Is Hypofractionation the Solution? The Financial Implications of Breast Gancer Treatments

摘要

Drs. Shaitelman and Kim have done an excellent job of describing the current practice of accelerated partial-breast irradiation (APBI) in this review. APBI is an example of how breast cancer treatments are constantly evolving as a result of advances in medicine and technology, and because of financial forces. While these advances have led to more treatment options for women with breast cancer, every change that occurs in treatment can, potentially result in different side effect profiles, outcomes, and costs. If all outcomes are shown to be equal, yet the costs of the treatments differ, how will this affect the decision-making process and trends for treatments? Accountable care organizations (ACOs) are being organized across the country as a result of, and following, the guidelines set forth in the Patient Protection and Af- fordable Care Act (ACA). ACOs will be held responsible for quality,, cost, and overall care of the Medicare beneficiaries enrolled in them. These ACOs are introducing a radical change in the reimbursement structure, from the current fee-fot-service model to a "bundled payment for care' improvement"(BPCI) model. Currently, reim-bursements are given for individual services associated with treatment. For example, a breast cancer patients insurance company would pay separately for diagnostic tests, biopsy, surgery, chemotherapy, and all aspects of radiation therapy, with this last including the CT simulation for radiation planning, radiation treatments, and on-treatment visits. In an AGO, a single flat-rate payment bundle is delivered to an entire oncology team per disease diagnosis, regardless of the treatment or tests administered. A pilot program was begun on January 1, 2013 to promote coordination among oncology providers and improve quality. The various doctors and facilities involved in breast cancer detection and therapy, including radiologists, surgeons, medical oncologists, and radiation oncologists, would need to negotiate how the payment is divided. The ACA asks oncology providers to strike a balance between the wise and efficient use of resources and the patients' preferences, and the changes flowing from the switch from the fee-for-service model to a BPCI model will likely influence treatment decisions. The estimated costs of different breast cancer treatments in 2004 and 2012, according to the Center for Medicaid and Medicare Services (www.cms.gov), are displayed in the Table. These costs do not incorporate: the transportation costs or opportunity costs incurred by patients as a result of missing time from work or other obligations. The treatment option with the lowest cost to the ACO for a patient who needs whole-breast irradiation (WBI) is a hypofractionated course of treatment, and for a patient who is suitable for APBI off-protocol, it is 3-dimensional conformal APBI.