Innovation, value and reimbursement in radiation and complex surgical oncology: Time to rethink

Abstract

Background and purpose: Complex surgery and radiotherapy are the central pillars of loco-regional oncology treatment. This paper describes the reimbursement schemes used in radiation and complex surgical oncology, reports on literature and policy reviews. Material and methods: A systematic review of the literature of the reimbursement models has been carried out separately for radiotherapy and complex cancer surgery based on PRISMA guidelines. Using searches of PubMed and grey literature, we identified articles from scientific journals and reports published since 2000 on provider payment or reimbursement systems currently used in radiation oncology and complex cancer surgery, also including policy models. Results: Most European health systems reimburse radiotherapy using a budget-based, fee-for-service or fraction-based system; while few reimburse services according to an episode-based model. Also, the reimbursement models for cancer surgery are mostly restricted to differences embedded in the DRG system and adjustments applied to the fees, based on the complexity of each surgical procedure. There is an enormous variability in reimbursement across countries, resulting in different incentives and different amounts paid for the same therapeutic strategy. Conclusion:A reimbursement policy, based on the episode of care as the basic payment unit, is advocated for. Innovation should be tackled in a two-tier approach: one defining the common criteria for reimbursement of proven evidence-based interventions; another for financing emerging innovation with uncertain definitive value. Relevant clinical and economic data, also collected real-life, should support reimbursement systems that mirror the actual cost of evidence-based practice.

Cost-effectiveness of hypofractionated versus conventional radiotherapy in patients with intermediate-risk prostate cancer: An ancillary study of the PROstate fractionated irradiation trial – PROFIT

“…Interestingly, physicianreported outcomes late GI and GU toxicities were comparable between arms. Using patients reported QoL is becoming of growing interest not only to get their view on treatment outcomes with similar efficacy [29] but also to value the treatments as done in European countries [30].…”

“…In European countries as well as elsewhere, hospitals are reimbursed based on DRGs. However, radiotherapy comes under separate payment schemes such as in England, Estonia and France [30,32]. RT is paid on a fee-for-service basis which financially incentivises the longer fractionated regimen and impacts clinical practices and hospital revenue [30,32].…”

“…However, radiotherapy comes under separate payment schemes such as in England, Estonia and France [30,32]. RT is paid on a fee-for-service basis which financially incentivises the longer fractionated regimen and impacts clinical practices and hospital revenue [30,32]. In France, to stimulate the implementation of the H-RT for intermediate-risk of PCa, some reimbursement arrangements with tariffs reflecting the most cost-effective RT are critical.…”

Hypofractionation as a solution to radiotherapy access in latin america: expert perspective

“…Thus, reimbursement for RT should be based on bundles or value-based approaches, such as pay-for-performance or outcome-based payments, instead of a fraction-based model [ 47 ]. A Brazilian study noted that the change from fee-for-service schemes to bundle payment strategies was reflected in the prescription of shorter schedules, benefitting low-resource settings [ 48 ].…”

“…Reimbursement modalities must prioritize resource optimization and population health outcomes. RT reimbursement should be based on the bundle payments or value-based approaches, such as outcome-based-payments or pay-for-performance instead of fee-for-service models [ 47 ].…”