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.

A systematic literature review of definitions and classification systems for radiotherapy innovation: A first step towards building a value-based assessment tool for radiation oncology

“…The RO specific classification in technologies, techniques and treatments proposed by Lievens et al, is combined with a categorisation in incremental or stepwise innovations. [4,8] Similarly, the RO specific classification in product, technology, market or organisational innovations, proposed by Jacobs et al, is combined with incremental and radical innovations by Jacobs et al, or combined with small, medium or large innovations as proposed by Swart et al [33,34].…”

“…the Magnitude of Clinical Benefit Scale by the European Society for Medical Oncology; the American Society of Clinical Oncology Value Framework; or the National Comprehensive Cancer Network evidence blocks TM2 ) are immediately transferable to locoregional cancer treatments, such as radiotherapy and oncological surgery. [5,[8][9][10] The difficulties to obtain evidence of longer term benefit in some radiotherapy innovations, combined with high upfront capital or human investments just to even test a new innovation, create challenges to appraise benefit and value. For example, the fact that reducing late toxicity is expected to be the major benefit of proton beam therapy, along with the high costs associated with dedicated proton therapy facilities, has hampered its evidence generation.…”

“…Therefore, a value-based scale specifically for radiotherapy interventions is required to justly assess innovations in RO [8]. Such a dedicated framework demands first a classification system that encompasses the broad range of innovations.…”

“…Such a dedicated framework demands first a classification system that encompasses the broad range of innovations. [4][5][6]8,14] This paper reviews the literature for definitions and categorisations of innovations in RO and describes their use and properties.…”

Optimal and actual rates of Stereotactic Ablative Body Radiotherapy (SABR) utilisation for primary lung cancer in Australia

“…Recently, ESTRO has introduced the value-based health care (VBHC) project, an initiative addressing key issues including defining the outcomes supporting the implementation of new innovations (e.g. clinical, economic and patient-centred outcomes) as well as defining the level of value and evidence needed before implementation into daily practice [73] , [74] . The model presented here can be easily modified to account for any updates to guideline recommendations as new evidence emerge, or changes in the distribution of epidemiological data within the population.…”