Moving to a Hypofractionated New World Order

Abstract

The proposed CMS Radiation Oncology Model emphasizes bundling and hypofractionation. At one of our sites between fiscal years 2013 and 2016, the mean number of treatments per patient decreased from 19.3 to 17.7, while the number of patients increased by 19%. While this could be in part due to a higher frequency of palliation, the mean number of plans per patient has remained stable (1.14 to 1.17), so we consider it far more likely to be due to increasing hypofractionation where supporting clinical data exist. We sought to describe our practice’s move to hypofractionation over the past 15 years. Dose and fractionation data were queried from the Moffitt Cancer Center MOSAIQ database from calendar years 2004 through 2018. The annual number of prescriptions written for specified number of fractions was collated. For instance, a breast boost is counted separately from the whole breast course preceding it. We consider this to be an optimal means to properly monitor workload, since it captures additional dosimetry and physics requirements better than simply recording the number of patients treated. Since 2009, a stable number of 9 accelerators have been in place, subject only to routine replacement. In that period of ∼10 years, the number of prescriptions has increased from fewer than 2600 to more than 4300. This is due to increasing patient numbers from 1895 to 3584. The number of brief courses as a percentage of all courses increased during that time. Single fraction prescriptions have increased more than fivefold in the past 15 years and now represent over a tenth of prescriptions. Courses of 2-5 fractions include SBRT, fractionated SRS, and most palliative courses; these constitute over a third of cases. Courses of 6 through 15 fractions have slipped by about 50%. About 5% of prescriptions are written each for 11-15, 16-20, and >30 fractions. Moffitt Cancer Center has substantially increased use of hypofractionated radiation therapy in the past 15 years. Although the move to hypofractionation allows for generally fewer charges and less revenue per patient, total revenue can increase if there is sufficient patient flow. The business model has shifted from maximizing revenue per patient to maximizing revenue per linear accelerator slot. This local trend is borne out in national data: an increase of 14% in wRVUs billed to CMS between 2012 and 2015 in the presence of essentially flat CMS costs per patient.