Medicare changes threaten access to radiation therapy

Two in five radiation-therapy clinics throughout the United States might shut their doors next year If proposed sharp reductions in federal reimbursements of their doctors go into effect next January 1. Or so concludes ASTRO, the Fairfax, Va.-based society representing physicians who employ radiation therapy to fight cancer.

The organization detailed its concerns, and the justifications for those fears, in a 25-page letter it just sent to the agency that manages the Medicare program.

Medicare’s proposed changes “would devastate cancer care,” ASTRO charges. And the expected fallout — nationwide reductions in patient access to radiation therapy — could extend well beyond individuals covered by Medicare.

Of some one million U.S. cancer patients receiving radiation therapy each year, roughly one-third get their treatments outside hospitals, in free-standing radiation-oncology centers. It’s these centers that would be hammered by the proposed changes in Medicare-reimbursement rules, says Dave Adler, assistant director for government relations at ASTRO, which stands for the American Society for Radiation Oncology.

A July 13 announcement by Medicare officials laid out a plan for 2010 to cut by 19 percent its reimbursement to doctors that use medical equipment worth $1 million or more, including most radiation-therapy equipment. In fact, Medicare cuts to many free-standing radiation-oncology centers could exceed 30 percent, ASTRO found, owing to the particular mix of patients treated and the government’s plan to keep Medicare funding largely static.

Clinics that could afford to stay open, despite the cuts, would likely reduce the number of Medicare patients they treat, lay off staff and/or trim other services, according to a July poll of 103 ASTRO members working at non-hospital-based radiation-oncology centers.

The main issue involves equipment-reimbursement rates. It gets a little complicated, but follow me on this because the implications are serious.

The first and most important proposed change would be in the presumed equipment-utilization rate. That’s how much a given machine is used during the course of a 10-hour day. Currently, Medicare assumes that big-ticket devices — like computed-tomography scanners, magnetic resonance imaging devices and the linear accelerators used to deliver beams of radiation to kill tumor cells — are used 50 percent of any given day. However, with a recent sharp increase in the number of imaging procedures conducted, Medicare decided to up the assumed utilization rate for high-cost machines to 90 percent. The effect: Each individual procedure would be reimbursed at a lower rate.

If machines were truly being used 90 percent of the time, the sum of a day’s lower reimbursements should still cover the capital costs of the pricey hardware. But if actual use of the machines is closer to 50 percent, clinics won’t be able to perform enough procedures to pay back their investment in these machines, much less their upkeep.

And that’s the problem in radiation oncology, Adler explains. An ASTRO-funded survey finds that utilization of its big-ticket equipment — largely linear-accelerator-based units — runs between 18 and 63 percent, depending on the precise technology. Typical utilization for most radiation-oncology systems is below 50 percent.

The reason the proposed rate changes would affect free-standing clinic physicians most: Unlike in hospitals, physicians here own their own equipment. So Medicare reimburses these physician-owners not only on the basis of their doctoring but also for patient use of their clinics’ equipment.

A Medicare Payment Advisory Commission wrote the acting administrator of the federal Centers for Medicare & Medicaid Services, also known as CMS, to say that it “supports CMS’s proposal as it applies to diagnostic imaging machines that cost more than $1 million.” The commission’s 15-page August 31 letter pointed out that it didn’t, however, recommend changing equipment-utilization rates for radiation “therapy” machines.

A second issue plays into the funding problem for radiation oncologists, Adler says. Several organizations, including the American Medical Association, periodically survey physicians on the costs of running their practices. And in some fields, costs have been rising substantially. Not so, the data show, for radiation oncologists. However, because Medicare has a fairly static pot of funds to work from, if costs go up for one field, the agency has to effectively rob Peter (in this case, radiation oncologists) to pay Paul some more.

CMS will announce its final decisions on 2010 reimbursements by early November, Adler says. So there’s still time to lobby Medicare officials — which is what ASTRO is asking its members to do.

Congress is also taking up the issue. Two weeks ago, 63 House members endorsed a letter to Kathleen Sebelius, the Secretary of Health and Human Services, which is CMS’ parent agency. A similar Senate letter is still collecting signatures. 

The House letter argues that owing to Medicare’s proposed changes, some radiation oncologists could experience a drop in compensation of up to 44 percent — even as their costs of doing business “have remained relatively stable or experienced modest increases.”

But how much doctors get paid isn’t the real issue here. It’s a patient’s access to therapy. Rural areas are those likely to see radiation-therapy clinics close first. Patients that would have visited nearby clinics daily for several weeks would now have to sign up for commutes of 50 miles or more. “This increased expense and time is a significant barrier to care,” ASTRO notes, citing studies that show a drop off in the chance elderly patients will sign on for radiation therapy as the distance to treatment increases.

Waiting times for treatment also could grow. One radiation oncologist told ASTRO that “Currently there are two practices in my [Lancaster, Pa.] community, a hospital-based practice and my freestanding office. A 20 percent cut would probably cause us to close. This would result in patients waiting for four to six weeks for an appointment at the other practice.”

And when any treatment clinic closes its doors, all would-be patients — young and old, on the government dole or possessing gold-plated insurance — risk losing ready access to life-sustaining care.