Intensity-Modulated Radiation Therapy: The Inverse, the ...Intensity-Modulated Radiation Therapy:...

Economic Impact of IMRTwith modest socio-economic

comments

Economic Impact of IMRTwith modest socio-economic

comments

Michael Gillin, Ph.D.Chief of Clinical Physics

Michael Michael GillinGillin, Ph.D., Ph.D.Chief of Clinical PhysicsChief of Clinical Physics

Intensity-Modulated Radiation Therapy: The Inverse, the

Converse, and the PerverseEli Gladstein, M.D.

Intensity-Modulated Radiation Therapy: The Inverse, the

Converse, and the PerverseEli Gladstein, M.D.

• Seminars in Radiation Oncology, Vol 12. No 3 (July) 2002

• “The present euphoria surrounding IMRT is difficult to dissect. IMRT has been heavily touted by both vendors and investigators, although actual clinical data for analysis have so far been sparse.”

•• Seminars in Radiation Oncology, Seminars in Radiation Oncology, Vol Vol 12. No 12. No 3 (July) 20023 (July) 2002

•• “The present euphoria surrounding IMRT is “The present euphoria surrounding IMRT is difficult to dissect. IMRT has been heavily difficult to dissect. IMRT has been heavily touted by both vendors and investigators, touted by both vendors and investigators, although actual clinical data for analysis although actual clinical data for analysis have so far been sparse.” have so far been sparse.”

The Inverse, the Converse, and the Perverse

Eli Gladstein, M.D.

The Inverse, the Converse, and the Perverse

Eli Gladstein, M.D.• Cost Considerations Negative

• “It should be obvious to all that IMRT is expensive in terms of (1) the space, hardware, and software that are required; (2) the time involved in preparation of plans and execution of treatment; (3) the manpoweravailable to carry out such planning and treatment; and (4) the expenditures that go along with all of those resources.”

•• Cost Considerations NegativeCost Considerations Negative

•• “It should be obvious to all that IMRT is “It should be obvious to all that IMRT is expensive in terms of (1) the expensive in terms of (1) the space, space, hardware, and softwarehardware, and software that are required; (2) that are required; (2) thethe timetime involved in preparation of plans and involved in preparation of plans and execution of treatment; (3) the execution of treatment; (3) the manpowermanpoweravailable to carry out such planning and available to carry out such planning and treatment; and (4) the expenditures that go treatment; and (4) the expenditures that go along with all of those resources.”along with all of those resources.”

Health Care Costs2000 Consumers Union

• 1996 7.9% of household income was spent on health care

• 2000 8.6% of household income was spent on health care

• 44 million uninsured • In 1998 18.4% of the people under 65

years old were uninsured.

•• 1996 7.9% of household income was 1996 7.9% of household income was spent on health carespent on health care

•• 2000 8.6% of household income was 2000 8.6% of household income was spent on health carespent on health care

•• 44 million uninsured 44 million uninsured •• In 1998 18.4% of the people under 65 In 1998 18.4% of the people under 65

years old were uninsured.years old were uninsured.

Health Care CostsHealth Care Costs• NCI estimated that in 1994 cancer care represented

5% of all health care costs or $41B of the approximate $834B. One rough estimate is that approximately 10% of cancer care costs are spent on radiation oncology or approximately $5B

• In the 2000’s, Medicare costs for Radiation Oncology represent approximately 8% of the Medicare expenditures or approximately $9B.

• 2002: ACS estimates $60.9B spent on cancer care, which means, after applying the 10% rule, approximately $6B on radiation oncology.

•• NCI estimated that in 1994 cancer care represented NCI estimated that in 1994 cancer care represented 5% of all health care costs or $41B of the 5% of all health care costs or $41B of the approximate $834B. One rough estimate is that approximate $834B. One rough estimate is that approximately 10% of cancer care costs are spent approximately 10% of cancer care costs are spent on radiation oncology or approximately $5Bon radiation oncology or approximately $5B

•• In the 2000’s, Medicare costs for Radiation In the 2000’s, Medicare costs for Radiation Oncology represent approximately 8% of the Oncology represent approximately 8% of the Medicare expenditures or approximately $9B. Medicare expenditures or approximately $9B.

•• 2002: ACS estimates $60.9B spent on cancer care, 2002: ACS estimates $60.9B spent on cancer care, which means, after applying the 10% rule, which means, after applying the 10% rule, approximately $6B on radiation oncology.approximately $6B on radiation oncology.

Radiation Oncology CostsRadiation Oncology Costs

• As a rough estimate, it appears that radiation oncology costs in the early 2000’s are between $5B to $10B per year.

• Less than half of this amount is paid to UT MDACC.

•• As a rough estimate, it appears that As a rough estimate, it appears that radiation oncology costs in the early radiation oncology costs in the early 2000’s are between $5B to $10B per 2000’s are between $5B to $10B per year.year.

•• Less than half of this amount is paid to UT Less than half of this amount is paid to UT MDACC.MDACC.

Radiation Oncology CostsRadiation Oncology Costs• Costs vs. Charges - An important

distinction

• What must an institution charge per hour or per treatment to collect its costs for providing external beam radiation treatments?

• What is the charge per hour to collect costs for providing external beam planning?

•• Costs vs. Charges Costs vs. Charges -- An important An important distinctiondistinction

•• What must an institution charge per hour What must an institution charge per hour or per treatment to collect its costs for or per treatment to collect its costs for providing external beam radiation providing external beam radiation treatments?treatments?

•• What is the charge per hour to collect What is the charge per hour to collect costs for providing external beam costs for providing external beam planning?planning?

Cost Accounting in Radiation Oncology: A Computer-

Based Model for Reimbursement

Cost Accounting in Radiation Oncology: A Computer-

Based Model for Reimbursement

Carlos A. Perez, M.D. et al.Int J. Radiation Oncology Biol. Phys.

Vol. 25, 895-906, 1993

Carlos A. Perez, M.D. et al.Carlos A. Perez, M.D. et al.Int Int J. Radiation Oncology Biol. Phys.J. Radiation Oncology Biol. Phys.

Vol. 25, 895Vol. 25, 895--906, 1993906, 1993

Cost Accounting: PerezCost Accounting: Perez

• 1991 Project - a procedure level cost accounting system of all of the costs involved in providing radiation oncology services

• Cost type: direct variable (labor and supplies), direct fixed (equipment), indirect variable (medical records), indirect fixed (building - exam rooms and offices, administration, computers, etc.)

•• 1991 Project 1991 Project -- a procedure level cost a procedure level cost accounting system of all of the costs accounting system of all of the costs involved in providing radiation oncology involved in providing radiation oncology servicesservices

•• Cost type: direct variable (labor and Cost type: direct variable (labor and supplies), direct fixed (equipment), indirect supplies), direct fixed (equipment), indirect variable (medical records), indirect fixed variable (medical records), indirect fixed (building (building -- exam rooms and offices, exam rooms and offices, administration, computers, etc.)administration, computers, etc.)

Cost Accounting: PerezAverage MD time per patient

1991Activity• Consultation Complex• Consultation Interm• Sim. Complex• Rx Planning Complex• Review dosimetry

ActivityActivity•• Consultation ComplexConsultation Complex•• Consultation Consultation IntermInterm•• SimSim. Complex. Complex•• Rx Planning ComplexRx Planning Complex•• Review dosimetryReview dosimetry

Minutes675450458

MinutesMinutes676754545050454588

Cost Accounting: PerezAverage time per patient

Activity CMD PhD

CT 65 min

Complex Ex Beam 47 min

Interm. Ex. Beam 21 min

Cont. Med. Physics 4.4 min 3.4 min

Activity CMD PhD

CT 65 min

Complex Ex Beam 47 min

Interm. Ex. Beam 21 min

Cont. Med. Physics 4.4 min 3.4 min

Cost Accounting: PerezCost per procedure

1991Activity MD

Professional Planning Technical

Sim. Interm. $188 $640

Rx Planning/ Isodose Complex

$147 $618

Activity MD Professional

Planning Technical

Sim. Interm. $188 $640

Rx Planning/ Isodose Complex

$147 $618

Cost Accounting: PerezTechnical cost per Rx procedure

Rx Interm. $182

Rx Complex $220

Gyn Implant $1557

Rx Interm. $182

Rx Complex $220

Gyn Implant $1557

A Comparison of Two Methods for Estimating the Technical Costs of External

Beam Radiation Therapy

A Comparison of Two Methods for Estimating the Technical Costs of External

Beam Radiation TherapyJames A. Hayman, M.D. M.B.A. et al.

University of MichiganJames A. James A. HaymanHayman, M.D. M.B.A. et al., M.D. M.B.A. et al.

University of MichiganUniversity of Michigan

Estimating the Technical Costs of External Beam Radiation

Therapy

Therapy• 1997 Data

• Cost Effective Analysis (CEA) estimates the additional cost per unit benefit associated with the use of a given intervention as compared to the most reasonable alternative strategy

• Int. J. Radiation Oncology Biol. Phys. 47, 461-467, 2000

•• 1997 Data1997 Data

•• Cost Effective Analysis (CEA) estimates the Cost Effective Analysis (CEA) estimates the additional cost per unit benefit associated additional cost per unit benefit associated with the use of a given intervention as with the use of a given intervention as compared to the most reasonable compared to the most reasonable alternative strategyalternative strategy

•• Int. J. Radiation Oncology Biol. Phys. 47, Int. J. Radiation Oncology Biol. Phys. 47, 461461--467, 2000467, 2000

Therapy

Therapy• Cost-to-Charge Ratios (CCR) • Institution’s annual operating costs• CCR for therapeutic radiology 0.4542• Cost Accounting Systems (CAS)• CAS uses a bottom up approach to

estimate the cost of labor, capital equipment, and overhead necessary to provide a particular service.

•• CostCost--toto--Charge Ratios (CCR) Charge Ratios (CCR) •• Institution’s annual operating costsInstitution’s annual operating costs•• CCR for therapeutic radiology 0.4542CCR for therapeutic radiology 0.4542•• Cost Accounting Systems (CAS)Cost Accounting Systems (CAS)•• CAS uses a bottom up approach to CAS uses a bottom up approach to

estimate the cost of labor, capital estimate the cost of labor, capital equipment, and overhead necessary equipment, and overhead necessary to provide a particular service.to provide a particular service.

Therapy

• Four typical treatment approaches:– Simple palliative - 6 MV single field, simulation– Complex palliative - 10 MV POP, simulation,

blocking– Breast -tangents + electron boost, simulation– Prostate - 35 Fx’s 10 MV 4-field + CT simulation

•• Four typical treatment approaches:Four typical treatment approaches:–– Simple palliative Simple palliative -- 6 MV single field, simulation6 MV single field, simulation–– Complex palliative Complex palliative -- 10 MV POP, simulation, 10 MV POP, simulation,

blockingblocking–– Breast Breast --tangents + electron boost, simulationtangents + electron boost, simulation–– Prostate Prostate -- 35 35 Fx’s Fx’s 10 MV 410 MV 4--field + CT simulationfield + CT simulation

Therapy

TherapyActivity CCR Cost Est. CAS Cost Est.

Palliative – S $1285 $1195

Palliative – C $2345 $1769

Curative Breast $6757 $4850

Curative Prostate

$9453 $7498

Activity CCR Cost Est. CAS Cost Est.

Palliative – S $1285 $1195

Palliative – C $2345 $1769

Curative Breast $6757 $4850

Curative Prostate

$9453 $7498

Estimating the Technical Costs of External Beam

Radiation Therapy

Estimating the Technical Costs of External Beam

Radiation Therapy

• The underlying cause of the difference between the two methods was primarily due to the estimated cost of delivering a daily treatment.

•• The underlying cause of the The underlying cause of the difference between the two methods difference between the two methods was primarily due to the estimated was primarily due to the estimated cost of delivering a daily treatment. cost of delivering a daily treatment.

Comparison of Two Institutions

MIR• 1991• Rx Complex $221/fx

MIRMIR•• 19911991•• Rx Complex $221/Rx Complex $221/fxfx

U of Michigan• 1997• Rx Complex• CCR CAS• $256/fx* $200/fx*• *Estimated cost of CT

study $500

U of MichiganU of Michigan•• 19971997•• Rx ComplexRx Complex•• CCRCCR CASCAS•• $256/$256/fxfx** $200/$200/fxfx**•• *Estimated cost of CT *Estimated cost of CT

study $500study $500

Comparing the costs of radiation therapy and radical prostatecomy for the initial

treatment of early-stage prostate cancer

Comparing the costs of radiation therapy and radical prostatecomy for the initial

treatment of early-stage prostate cancerBurkhardt et al. (ACR)

J Clin Oncol 2002 20(12):2869-75Burkhardt Burkhardt et al. (ACR)et al. (ACR)

J J Clin Oncol Clin Oncol 2002 20(12):28692002 20(12):2869--7575

Comparing the costs of radiation therapy and radical

prostatecomy

prostatecomy• 1992 and 1993 Medicare approved

payment amounts • Direct medical costs• Patients 65 and older and coded by the

Surveillance, Epidemiology, and End Results (SEER) Registry

•• 1992 and 1993 Medicare approved 1992 and 1993 Medicare approved payment amounts payment amounts

•• Direct medical costsDirect medical costs•• Patients 65 and older and coded by the Patients 65 and older and coded by the

Surveillance, Epidemiology, and End Surveillance, Epidemiology, and End Results (SEER) RegistryResults (SEER) Registry

prostatecomy

prostatecomyAverage direct

medical costs• External beam RT• $14,048 (95% CI,

$13,765 to $$14,330)• Assuming 35 Fx’s,

then the average direct medical costper fraction is $400.

Average direct Average direct medical costsmedical costs

•• External beam RTExternal beam RT•• $14,048 (95% CI, $14,048 (95% CI,

$13,765 to $$14,330)$13,765 to $$14,330)•• Assuming 35 Assuming 35 Fx’sFx’s, ,

then the average then the average direct medical costdirect medical costper fraction is $400.per fraction is $400.

Average direct medical costs

• Radical prostatectomy

• $17,226 (95% CI, $16,891 to $17,560)

Average direct Average direct medical costsmedical costs

•• Radical Radical prostatectomyprostatectomy

•• $17,226 (95% CI, $17,226 (95% CI, $16,891 to $17,560)$16,891 to $17,560)

Modeling Direct Costs for RT Rx

Item Initial Costs Cost per Year Rx Room (600 sq.ft at $250/ft2)

$150,000 $25,000

Accelerator $2,000,000 $300,000 Maintenance $200,000 2 RTT’s $150,000 0.5 Physicist $62,500 Approximate direct cost per hour

Item Initial Costs Cost per Year Rx Room (600 sq.ft at $250/ft2)

$150,000 $25,000

Accelerator $2,000,000 $300,000 Maintenance $200,000 2 RTT’s $150,000 0.5 Physicist $62,500 Approximate direct cost per hour

Modeling Direct Costs for RT Rx

Direct costs per hour• Overhead• Total• Collection rate• Charge per hour

for a Rx room• Charge per Rx

(4 patients/hour)

Direct costs per hourDirect costs per hour•• OverheadOverhead•• TotalTotal•• Collection rateCollection rate•• Charge per hour Charge per hour

for a Rx roomfor a Rx room•• Charge per Rx Charge per Rx

(4 patients/hour)(4 patients/hour)

$35050%$52550%

$1,050

$350$35050%50%$525$52550%50%

$1,050$1,050

$262$262

Modeling Direct Costs for RT Planning

Item Initial Cost Cost per year Room, 225 ft2 at $200 ft2

$45,000 $6,500

Planning System $300,000 $100,000 Software support $50,000 Dosimetrist $100,000 0.5 Physicist $62,500 Approximate direct cost/hour

Item Initial Cost Cost per year Room, 225 ft2 at $200 ft2

$45,000 $6,500

Planning System $300,000 $100,000 Software support $50,000 Dosimetrist $100,000 0.5 Physicist $62,500 Approximate direct cost/hour

Modeling Direct Costs for RT Planning

Direct costs per hour• Overhead• Total• Collection rate• Charge per hour

for a Rx room• Charge per Plan

(5 hours/plan)

Direct costs per hourDirect costs per hour•• OverheadOverhead•• TotalTotal•• Collection rateCollection rate•• Charge per hour Charge per hour

for a Rx roomfor a Rx room•• Charge per Plan Charge per Plan

(5 hours/plan)(5 hours/plan)

$15050%$22550%

$2,250

$150$15050%50%$225$22550%50%

$450$450

$2,250$2,250

Average Treatment TimesMIR*

• Conventional 10 min• 3D CRT 18 min• IMRT - MiMiC 30 min• IMRT - SMLC 19 min

* J. Michalski M.D. Target Delineation Symposium, January, 2003

•• ConventionalConventional 10 min10 min•• 3D CRT3D CRT 18 min18 min•• IMRT IMRT -- MiMiCMiMiC 30 min30 min•• IMRT IMRT -- SMLCSMLC 19 min19 min

* J. * J. Michalski Michalski M.D. Target Delineation M.D. Target Delineation Symposium, January, 2003Symposium, January, 2003

Average Treatment TimesUT MDACC

Prostate• Conventional

10 min• 3D-CRT 15 min• IMRT - SMLC

20 min

ProstateProstate•• Conventional Conventional

10 min10 min•• 3D3D--CRT 15 minCRT 15 min•• IMRT IMRT -- SMLC SMLC

20 min20 min

Head and Neck• Conventional

15 min• 3D-CRT 20 min• IMRT - SMLC

25 min

Head and NeckHead and Neck•• Conventional Conventional

15 min15 min•• 3D3D--CRT 20 minCRT 20 min•• IMRT IMRT -- SMLC SMLC

25 min25 min

Average Treatment TimesUT MDACC

• At the risk of stating the obvious with a simple model, if the treatment time is doubled between conventional treatments and IMRT treatments, as is the case at UT MDACC, the cost of delivering such treatments will double

• Treatment room time is expensive.

•• At the risk of stating the obvious with a At the risk of stating the obvious with a simple model, if the treatment time is simple model, if the treatment time is doubled between conventional treatments doubled between conventional treatments and IMRT treatments, as is the case at UT and IMRT treatments, as is the case at UT MDACC, the cost of delivering such MDACC, the cost of delivering such treatments will doubletreatments will double

•• Treatment room time is expensive.Treatment room time is expensive.

Average Planning Times*UT MDACC

Prostate

Prostate• Conventional 3.0 hours• 3D-CRT 6.0 hours• IMRT-DMLC 8.0 hours* Treatment planning times are very difficult to

estimate. Time = Time(definition of task, learning curve, specific

patient, etc.)Planning time has decreased as a result of the use of

a template and the electronic chart.

•• ConventionalConventional 3.0 hours3.0 hours•• 3D3D--CRTCRT 6.0 hours6.0 hours•• IMRTIMRT--DMLCDMLC 8.0 hours8.0 hours* * Treatment planning times are very difficult to Treatment planning times are very difficult to

estimate. estimate. Time = Time(definition of task, learning curve, specific Time = Time(definition of task, learning curve, specific

patient, etc.)patient, etc.)Planning time has decreased as a result of the use of Planning time has decreased as a result of the use of

a template and the electronic chart.a template and the electronic chart.

Head and Neck

Head and Neck• 3D CRT Initial effort 2.0 days

Rework effort 1.5 days• IMRT Initial effort 3.0 days

Rework effort 2.0 daysOne accepted plan per week from a

CMD for H&N.* Times are difficult to estimate,

but UT MDACC is averaging between two to three plans per week per dosimetist.

•• 3D CRT3D CRT Initial effortInitial effort 2.0 days2.0 daysRework effort 1.5 daysRework effort 1.5 days

•• IMRTIMRT Initial effortInitial effort 3.0 days3.0 daysRework effortRework effort 2.0 days2.0 days

One accepted plan per week from a One accepted plan per week from a CMD for H&N.CMD for H&N.

* Times are difficult to estimate, * Times are difficult to estimate, but UT MDACC is averaging between two but UT MDACC is averaging between two to three plans per week per to three plans per week per dosimetistdosimetist..

Survey of Physics Time per Patient Procedure

• 2001 survey data from 30 institutions (11 academic and 19 community or free standing)

• Average qualified medical physicist hours per patient for IMRT - 12 hours. This is divided between planning and QA

• Reimbursement versus Effort in Medical Physics Practice in Radiation Oncology, Herman, Mills, and Gillin, JACMP, March 2003

•• 2001 survey data from 30 institutions (11 2001 survey data from 30 institutions (11 academic and 19 community or free standing)academic and 19 community or free standing)

•• Average qualified medical physicist hours per Average qualified medical physicist hours per patient for IMRT patient for IMRT -- 12 hours12 hours. This is divided . This is divided between planning and QAbetween planning and QA

•• Reimbursement versus Effort in Medical Physics Reimbursement versus Effort in Medical Physics Practice in Radiation Oncology, Herman, Mills, Practice in Radiation Oncology, Herman, Mills, and and GillinGillin, JACMP, March 2003, JACMP, March 2003

Survey of Physics Time per Patient ProcedureAbt 2003 Survey

• Procedure Median QMP Total Timehours

• 77315 Complex 0.83• 77301 IMRT 5.53• 77370 Consultation 5.60• 773xx IMRT

Consultation 6.00

•• ProcedureProcedure Median QMP Total TimeMedian QMP Total Timehourshours

•• 77315 Complex77315 Complex 0.830.83•• 77301 IMRT77301 IMRT 5.535.53•• 77370 Consultation77370 Consultation 5.605.60•• 773xx IMRT 773xx IMRT

ConsultationConsultation 6.006.00

Physics Time per IMRT Patient

• Two independent surveys indicate that on the average physicists are spending 12 hours per patient.

• The cost of physics time depends upon the assumption of the number of hours worked per week.

• Assuming $50/hr for physics time, then the cost of physics effort per IMRT patient is approximately $600.

•• Two independent surveys indicate that on Two independent surveys indicate that on the average physicists are spending 12 the average physicists are spending 12 hours per patient. hours per patient.

•• The cost of physics time depends upon The cost of physics time depends upon the assumption of the number of hours the assumption of the number of hours worked per week.worked per week.

•• Assuming $50/hr for physics time, then Assuming $50/hr for physics time, then the cost of physics effort per IMRT patient the cost of physics effort per IMRT patient is approximately $600.is approximately $600.

Staffing Patterns Abt 2003Staffing Patterns Abt 2003Overall Com Hosp Academic Phys Con

Patients 1080 816 1500 465

MD’s 4.0 2.8 7.5 1.5

Physicists 3.5 2.0 5.4 1.3

CMD/Jr P 2.5 1.9 4.0 1.3

Phy Asst 0 0 1 0

RTT’s 7.0 6.0 10.5 3.8

Staffing Patterns Abt 2003Staffing Patterns Abt 2003Overall Com Hos Academic Phy Con

Patients 1080 816 1500 465

Patients/Physicist

309 408 278 358

IMRT Start Up CostsIMRT Start Up Costs• MCW• Physics

commissioning time1 yr

• Planning system$170K

• QA Equipment $20K• Delivery System

$0 - Existing equipment used

•• MCWMCW•• Physics Physics

commissioning timecommissioning time1 yr1 yr

•• Planning systemPlanning system$170K$170K

•• QA Equipment $20KQA Equipment $20K•• Delivery System Delivery System

$0 $0 -- Existing Existing equipment usedequipment used

• UT MDACC• Physics

commissioning time1 - 2 yrs.

• Planning systems>$500

• QA Equipment $20K• Delivery Systems

>$300K - Mimic purchased

•• UT MDACCUT MDACC•• Physics Physics

commissioning timecommissioning time1 1 -- 2 yrs.2 yrs.

•• Planning systemsPlanning systems>$500>$500

•• QA Equipment $20KQA Equipment $20K•• Delivery Systems Delivery Systems

>$300K >$300K -- Mimic Mimic purchasedpurchased

Estimated Added Cost for IMRT at UT MDACC

• Corvus Planning System(s) $40K/yr/system9 clinical systems

• MiMiC (Used for < 3 years) $90K/yr• QA Equipment $20K/yr• MLC’s ? Also used for 3D CRT• QA Specialists 2 FTE/yr $125K/yr

Perform routine QA which is required for every patient.

•• Corvus Corvus Planning System(s)Planning System(s) $40K/yr/system$40K/yr/system9 clinical systems9 clinical systems

•• MiMiCMiMiC (Used for < 3 years) (Used for < 3 years) $90K/yr$90K/yr•• QA Equipment QA Equipment $20K/yr$20K/yr•• MLC’s MLC’s ? Also used for 3D CRT? Also used for 3D CRT•• QA Specialists 2 FTE/yrQA Specialists 2 FTE/yr $125K/yr$125K/yr

Perform routine QA which is required for Perform routine QA which is required for every patient.every patient.

Estimated Added Cost for IMRT at UT MDACC/Year

• Planning Computers: $360K9 ea x $40K

• Labor $640K(2 QA specialists, 1 additional engineer, 2 additional dosimetrists, 2 additional physicists)

Total $1M+

Rough estimate of the additional costs above existing costs for IMRT.

•• Planning Computers: Planning Computers: $360K$360K9 ea x $40K9 ea x $40K

•• Labor Labor $640K$640K(2 QA specialists, 1 additional engineer, (2 QA specialists, 1 additional engineer, 2 additional dosimetrists, 2 additional physicists)2 additional dosimetrists, 2 additional physicists)

TotalTotal $1M+$1M+

Rough estimate of the additional costs above Rough estimate of the additional costs above existing costs for IMRT.existing costs for IMRT.

UT MDACC IMRTAre the added costs recovered?

• This is very difficult to know for sure

• Substantial charges are generated

• If the added expenses are $1M/year, and if the service is offered on 5 Rx units, then an additional $100/hr/machine must be collected, so $200/hr must be billed

• Charge per hour per machine has increased by > 20%for IMRT services.

•• This is very difficult to know for sureThis is very difficult to know for sure

•• Substantial charges are generatedSubstantial charges are generated

•• If the added expenses are $1M/year, and if If the added expenses are $1M/year, and if the service is offered on 5 Rx units, then an the service is offered on 5 Rx units, then an additional $100/hr/machine must be additional $100/hr/machine must be collected, so $200/hr must be billedcollected, so $200/hr must be billed

•• Charge per hour per machine has increased Charge per hour per machine has increased by > 20%for IMRT services.by > 20%for IMRT services.

2003 Medicare Payments for HOPPs

APC Description Payment Rate

0300 Level I, RT $82.37

0301 Level II, RT $164.73

IMRT $400

0305 Level II, RT Prep $190.51

0310 Level III, RT Prep $712.51

IMRT Dose Plan $875

APC Description Payment Rate

0300 Level I, RT $82.37

0301 Level II, RT $164.73

IMRT $400

0305 Level II, RT Prep $190.51

0310 Level III, RT Prep $712.51

IMRT Dose Plan $875

UT MDACC Costs versus 2003 Medicare Payment

Schedule

UT MDACC Costs versus 2003 Medicare Payment

Schedule• Medicare IMRT Planning $875• H&N Planning Labor Costs

5 days of CMD time $2,000• H&N Planning Computer

Costs/week$1,000

• $3,000 vs $875• More efficiency is needed, e.g.

•• Medicare IMRT PlanningMedicare IMRT Planning $875$875•• H&N Planning Labor Costs H&N Planning Labor Costs

5 days of CMD time 5 days of CMD time $2,000$2,000•• H&N Planning Computer H&N Planning Computer

Costs/weekCosts/week$1,000$1,000

•• $3,000 $3,000 vs vs $875$875•• More efficiency is needed, e.g. More efficiency is needed, e.g.

Economic ConsiderationsEconomic Considerations

• Is the added cost in terms of time in the treatment room, time in the planning, time in QA,and additional equipment required by IMRT reimbursed by Medicare 2003 rates?

• Possibly, depending on time spent delivering treatment and time spent in planning

•• Is the added cost in terms of time in the Is the added cost in terms of time in the treatment room, time in the planning, time treatment room, time in the planning, time in QA,and additional equipment required in QA,and additional equipment required by IMRT reimbursed by Medicare 2003 by IMRT reimbursed by Medicare 2003 rates?rates?

•• Possibly, depending on time spent Possibly, depending on time spent delivering treatment and time spent in delivering treatment and time spent in planningplanning

Socio-Economic ConsiderationsUT MDACC Planning Activity

Appropriate use of technology

Socio-Economic ConsiderationsUT MDACC Planning Activity

Appropriate use of technology

January, 2003 Plans• Complex 200 47%• 3D 175 40%• IMRT 55 13%

January, 2003 PlansJanuary, 2003 Plans•• Complex 200Complex 200 47%47%•• 3D3D 175175 40%40%•• IMRTIMRT 5555 13%13%

February, 2003 Plans• Complex 170 45%• 3D 170 45%• IMRT 40 10%

February, 2003 PlansFebruary, 2003 Plans•• Complex 170Complex 170 45%45%•• 3D3D 170170 45%45%•• IMRTIMRT 4040 10%10%

Socio-Economic Considerations

UT MDACC Planning ActivityAppropriate use of technology

March, 2003 Plans• Complex 175 47%• 3D 155 42%• IMRT 40 11%

March, 2003 PlansMarch, 2003 Plans•• Complex 175Complex 175 47%47%•• 3D3D 155 42%155 42%•• IMRT IMRT 40 11%40 11%

April, 2003 Plans• Complex 170 42%• 3D 175 44%• IMRT 55 14%

April, 2003 PlansApril, 2003 Plans•• Complex 170Complex 170 42%42%•• 3D3D 175175 44%44%•• IMRT 55IMRT 55 14%14%

UT MDACC Planning ActivityAppropriate use of technology, April, 2003

• IMRT Plans per Service• CNS 4%• GU 46%• GYN 13%• H&N 29%• THORACIC 8%

•• IMRT Plans per ServiceIMRT Plans per Service•• CNSCNS 4%4%•• GUGU 46%46%•• GYNGYN 13%13%•• H&NH&N 29%29%•• THORACICTHORACIC 8%8%

Socio-Economic ConsiderationsSocio-Economic Considerations

• The appropriate allocation of cancer care, which is based upon cost-effectiveness or efficacy, is a very challenging exercise. In a 1992 JAMA article Eddy identified the 4 toughest problems:1. Defining an understandable benefit, e.g. lives

saved2. Dealing with inadequate information3. Measuring the costs of care4. Defining the treatment efficacy outside of a

clinical trial, i.e. clinical trial results may not transfer directly to the community setting

•• The appropriate allocation of cancer care, The appropriate allocation of cancer care, which is based upon costwhich is based upon cost--effectiveness or effectiveness or efficacy, is a very challenging exercise. In a efficacy, is a very challenging exercise. In a 1992 JAMA article Eddy identified the 4 1992 JAMA article Eddy identified the 4 toughest problems:toughest problems:1.1. Defining an understandable benefit, e.g. lives Defining an understandable benefit, e.g. lives

savedsaved2.2. Dealing with inadequate informationDealing with inadequate information3.3. Measuring the costs of careMeasuring the costs of care4.4. Defining the treatment efficacy outside of a Defining the treatment efficacy outside of a

clinical trial, i.e. clinical trial results may not clinical trial, i.e. clinical trial results may not transfer directly to the community settingtransfer directly to the community setting

• For the purposes of discussion, assume that IMRT long term outcomes are equal to 3D-CRT outcomes, but have a 50% lower complication rate for prostate cancer patients with Gleason 7 and PSA < 15

• Also assume that the technical treatment costs for IMRT are double than of 3D-CRT, $10K to $20K

• From a socio-economic perspective, can the added cost to lower the complications be justified?

•• For the purposes of discussion, assume that IMRT For the purposes of discussion, assume that IMRT long term outcomes are equal to 3Dlong term outcomes are equal to 3D--CRT outcomes, CRT outcomes, but have a 50% lower complication rate for prostate but have a 50% lower complication rate for prostate cancer patients with Gleason 7 and PSA < 15cancer patients with Gleason 7 and PSA < 15

•• Also assume that the technical treatment costs for Also assume that the technical treatment costs for IMRT are double than of 3DIMRT are double than of 3D--CRT, $10K to $20KCRT, $10K to $20K

•• From a socioFrom a socio--economic perspective, can the added economic perspective, can the added cost to lower the complications be justified?cost to lower the complications be justified?

• Possibly yes, if the patient is a healthy 60 year old male who is expecting to work for another 10 years and whose life expectancy is approximately 20 years

• Possibly no, if the patient is a 75 year old whose life expectancy is less than 5 years

•• Possibly yes, if the patient is a healthy 60 Possibly yes, if the patient is a healthy 60 year old male who is expecting to work for year old male who is expecting to work for another 10 years and whose life another 10 years and whose life expectancy is approximately 20 yearsexpectancy is approximately 20 years

•• Possibly no, if the patient is a 75 year old Possibly no, if the patient is a 75 year old whose life expectancy is less than 5 yearswhose life expectancy is less than 5 years

• Consider a H&N patient, who is receiving IMRT.

• Assume the cost of IMRT over 3D CRT is 1.3 times greater.

• If the principle benefit to the patient is continued saliva product and if there is a 1 in 2 chance of this benefit, can the added cost (>$4K) be justified?

• If Yes, should the patient, as opposed to insurance, be expected to pay for this additional cost?

•• Consider a H&N patient, who is receiving Consider a H&N patient, who is receiving IMRT.IMRT.

•• Assume the cost of IMRT over 3D CRT is Assume the cost of IMRT over 3D CRT is 1.3 times greater.1.3 times greater.

•• If the principle benefit to the patient is If the principle benefit to the patient is continued saliva product and if there is a 1 continued saliva product and if there is a 1 in 2 chance of this benefit, can the added in 2 chance of this benefit, can the added cost (>$4K) be justified?cost (>$4K) be justified?

•• If Yes, should the patient, as opposed to If Yes, should the patient, as opposed to insurance, be expected to pay for this additional insurance, be expected to pay for this additional cost?cost?

Economic Burden of CancerCost of Illness

• Direct cost: medical procedure and services• Morbidity cost: lost income due to disability• Mortality cost: lost income due to premature

death• From this socio-economic perspective, time

in terms of years lived represents money and it is easier to justify high costs if there is a longer life expectancy with a higher quality of life.

•• Direct cost: medical procedure and servicesDirect cost: medical procedure and services•• Morbidity cost: lost income due to disabilityMorbidity cost: lost income due to disability•• Mortality cost: lost income due to premature Mortality cost: lost income due to premature

deathdeath•• From this socioFrom this socio--economic perspective, time economic perspective, time

in terms of years lived represents money and in terms of years lived represents money and it is easier to justify high costs if there is a it is easier to justify high costs if there is a longer life expectancy with a higher quality of longer life expectancy with a higher quality of life. life.

Economic Burden of CancerACS Data

• 2002 NIH estimates overall annual cost of cancer:– Direct $60.9B– Morbidity Costs $15.5B– Mortality Costs $95.2B

It is interesting to note that the largest component in the cost of cancer is the cost of productivity due to premature death.

•• 2002 NIH estimates overall annual 2002 NIH estimates overall annual cost of cancer:cost of cancer:–– DirectDirect $60.9B$60.9B–– Morbidity CostsMorbidity Costs $15.5B$15.5B–– Mortality CostsMortality Costs $95.2B$95.2B

IIt is interesting to note that the largest t is interesting to note that the largest component in the cost of cancer is the cost of component in the cost of cancer is the cost of productivity due to premature death.productivity due to premature death.

Economic Burden of Cancer Economic Burden of Cancer

• In 1997 four cancer sites, lung, prostate, breast, and colon/rectum accounted for 52% of the estimated new cancers and 55% of the estimated cancer deaths. The relative 5 year survival rates are 93% for prostate, 86% for breast, 61% for colorectal and 14% for lung.

• Will IMRT make a significant survival contribution to any of these sites besides prostate with its 93% 5 year survival?

•• In 1997 four cancer sites, lung, prostate, In 1997 four cancer sites, lung, prostate, breast, and colon/rectum accounted for breast, and colon/rectum accounted for 52% of the estimated new cancers and 52% of the estimated new cancers and 55% of the estimated cancer deaths. The 55% of the estimated cancer deaths. The relative 5 year survival rates are 93% for relative 5 year survival rates are 93% for prostate, 86% for breast, 61% for prostate, 86% for breast, 61% for colorectal and 14% for lung.colorectal and 14% for lung.

•• Will IMRT make a significant survival Will IMRT make a significant survival contribution to any of these sites besides contribution to any of these sites besides prostate with its 93% 5 year survival?prostate with its 93% 5 year survival?

• The potential economic gains from any new, effective cancer therapy are substantial

• For example, a 2% increase in the cure rate, 10,000 lives, could save $1B (1/75 of the total cost of cancer care in 2000), assuming that the cost of care for these patients as their disease progresses through end of life is $100,000

•• The potential economic gains from any The potential economic gains from any new, effective cancer therapy are new, effective cancer therapy are substantialsubstantial

•• For example, a 2% increase in the cure rate, For example, a 2% increase in the cure rate, 10,000 lives, could save $1B (1/75 of the 10,000 lives, could save $1B (1/75 of the total cost of cancer care in 2000), assuming total cost of cancer care in 2000), assuming that the cost of care for these patients as that the cost of care for these patients as their disease progresses through end of life their disease progresses through end of life is $100,000is $100,000

IMRT and Mesothelioma30 Gy Yellow, 50 Gy Blue

• One fundamental economic fact that perseveres in cancer management is that an expensive cure is far less costly in the long run than a treatment failure.

•• One fundamental economic fact that One fundamental economic fact that perseveres in cancer management is perseveres in cancer management is that an expensive cure is far less that an expensive cure is far less costly in the long run than a treatment costly in the long run than a treatment failure.failure.

• Houston Chronicle June 8, 2003Milton Weinstein - Kaiser

Professor of Health Policy and Management at Harvard School of Public Health

• “We now ration health care, so why not do it rationally?”

• Quality-adjusted life years - QALYs

•• Houston Chronicle June 8, 2003Houston Chronicle June 8, 2003Milton Weinstein Milton Weinstein -- Kaiser Kaiser

Professor of Health Policy and Professor of Health Policy and Management at Harvard School of Management at Harvard School of Public HealthPublic Health

•• “We now ration health care, so why “We now ration health care, so why not do it rationally?”not do it rationally?”

•• QualityQuality--adjusted life years adjusted life years -- QALYsQALYs

• “… we could save more quality-adjusted years of life - five times as many in this example - if mammograms were done every two years and the money saved was spent on giving every woman a colonoscopy every 5 to 10 years. But at the present time, more women get annual mammograms than ever get screened for colon cancer.”

•• “… we could save more quality“… we could save more quality--adjusted adjusted years of life years of life -- five times as many in this five times as many in this example example -- if mammograms were done if mammograms were done every two years and the money saved was every two years and the money saved was spent on giving every woman a spent on giving every woman a colonoscopy every 5 to 10 years. But at colonoscopy every 5 to 10 years. But at the present time, more women get annual the present time, more women get annual mammograms than ever get screened for mammograms than ever get screened for colon cancer.”colon cancer.”

• The New York Times NATIONAL Sunday, June 8, 2003. White House Memo - Richard Stevenson

• “After signing his third tax cut into law last month and plunging into Middle East peacekeeping this past week, Mr. Bush is now making Medicare his focus. …”

•• The New York Times NATIONAL The New York Times NATIONAL Sunday, June 8, 2003. White House Sunday, June 8, 2003. White House Memo Memo -- Richard StevensonRichard Stevenson

•• “After signing his third tax cut into “After signing his third tax cut into law last month and plunging into law last month and plunging into Middle East peacekeeping this past Middle East peacekeeping this past week, Mr. Bush is now making week, Mr. Bush is now making Medicare his focus. …”Medicare his focus. …”

• When will Medicare apply a QALY’s analysis on the treatment of patients with lung cancer?

• Stage III Lung Cancer -– workup includes multiple CT exams and

now PET.– Treatment may soon include an IMRT,

gated, guided with multiple image sets treatment with protons.

– Survival < 10%

•• When will Medicare apply a When will Medicare apply a QALY’s QALY’s analysis on the treatment of patients with analysis on the treatment of patients with lung cancer?lung cancer?

•• Stage III Lung Cancer Stage III Lung Cancer --–– workup includes multiple CT exams and workup includes multiple CT exams and

now PET.now PET.–– Treatment may soon include an IMRT, Treatment may soon include an IMRT,

gated, guided with multiple image sets gated, guided with multiple image sets treatment with protons.treatment with protons.

–– Survival < 10%Survival < 10%

Intensity-Modulated Radiation Therapy: The Inverse, the ...Intensity-Modulated Radiation Therapy:...

Documents

Kilovoltage Intensity Modulated Radiotherapy

IMRT: Intensity Modulated Radiotherapy

Markov-modulated Hawkes process with stepwise · PDF fileMarkov-modulated Hawkes process with stepwise decay ... process is a Markov chain, ... Markov-modulated Hawkes process with

Section 1.8 Inverse Functions. Inverse Functions

VMAT Treatment Planning - aapm.orgaapm.org/meetings/amos2/pdf/49-14593-86162-718.pdf · “Aperture Based Inverse Planning”, Intensity Modulated Radiation Therapy ¬ – The State

Volume 2, Issue 1 (February 2010) - Dr. Babette Gladstein, VMD

Time Modulated Linear Arrays

Intensity Modulated Radiation Therapy

Volumetric Modulated Arc Therapy

Amplitude modulated-systems

Randomly Modulated Periodic Signals

Ppt on modulated and un modulated signal

Modulated Power Supply - Accel Instruments · PDF fileTS200 Accel Instruments accelinstruments.com Modulated Power Supply The TS200 Modulated Power Supply

Dosimetric comparison of volumetric modulated arc therapy ......advances in RT techniques including intensity-modulated radiation therapy (IMRT), volumetric modulated arc therapy (VMAT),

HARMONICALLY MODULATED STRUCTURES

MELTING BY TEMPERATURE-MODULATED

Commensurability Oscillations Periodically Modulated

1.4c Inverse Relations and Inverse Functions

Intensity Modulated Radiotherapy (IMRT)...Intensity-Modulated Radiotherapy Intensity-modulated radiotherapy (IMRT), which uses computer software, CT images, and magnetic resonance

Inverse Problems, Inverse Methods ... - Harvard University