A Threat to Quality Cancer Care, Accessibility, and Sustainability: Medicare Payment Policies and Changing Utilization Patterns in Radiation Oncology.

Journal: Cureus
Published:
Abstract

Radiation oncology (RO) has undergone dramatic changes in clinical practice and reimbursement policy due to changes in the Medicare payment system, technological innovation in treatment modalities, and changing use patterns. This study aims to analyze the financial impact of these changes between 2016 and 2022 and their implications for the sustainability of practice and patient access. 

Methods: We reviewed Medicare beneficiary-level claims data from 2016 and 2022 to determine trends in payment under the Medicare Physician Fee Schedule (MPFS) and Outpatient Prospective Payment System (OPPS). Treatment episodes were classified by modality (external beam radiation therapy (EBRT) and stereotactic body radiation therapy (SBRT)) and cancer type, with financial effects determined by payment policy changes, utilization changes, and conversion factor changes. 

Results: The effect of payment policy changes was stable in relative value units (RVUs) and relative weights (RWs) with no combination of cancer type, service type, and practice setting, showing a difference of more than + 8% or -4%. Reimbursement for technical services in free-standing office practices declined by -16.9% for breast cancer and -14.2% for prostate cancer by greater use of hypofractionation. Inflation-adjusted Medicare conversion factors fell 12.2% in hospital outpatient departments and 20.8% in free-standing offices. The aggregate overall effects were favorable due to the geographic adjustment of national payment rates. For breast episodes, the impact sum for technical charges in the hospital outpatient setting was -21.8%, and the overall impact was -15.6%. 

Conclusion: RO practices from 2016 to 2022 showed stable RVUs and RWs, indicating minimal changes to payment policy. However, due to transitioning to hypofractionated regimens and lower treatment volumes, reimbursement rates for technical services for breast and prostate cancers significantly declined. Geographic adjustments reduced overall impacts. However, specific policy initiatives are necessary to guarantee fair reimbursement and maintain access to quality cancer treatment.

Relevant Conditions

Prostate Cancer, Breast Cancer

Similar Publications

Medicare program; revisions to payment policies under the physician fee schedule, and other Part B payment policies for CY 2008; revisions to the payment policies of ambulance services under the ambulance fee schedule for CY 2008; and the amendment of the e-prescribing exemption for computer generated facsimile transmissions. Final rule with comment period.
Medicare program; revisions to payment policies under the physician fee schedule, and other Part B payment policies for CY 2008; revisions to the payment policies of ambulance services under the ambulance fee schedule for CY 2008; and the amendment of the e-prescribing exemption for computer generated facsimile transmissions. Final rule with comment period.
Journal: Federal register
Published: November 30, 2007
Medicare program; revisions to payment policies under the physician fee schedule for calendar year 2001. Health Care Financing Administration (HCFA), HHS. Final rule with comment period.
Medicare program; revisions to payment policies under the physician fee schedule for calendar year 2001. Health Care Financing Administration (HCFA), HHS. Final rule with comment period.
Journal: Federal register
Published: August 16, 2001
Medicare program; revisions to payment policies and adjustments to the relative value units under the physician fee schedule for calendar year 1999--HCFA. Final rule with comment period.
Medicare program; revisions to payment policies and adjustments to the relative value units under the physician fee schedule for calendar year 1999--HCFA. Final rule with comment period.
Journal: Federal register
Published: October 05, 1998