Cost Comparison From a Patient Perspective for Gamma Knife and Linear Accelerator-Based Intracranial Stereotactic Radiation Therapy

Abstract

Financial toxicity is a highly prevalent and damaging consequence of oncologic therapy that is partially driven by inability to make copayments. The US Centers for Medicare and Medicaid Services recently mandated that all hospitals publish a "shoppable" list of negotiated prices for ≥ 300 common services as well as a "chargemaster" documenting non-negotiated list charges for every provided service. Patients often travel to tertiary centers for intracranial stereotactic radiotherapy (SRT), but cost comparison is complicated by multiple delivery systems and fractionation schemes. SRT is not included in shoppable price listing, and it is unknown whether list prices have utility in this complex setting. We hypothesized that list prices for intracranial SRT vary by delivery system and fractionation schemes and by institution.In August 2020, we obtained online available chargemasters for the 63 US clinical National Cancer Institute (NCI)-designated centers. Listed technical charges for Gamma Knife (GK), single fraction linear-accelerator stereotactic radiosurgery (SRS), and 3-fraction fractionated stereotactic radiation therapy (FSRT) were obtained by searching for Current Procedural Terminology (CPT) billing codes first and then keywords. Institutional cost data was adjusted by the Medicare geographic cost price index (GPCI) to control for cost-of-living associated reimbursement differences. Pairwise comparisons were conducted to compare prices across modalities and geographic regions. Price association between modalities and relationships with cost index were examined using Spearman correlations.62 chargemasters were obtainable, and 58 listed intracranial SRT prices. For each modality, prices varied widely, and after adjusting for GPCI, GK (P = 0.0003) and FSRT (P = 0.001) were more expensive than SRS (Table 1). No adjusted difference in price was noted between regions. FSRT price was positively correlated with GPCI (P = 0.033) but other modalities were not. All modality prices were positively correlated (all P < 0.001).Despite overlapping indications, GK and FSRT list prices outpace SRS. Overall, institutional prices varied significantly, but differences in cost of living do not explain variability. A high institutional price for one modality corresponded to higher prices for the others. Although list prices are ill suited for absolute price estimates, motivated patients may use chargemasters to attempt relative cost comparisons. However, the impact of ancillary fees and negotiations by insurers on relative price differences is difficult to assess. Thus, policy changes promoting improved patient access to streamlined cost data are necessary to address therapy-related economic distress in this population.