Rational use of intensity-modulated radiation therapy (IMRT) as determined by radiation oncologists in cooperation with Blue Cross Blue Shield of Massachusetts (BCBSMA).

Abstract

73 Background: IMRT is a sophisticated radiation technique that allows more precise delivery than conventional external beam radiation (EBRT). Prospective randomized data indicating which patients are most likely to benefit from IMRT are limited, and the rate of IMRT utilization varies widely. Methods: BCBSMA reached out to radiation oncologists to develop a consensus regarding the use of IMRT. Initial discussions started in 2009. The process included discussions within radiation oncology departments and meetings and conference calls with BCBSMA. In April 2011 a survey was sent to radiation oncologists, followed by the formation of a Physician Advisory Council consisting of representatives of 11 large academic and private practices. The council met in June 2011 and continued to develop guidelines over a series of conference calls. Results: The BCBSMA IMRT policies went into effect on 9/1/11. No policies for the use of EBRT were created. It was agreed that IMRT is appropriate for cancers of the head and neck, prostate, and anus. For other sites, emphasis was placed on the QUANTEC recommendations regarding acceptable doses to normal tissues. To justify the use of IMRT, radiation oncologists were asked to demonstrate that conventional EBRT resulted in excess dose to normal tissues, and that IMRT could lower the doses to an acceptable range. In addition, a process was set up for peer-to-peer review to consider the application of IMRT to cases outside of the guidelines. Preliminary analysis of claims compared the case rat /1,000 BCBSMA members over a 6 month pre-IMRT policy implementation base period to a 6 month post-implementation case rate. The number of IMRT cases during the study period was decreased by 20% while the EBRT cases/1,000 members during the study period increased by 14%. During the two prior years, the IMRT cases/1,000 members for IMRT increased 20%, while the EBRT cases/1000 members decreased 3%. Conclusions: The experience in Massachusetts suggests that practicing physicians and insurers can work together to achieve a consensus regarding the appropriate application of high-technology treatments potentially impacting their rate of utilization.