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Title: Proton Therapy Expansion Under Current United States Reimbursement Models

Abstract

Purpose: To determine whether all the existing and planned proton beam therapy (PBT) centers in the United States can survive on a local patient mix that is dictated by insurers, not by number of patients. Methods and Materials: We determined current and projected cancer rates for 10 major US metropolitan areas. Using published utilization rates, we calculated patient percentages who are candidates for PBT. Then, on the basis of current published insurer coverage policies, we applied our experience of what would be covered to determine the net number of patients for whom reimbursement is expected. Having determined the net number of covered patients, we applied our average beam delivery times to determine the total number of minutes needed to treat that patient over the course of their treatment. We then calculated our expected annual patient capacity per treatment room to determine the appropriate number of treatment rooms for the area. Results: The population of patients who will be both PBT candidates and will have treatments reimbursed by insurance is significantly smaller than the population who should receive PBT. Coverage decisions made by insurers reduce the number of PBT rooms that are economically viable. Conclusions: The expansion of PBT centers inmore » the US is not sustainable under the current reimbursement model. Viability of new centers will be limited to those operating in larger regional metropolitan areas, and few metropolitan areas in the US can support multiple centers. In general, 1-room centers require captive (non–PBT-served) populations of approximately 1,000,000 lives to be economically viable, and a large center will require a population of >4,000,000 lives. In areas with smaller populations or where or a PBT center already exists, new centers require subsidy.« less

Authors:
 [1]
  1. Indiana University Health Proton Therapy Center, Bloomington, Indiana (United States)
Publication Date:
OSTI Identifier:
22416568
Resource Type:
Journal Article
Journal Name:
International Journal of Radiation Oncology, Biology and Physics
Additional Journal Information:
Journal Volume: 89; Journal Issue: 2; Other Information: Copyright (c) 2014 Elsevier Science B.V., Amsterdam, The Netherlands, All rights reserved.; Country of input: International Atomic Energy Agency (IAEA); Journal ID: ISSN 0360-3016
Country of Publication:
United States
Language:
English
Subject:
62 RADIOLOGY AND NUCLEAR MEDICINE; COST RECOVERY; FINANCIAL INCENTIVES; INSURANCE; NEOPLASMS; PATIENTS; PROTON BEAMS; RADIOTHERAPY; URBAN AREAS; USA

Citation Formats

Kerstiens, John, Johnstone, Peter A.S., E-mail: pajohnst@iupui.edu, and Department of Radiation Oncology, Indiana University School of Medicine, Indianapolis, Indiana. Proton Therapy Expansion Under Current United States Reimbursement Models. United States: N. p., 2014. Web. doi:10.1016/J.IJROBP.2014.02.014.
Kerstiens, John, Johnstone, Peter A.S., E-mail: pajohnst@iupui.edu, & Department of Radiation Oncology, Indiana University School of Medicine, Indianapolis, Indiana. Proton Therapy Expansion Under Current United States Reimbursement Models. United States. https://doi.org/10.1016/J.IJROBP.2014.02.014
Kerstiens, John, Johnstone, Peter A.S., E-mail: pajohnst@iupui.edu, and Department of Radiation Oncology, Indiana University School of Medicine, Indianapolis, Indiana. 2014. "Proton Therapy Expansion Under Current United States Reimbursement Models". United States. https://doi.org/10.1016/J.IJROBP.2014.02.014.
@article{osti_22416568,
title = {Proton Therapy Expansion Under Current United States Reimbursement Models},
author = {Kerstiens, John and Johnstone, Peter A.S., E-mail: pajohnst@iupui.edu and Department of Radiation Oncology, Indiana University School of Medicine, Indianapolis, Indiana},
abstractNote = {Purpose: To determine whether all the existing and planned proton beam therapy (PBT) centers in the United States can survive on a local patient mix that is dictated by insurers, not by number of patients. Methods and Materials: We determined current and projected cancer rates for 10 major US metropolitan areas. Using published utilization rates, we calculated patient percentages who are candidates for PBT. Then, on the basis of current published insurer coverage policies, we applied our experience of what would be covered to determine the net number of patients for whom reimbursement is expected. Having determined the net number of covered patients, we applied our average beam delivery times to determine the total number of minutes needed to treat that patient over the course of their treatment. We then calculated our expected annual patient capacity per treatment room to determine the appropriate number of treatment rooms for the area. Results: The population of patients who will be both PBT candidates and will have treatments reimbursed by insurance is significantly smaller than the population who should receive PBT. Coverage decisions made by insurers reduce the number of PBT rooms that are economically viable. Conclusions: The expansion of PBT centers in the US is not sustainable under the current reimbursement model. Viability of new centers will be limited to those operating in larger regional metropolitan areas, and few metropolitan areas in the US can support multiple centers. In general, 1-room centers require captive (non–PBT-served) populations of approximately 1,000,000 lives to be economically viable, and a large center will require a population of >4,000,000 lives. In areas with smaller populations or where or a PBT center already exists, new centers require subsidy.},
doi = {10.1016/J.IJROBP.2014.02.014},
url = {https://www.osti.gov/biblio/22416568}, journal = {International Journal of Radiation Oncology, Biology and Physics},
issn = {0360-3016},
number = 2,
volume = 89,
place = {United States},
year = {Sun Jun 01 00:00:00 EDT 2014},
month = {Sun Jun 01 00:00:00 EDT 2014}
}