Trends in Medicare Reimbursement: Analysis of Prostate IMRT and Breast 3D-CRT Fees from 2011-2019

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Passage of the Affordable Care Act (ACA) in 2010 drew national attention to the need to reduce healthcare costs. In July of 2018, the Centers for Medicare and Medicaid Services (CMS) announced a proposal to reduce payments for radiation oncology services by 2% in 2019. This prompted resistance from the radiation oncology community, yet the context for this 2019 proposal is poorly understood. The goal of this study is to explore historical trends in Medicare reimbursement rates in radiation oncology since the passage of the ACA in 2010, for several of the most commonly prescribed radiation therapy treatments. Process maps modeled each step in treatment of 4 different types of radiation therapy: conventionally-fractionated 3-D whole breast irradiation (CF-WBI, 25 fractions + 5 fraction boost), hypofractionated 3-D whole breast irradiation (HF-WBI, 16 fractions + 4 fraction boost), conventionally fractionated prostate IMRT (CF-P, 39 fractions), and hypofractionated prostate IMRT (HF-P, 20 fractions). Reimbursement rates were determined from the 2019 CMS Medicare Physician Fee Schedule (MPFS) database. Annual Inflation rate from 2011 to 2018 was obtained from the Federal Reserve Bank. Inflation-adjusted reimbursement was determined for each treatment modality from 2011 to 2019 and reported in 2019 dollars. Each of the 4 treatment techniques demonstrated decline in inflation-adjusted reimbursement from 2011 to 2019. HF-WBI inflation-adjusted reimbursement decreased from $9,333 in 2011 to $9,162, representing mean annual decrease (MAD) and total decreases (TD) of 0.1% and 1.8% respectively. CF-WBI reimbursement decreased from $12,575 to $12,405 (MAD 0.1%, TD 1.3%). HF-P reimbursement decreased from $21,637 to $14,386 (MAD 4.8%, TD 33.5%) and CF-P reimburse decreased from $38,240 to $24,710 (MAD 5.2%, TD 35.4%). The large decline in prostate IMRT reimbursement was predominantly due to decrease in the fee for treatment delivery, which accounted for 70.7% and 71.5% of the drop for HF-P and CF-P respectively. Since passage of the ACA in 2010, inflation-adjusted Medicare reimbursement for prostate IMRT and breast 3D-CRT have decreased. While breast 3D-CRT has shown a modest average drop of 0.1% per year, average prostate IMRT reimbursements have dramatically decreased, approximately 5% per year, representing a total decrease of over 30% over the past 8 years. These declines in Medicare reimbursement, combined with increasing pressures to move towards hypofractionation, creates a "double-hit” effect. Prostate IMRT reimbursement is diminished due to both a lower number of billable treatments and decreased reimbursement per treatment. This places significant financial pressure on radiation oncology practices. Not only is there a disincentive for hypofractionated treatment, but with decreasing revenues, departments may face a choice of reducing salaries or staffing levels, delaying equipment purchases, or cutting research support.