James B. Yu, MD, MHS 

Imagine back to 1998. Bill Clinton is president, and Michael Jordan has just hit his iconic “last jumper” to help the Bulls win a sixth NBA championship over the Utah Jazz. Five years prior, the Clinton administration had attempted to push a universal coverage health care plan in its first term. Many in Congress believed that government spending was spiraling out of control and that Medicare was a large component of this spending growth. As a result of these national priorities, in 1998, Medicare implemented a methodology known as the sustainable growth rate (SGR). This methodology was intended to limit growth of Medicare spending to what was “sustainable.” If growth 1 year exceeded the predefined limit (the SGR), the next year would result in reduced payments to providers.

Over the years that followed, Medicare spending would consistently rise faster than the SGR, causing a scramble in the halls of Washington to pass a temporary reprieve to prevent ever-more devastating cuts to health care providers across the country. Year after year, as the required spending cuts needed to get spending back to a “sustainable” level loomed larger and larger, policymakers and researchers wondered: Why couldn’t we as a country meet the annual SGR growth targets? Where were these increasing costs coming from? Were some disciplines more at fault than others? As with any pressure-filled zero-sum system, fingers were pointed in the form of a New England Journal of Medicine article in 2012 by Alhassani et al entitled “The Sources of the SGR ‘Hole’.”1

Though not explicitly mentioned in the body of the article, radiation oncology was identified in the figures of the text as the discipline with the largest percentage excess expenditure (as measured by physician services) in 2003 to 2009 relative to what would have been predicted relative to 2002. The scrutiny on health care costs fell hard on radiation oncology. Perhaps more than any other specialty, stung by the initial spotlight of rapid cost growth and packed with academic and evidence-based physicians, the field of radiation oncology underwent (and continues to undergo) a period of intense self-examination. Examining papers that have cited the Alhassani et al piece as of the writing of this editorial, of the 36 manuscripts noted on the New England Journal of Medicine website, all but 7 are written by radiation oncologists or radiation physicists.

What did we learn from this decade of soul searching? First, we learned that in the story of radiation oncology cost growth, the timing of the measurement was everything. The Alhassani et al paper was perfectly timed to villainize radiation oncology, evaluating the health care system in the years that intensity modulated radiation therapy (IMRT) was adopted and popularized. The S curve of IMRT adoption was steepest during this time, and predictably so was the growth in costs. In the intervening years since the 2012 publication, the curve has flattened.2

 In this issue of the Red Journal, Hogan et al now report the curve may be pointed downward into negative growth.3

 Second, we learned that in the years that followed, radiation oncologists readily developed and adopted treatments that were more convenient and lower cost for the patient—and these innovations were supported by the American Society for Radiation Oncology and other academic radiation oncology societies.4

 Third, we learned that all around us, the costs of prescription medications, pathology, laboratories, and health care in general have continued to rise.5

 It is clear that from the fog of the early 2010s a greater truth has emerged: that in the United States, modern radiation therapy is generally cost-effective and responsibly delivered. And since radiation oncologists have held the line in terms of costs to Medicare, Hogan et al rightly conclude that “Policy makers should consider these trends and their impact on quality and access to healthcare when considering further cuts.”

Thankfully, in 2015 the SGR was finally repealed. The sword of ever larger and larger payment cuts no longer hung over physicians. Health policymakers wondered, if the SGR was too blunt a tool, surely a more sophisticated one could be created to hold down health care costs instead. Perhaps a payment system where quality, evidence, and efficiency were rewarded?

In 2016, after a demonstration period, the Center for Medicare and Medicaid Innovation launched the voluntary Oncology Care Model (OCM). The model paid physicians and hospitals a per-patient fee, initiated with the first chemotherapy administration. There were electronic health record and care navigation requirements, along with reporting and care guidelines. If successful in meeting predefined cost and health outcomes goals, physicians and hospitals would receive a performance incentive.

Crucially, for radiation oncology, radiation therapy was included in the overall cost of care but at the same time could not initiate an episode of care. Therefore, evaluating radiation oncology practice within OCM participating programs could theoretically serve as a judgment of both the necessity and perceived cost effectiveness of radiation therapy. If radiation was considered too costly in present form, practice patterns would conceivably change to exclude unnecessary treatments, revert to less costly techniques, or change the timing of radiation so it would not be included in the OCM episode of care. Alternately, no change in radiation oncology patterns would suggest that oncologists generally considered radiation necessary, appropriately delivered, and worthwhile.

Kapadia et al have delivered an analytical verdict but have waffled on the policy implications.6

 Evaluating over 27,000 breast cancer episodes, the OCM had no discernable impact. Adjuvant IMRT use declined equally for both OCM patients and non-OCM patients. Similarly, for patients with bone metastases from breast or prostate cancer, no difference was found between OCM and non-OCM fractionation schemes. Unfortunately, the authors conclude that “Given its specialty-specific focus, prospective payment rates, and mandatory nature, the proposed Radiation Oncology Alternative Payment Model (RO-APM) might be more effective than OCM in reducing low-value radiation care.” Although they note that this statement is “conjecture,” I would go further and say that it is much more likely to be false than true.

I would guess that many radiation oncologists would embrace an alternative payment model if it were fairly designed and recognized the value of modern radiation therapy. Radiation oncology already carries a heavy burden of insurance prior authorizations, and so a simplified payment system could potentially benefit radiation oncology practices.7

 Indeed, the American Society for Radiation Oncology advocated for an alternative payment model before the RO-APM, believing that radiation oncology could thrive in a fair and value-based system.8

 Unfortunately, the current RO-APM model proposed by Center for Medicare and Medicaid Innovation is deeply flawed and ignored many of the changes advocated for by radiation oncologists. Many authors have ably noted the poorly designed nature of the RO-APM and potential negative impact on not only rural practices and underserved patients, but academic centers engaging in research and treatment of advanced stage disease.9,10

As we move into 2022, it is time to let go of the tired notion that radiation oncology is an overly costly therapy. Certainly, when used safely and effectively, radiation is technologically and labor intensive. However, many studies have shown that radiation oncology is cost-effective, particularly in light of the ever-increasing costs of systemic oncologic therapies. Centers for Medicare & Medicaid Services can and has set the cost of radiation therapy, whereas negotiating the price of drugs is currently forbidden. I believe the papers by Hogan et al and Kapadia et al in this issue of the Red Journal show that the cost curve of radiation has bent downward and that episode-based payments will likely have no impact on radiation therapy practice patterns—the vast majority of practices are already engaging in value-based care. Therefore, the motivation and the desired outcome of the RO-APM are not based on current evidence. The poor design of the RO-APM means that, if implemented, it will negatively affect practices serving our most difficult-to-treat and difficult-to-reach patients. To move forward with the current RO-APM would be like drafting a modern NBA team to defend against Michael Jordan. Although well meaning, it is trying to solve a challenge from another time, with a design that is doomed to fail.

DOI: https://doi.org/10.1016/j.ijrobp.2022.02.006

References

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