Christopher Pericak and David Gaffin
On day three of American Society for Radiation Oncology (ASTRO), we’ve gotten some relief from the inclement weather and are excited to resume our coverage of the 2012 conference.
Our discussions today continued to unravel some of the major themes of the conference, while also providing the opportunity to take a closer look on the elephant-sized (or larger!) particle accelerator in the room: proton beam therapy.
We’ve heard much about the importance of cost reduction in radiation oncology in general, including plenty of facts and figures, putting this field at the forefront of cost growth within the health care industry. While the community certainly seems dedicated to reducing these costs, radiation oncology is still a capital intensive specialty that requires substantial investment to solve a range of complex problems.
Proton therapy industry identifies areas to cut costs
As far as complexity goes, protons certainly take the cake, which explains the high cost of this technology. The industry has been working to set itself up to target key areas for cost reduction.
The main costs can be divided into a few major areas: the accelerator, the gantry, operations, and construction. With the FDA approval of Mevion’s accelerator design, a single room solution—and therefore a smaller footprint—is possible. Hospital interest has spiked considerably as more institutions muse over the possibility of affording the $30 million price tag quoted by Mevion.
This headline has also spurred sales for other vendors. While a low-cost single room solution is restricted to Mevion for the time being (IBA’s Proteus One is not yet approved), other vendors offer small scale options, such as the Varian system, which could range around $50 million for a two-room configuration.
The reduction in cost has led to many hospitals to consider a self-sufficient approach to proton beam therapy, but ongoing operational costs must be considered as well, particularly those related to maintenance. Here, key staff members, experience, and appropriate components support continuous functionality of a proton system—and this process is critical to receiving the patient volume required to generate revenue.
The large-scale incumbent, IBA, for example, works with institutions to do preventive maintenance on a daily basis and offers centralized maintenance support and 24-hour coverage, which adds scale to an otherwise costly endeavor. From an efficiency standpoint, pencil beam scanning is another important technology development that will continue to be refined into the future through further research and experience. In addition to offering the potential for greater accuracy, this technology may deliver faster treatments and requires less time to prepare for subsequent treatments.
In the future, cost may be reduced with alternative approaches to a traditional gantry. For example, P-Cure’s solution offers a mobile patient positioning system to permit a cheaper fixed gantry. P-Cure and ProCure are partnering to bring this system to life in ProCure’s metro New York/New Jersey treatment center. These developments mark a cultural shift in the industry, although more investigation is needed to substantiate the role of a mobile patient positioning system as opposed to a mobile gantry.
Researchers work to demonstrate comparative effectiveness of proton therapy
At the same time, proton therapy’s mission to demonstrate quality requires results—much of which has come to pass, but with much to still be proven. And the bar continues to rise for demonstrating comparative effectiveness, in part due to the manpower behind photon research.
As oncology programs position themselves to pursue more multidisciplinary care that integrates surgery, RT and medical oncology—as well as strive toward comprehensive management of patients, from screening to palliative care—photon research continues to benefit from a plethora of studies about the role of this technology within the care continuum.
At this year’s ASTRO, we’ve seen several large-scale studies on prostate cancer—an indication that protons have faced challenges gaining traction for. For example:
- Dosoretz et al. conducted a randomized study of approximately 162,000 men to explore the benefits of IMRT to treat a population screened for prostate cancer, noting a benefit in QALYs of 13.70 compared to 13.24.
- Zelefsky et al. conducted a prospective randomized double-blind placebo controlled trial of 290 patients to evaluate the impact of Sildenafil Citrate in patients receiving radiation therapy, showing an IIEF score of 54.9 compared to the placebo score of 47.6 after 24 months.
- Advanced RT modalities, specifically SBRT, continue to make headway, such as in the Katz et al. study pooling data from 1,101 patients from eight institutions to show a five-year biochemical relapse-free survival rate of 93%, suggesting that SBRT is viable in comparison to other treatments, such as surgery.
Still, as patients continue to live longer after treatment—and as the field of radiation oncology aims to mitigate the long term effects of radiation—the promise of protons remains attractive. Proton centers will need to work collaboratively to engage in more widespread clinical trials to continue to mount clinical evidence supporting coverage expansion, all while pursuing innovative approaches to cost reduction.
ASTRO prepares for new payment models
As the proton versus photon discussion continues, hospitals must also monitor a, uncertain payment horizon—although it will certainly mandate cost containment.
Today at ASTRO, luminaries in the field of health policy and radiation therapy practice held an informative session, explaining to rapt audience the need, promise, and likely outcome of new payment and care delivery models for radiation therapy.
ASTRO leadership collaborates with CMS, OMB, and AMA
Presenters highlighted cuts to physician payments proposed by the CMS in their 2013 rule.
ASTRO leadership has begun to work with stakeholders at CMS, the OMB, the AMA, and legislators to examine the impact of the cuts on access, innovation, and outcomes. In particular, they examined the likely results of the proposed cuts to IMRT and SBRT delivery codes.
They acknowledged that because of the cost growth experienced in radiation oncology procedures across the last year, reduced payments would likely be inevitable.
New payment models present benefits and challenges to clinical practice
Presenters described some potential new payment and care delivery models for radiation therapy and how they might work in clinical practice. Chief among these potential new models were medical home models and bundled payments.
The medical home model has been shown to reduce ED admissions while driving volumes for low cost, highly effective interventions. In cancer care, where outcomes are often determined by the vigor of long-term follow-up and monitoring, the medical home model could foster better outcomes and reduce costs.
Medical home models require sophisticated health information technology systems and a high level of patient compliance. These challenges present hospitals with a unique set of hazards when implementing medical home payment models.
Another candidate for payment reform is the bundled payment model. While pilot programs for oncology are currently lacking, presenters suggest that disease or modality-specific bundled payments would prompt providers to better integrate sub-specialties and focus on care coordination.
Accommodations for complexity, risk of recurrence, and other variations in care pathways are challenges that bundled payment models could present.
Providers increasingly pursue ACO and medical home model partnerships
When polled at the beginning of the session, approximately half of attendees reported that their practice had seriously considered or already pursued partnerships with organizations to participate in an ACO or medical home model.
By the end of the presentation, almost 70% thought they should now pursue those arrangements. Practitioners demurred when asked if these new models were likely to result in reduced payments to physicians. Nearly 60% believed it would be impossible to maintain the current level of revenues for their practice under a new model.
More coverage of the 2012 ASTRO conference
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