Price Variability of Standard Radiotherapy Procedure Codes in a Large Metropolitan Area from 2015-2021

Abstract

<h3>Purpose/Objective(s)</h3> Compliance amongst cancer centers has been poor despite price transparency rules by the US Centers for Medicare & Medicaid Services in 2021. We investigated variability in the charged and reimbursed payments in Medicare claims for standard intensity modulated radiation therapy (IMRT) for breast and prostate cancer within a large metropolitan area. <h3>Materials/Methods</h3> Medicare claims data for radiation therapy CPT codes 77336, 77385, and 77412 from 2015 to 2021 were selected from the Definitive Healthcare claims database for providers in New York within 25 miles of the zip code 10065. Providers with unknown number of claims were excluded. Average charges, reimbursements, and total claims were obtained. Annual percentage changes (APC) were calculated. The 10 highest volume centers by total number of claims for code 77336 over the study period were analyzed. Inflation adjustment (2021 US dollars) was done. Analyses were performed in spreadsheet software. <h3>Results</h3> Of 10 cancer centers, 5 were NCI-centers including 1 that was Prospective Payment System (PPS) exempt; these 10 high-volume centers represented 82% of claims. There was variability in charges for Medicare claims for each code; for example, in 2021, the average charges ranged widely for CPT 77336 ($644-1994), 77385 ($2797-7324), and 77412 ($1775-4527). The average reimbursement per procedure was similar across centers: CPT 77336 ($110-114), 77385 ($511-526), and 77412 ($225-234) in 2021. While average charges increased yearly, the percentage reimbursed remained stable or decreased (Table). The highest average charge for each code in 2021 were from non-NCI centers; the lowest charge per code varied from PPS-exempt (77336), NCI-center (77385), and non-NCI (77412). Reimbursement per code did not appear to vary greatly by center status. <h3>Conclusion</h3> We note significant price variability for commonly used IMRT codes within one large metropolitan area with multiple high-volume cancer centers. These prices outpaced annual rate of inflation. Service charges higher than what a hospital reasonably expects to be reimbursed may both prevent competitive price shopping by the consumer and result in catastrophic financial toxicity for small payors and under/uninsured individuals. This study supports the continued efforts to prioritize price transparency and associated policy reform.