UCLA Journal of Radiation Oncology SPRING 2024 - Flipbook - Page 32
UCLA RADIATION ONCOLOGY JOURNAL
radiation oncology which has been relatively stable for decades. More than just a linear accelerator
combined with an MRI device, this technology has been acknowledged to offer more than the sum of
its parts, largely due to the real-time imaging features, adaptive planning possibilities of MRgRT, and
functional imaging serving as a real-time biomarker for treatment response. In total, MRgRT allows
radiation oncologists to operate more akin to surgeons who observe, modify and actively manage
their treatments with real-time feedback. The rapidly developing and transformative treatment
delivery modality of MRgRT thus invites several important health policy and healthcare economic
considerations which will be discussed herein.
The Value Proposition of MRgRT
When a new medical technology emerges that disrupts the routine process of care, it is incumbent for
stakeholders to evaluate how the new technology will fit into the existing system from the perspective
of delivery of care and value. Incorporation of a new technology, in this case MRgRT, requires that it
demonstrates value within the healthcare system. This is particularly true in radiation oncology, which
has often been historically singled out for scrutiny given the typically high upfront costs in spite of
eventually proving to be high-value care. 7, 8 As proposed by Steinberg et al.,9 value within the field of
radiation oncology is influenced by 4 key components: cost, outcomes, structure, and process. Cost
and outcomes represent recognizable and intuitive components of value,10 while the other components
of structure and process derive from a separate yet related model for assessing quality in healthcare.11
Structure refers to the larger organization of care delivery as well as the facilities where medical care
is being provided, including the equipment, staff, and institutions, and emphasizes technologically
current and safe environments. Structure can also extend to include insurance coverage and
reimbursement models.12 Process, on the other hand, relates to the components of healthcare delivery
that originate from the patient perspective, emphasizing patient-centered care as well as the technical
delivery of care including factors such as physician expertise and physics quality assurance methods.
This model can be summarized and expressed as an equation which includes all 4 components, in
which value = (outcomes + structure + process)/cost, and where the numerator can also be considered
as “quality.” Through this equation, there are multiple ways in which value can be enhanced, such as
by increasing the numerator of quality and/or decreasing the denominator of cost. However, it is worth
noting that value can also be enhanced even in the context of increasing costs through proportionally
greater increases in quality, and it is ultimately the overall ratio of quality/cost that is of importance
when evaluating value. Thus, a new treatment or technology, in this case MRgRT, can still demonstrate
value in radiation oncology despite potentially increased costs, by offsetting these costs with substantial
improvements in the structure, process, and outcomes of care.
Cost
As described above, cost is a key component in determining the value of a treatment or technology. In
addition, both provider and patient perspectives on cost are important. While this is true for all new
treatments, it is of particular importance in radiation oncology where upfront technology costs can
be significant.13 Such is the case for MRgRT, where the device cost is typically higher than state of the
art CT-based treatment delivery devices, and there are supplemental construction costs associated
with installing MRI shielding.14 Moreover, setting in place the additional care delivery infrastructure
such as increased medical physics oversight and staffing cost required for these devices, which may
have lower throughput compared to standard CT-based treatment devices, all need to be taken into
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