Voluntary residency contraction and the development of IMRT saved the field in the early 2000s: an analysis of the past 30 years

[radiaterMike]

Scarbrjt - interesting data. Any idea what the separate lines for radiation oncology and radiation therapy centers mean ?

I assume a service is a billing code ? If that is so, one would expect a reduction in services with bundling but perhaps not a major change in reimbursements. There are often dozens of codes billed so I’m not sure what to make of “allowed services” but ultimately the amount of reimbursements should give you a gauge of the field.

Thanks for posting this.

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[radiation]

I would like to think it should.
And it probably would were rad onc just to go "all in" for 15-16fx breast (I was kinda "shocked" recently to discover most breast hypofractionators give ~21 fx's e.g.) or single fraction bone met.
I can say it has in my own practice; I treat about 33% less on beam and collect about 25% less $$$ I reckon than ~5-7y ago.
But let's talk data.
There were about 15 million allowable Part B radiation procedures in 2011; reimbursement about $1.8 billion.
In 2018 there were about 16.5 million radiation services; reimbursement about $1.5 billion.
So to bust one myth/fake news a little... reimbursement is falling in rad onc over time. In 2011 rad oncs were paid about $120 per service, and now we get $90/service. That's a ~25% drop off. Wowie. Matches my own experience lol.
The amount of rad onc services has increased ~10% since 2011. But rad onc MD numbers have probably increased at least ~20+% since that time per OP's nice line graph above.
So to summarize:
1) Rad onc reimbursement down about 25% in 7 years; rate ~3.5%/year.
2) Rad onc services up about 10% over 7 years; rate ~1.4%/year.
3) Rad onc MD numbers up about 20% over 7 years; rate ~2.8%/year.
4) Current data would shift #3 to about 3-4%/year going forward, but looking at #2 this rate increase seems to be slowing over time.

But to your original question: hypofractionation has not put much of a dent in radiation services overall. And thus this is why Medicare is now essentially saying WTF. You CAN NOT blame private practice for this (lack of hypofractionation adoption). There's too many Medicare patients treated in academic centers for this to carry much water.

Awesome link. Just an aside, the reimbursement numbers don't seem to have gone down in a linear fashion. 2011 was outlier year for some reason. If you take the same Part B document (change the year on the link) overall rad onc seems relatively stable. So your point still stands, if services are up but reimbursement is down/stable then cost per service is down. However, if you go back to 2008, the services have actually increased by ~20%, with most of the jump in the last couple years. If somebody can synchronize hypofract use with these data, that would be great.

Radiation Oncology Reimbursement
2008 1,513,404,834
2009 1,561,789,817
2010 1,631,201,459
2011 1,768,046,938
2012 1,592,662,719
2013 1,482,720,926
2014 1,546,981,500
2015 1,517,657,009
2016 1,446,459,433
2017 1,487,003,122
2018 1,526,401,470

Radiation Oncology Services
2008 13,561,221
2009 14,241,346
2010 14,337,350
2011 14,880,501
2012 14,521,713
2013 14,515,693
2014 14,573,494
2015 14,685,809
2016 15,304,565
2017 15,896,685
2018 16,472,010

However, the heme/onc reimbursement is much more unusual, there seems to have been some black swan event starting in 2015-2016 where reimbursement really took off. Not sure about the distinction between that and med onc category, but that has gone up also

Heme/Onc
2009 4,466,687,385
2010 4,582,939,187
2011 4,884,520,469
2012 4,778,881,599
2013 4,490,544,837
2014 4,441,769,781
2015 4,619,895,847
2016 5,104,929,065
2017 5,424,696,919
2018 5,869,456,864

 

[scarbrtj]

Scarbrjt - interesting data. Any idea what the separate lines for radiation oncology and radiation therapy centers mean ?

I assume a service is a billing code ? If that is so, one would expect a reduction in services with bundling but perhaps not a major change in reimbursements. There are often dozens of codes billed so I’m not sure what to make of “allowed services” but ultimately the amount of reimbursements should give you a gauge of the field.

Thanks for posting this.

I don't know that there's a difference although for my purposes I usually exclude "centers" 'cause it's a small number. My guess is CMS is a bit dumb (even in the CMS manual up until a couple years ago the words "radiation oncologist" did not exist... we were always referred to as radiologists) and has them split apart for some historical, random reason. And yes I think services are discrete codes, probably mostly 77xxx and some G's, but also including E/M.

Awesome link. Just an aside, the reimbursement numbers don't seem to have gone down in a linear fashion. 2011 was outlier year for some reason. If you take the same Part B document (change the year on the link) overall rad onc seems relatively stable.

Adding in more time points definitely shows rad onc is VERY stable. But I think pre-2008 it shot up quite a bit re: reimbursement. But look at that: rad onc is reimbursing EXACTLY the same in 2018 as in 2008. Hem/onc is growing great! Good for them.

"Services" have been on an up-swing though, slightly, over time in rad onc. Maybe rad oncs do more services to keep the reimbursement from declining too much, esp. with the advent of hypofx? These are things that should be studied. But, again, one thing is clear in terms of growth rates:
Number of rad onc MDs* >> number of rad onc "service" events >> rad onc reimbursement ...
unsustainable.

*The slope of rad onc MDs is about twice that of rad onc services

 

[Mandelin Rain]

Growth of: Number of rad onc MDs* >> number of rad onc "service" events >> rad onc reimbursement = unsustainable.

*The slope of rad onc MDs is about twice that of rad onc services

I slightly edited and emphasized for effect, but I think this succinctly, accurately, unemotionally describes the current situation.

Twice the docs. Same total reimbursement for more codes billed. What follows? Half the salary while performing more work.

 

[BobbyHeenan]

Maybe I missed it - but does "services" refer to total number of cpt codes billed?

Maybe more "services" because more codes now exist over the past 5 years - things like respiratory motion mgmt (77293), proton codes, Xofigo codes and y-90 codes?

For instance, if I do a 3D hypofrac breast, deep inspiration breath hold case (utilizing patient coaching and gate triggered treatment/real time breathing monitoring to justify a 77293 charge), this patient would actually have more radiation cpt codes billed than someone that gets standard fractionation no DIBH...yet total revenue would be down.

I'd usually think to just use CT sim charges as an estimation of our "services," but as noted, those were bundled with IMRT charges years ago.

 

[scarbrtj]

Maybe I missed it - but does "services" refer to total number of cpt codes billed?

It's all a bit of a black box but I think it probably must mean that. For example... 16.5 million rad onc services reimbursing at about $1.5 billion. This would mean $90/service. If one RVU equals about $36, this would mean 1.5E9/36 = 42E6 RVUs nationwide. Across about 5000 rad oncs, 42E6/5000 = 8333 RVUs per rad onc in America. Which sounds reasonable esp just Part B RVUs per rad onc.