnosis was $7,179 for non-IMRT patients and $15,230 for IMRT patients. Overall, mean radiation-related costs increased by 33 percent for all patients combined, climbing from $6,334 to $8,473. The use of IMRT billing was more than fivefold higher in regions with coverage favorable toward breast IMRT as compared with regions with coverage unfavorable toward breast IMRT. In addition, the use of IMRT billing was 36 percent higher for patients treated in free-standing radiation centers compared with patients treated in hospital-based outpatient clinics.

Authors cite “field in field” forward planning as one proven alternative radiation therapy approach that can achieve the goals of IMRT, but with lower cost and less physician involvement than IMRT. “Field in field” consists of creating one or more subfields within the initial radiation field to improve homogeneity of the delivered radiation dose. This technique ultimately accomplishes the same clinical effect as IMRT, according to Smith, however, a lack of consensus exists on whether such treatment should be considered IMRT for the purposes of billing and reimbursement.

In addition to Smith, other MD Anderson researchers contributing to this study include: Thomas A. Buchholz, M.D. and Grace Li Smith, M.D., both Department of Radiation Oncology; I-Wen Pan, Ph.D., in the Division of Quantitative Sciences; Ya-Chen T. Shih, Ph.D. in the Department of Biostatistics and Sharon H. Giordano in the Department of Breast Medical Oncology. Co-authors on the study include: Jay R. Harris, M.D. and Rinaa Punglia, M.D., M.P.H. both of Dana Farber Cancer Institute; and Lori J. Pierce, M.D., Reshma Jagsi, M.D., and James A. Hayman, M.D. of The University of Michigan.