UCLA Journal of Radiation Oncology SPRING 2024 - Flipbook - Page 34
UCLA RADIATION ONCOLOGY JOURNAL
A valid concern is that, in its current rendition, treatment times are relatively long with MRgRT,
yielding decreased patient throughput with this technology.25 This phenomenon holds true even when
not performing real-time on-table adaptive treatment and is thought to be related to issues of machine
functionality and capability, such as the intensity modulated radiation therapy (IMRT) treatment
delivery modality being a step-and-shoot technique rather than the more efficient volumetric arc
therapy technique,14 as well as the need to further optimize adaptive workflows. Longer treatment
times and workflow inefficiency thus impact the value proposition for MRgRT at this point in time.
It should be pointed out, however, that full implementation of a MRgRT-only workflow (ie, MRI
simulation only) is likely to be associated with reduced cost and improved efficiency over the current
process of care.26, 27 In the current fee-for-service model, included in the value equation is the number
of fractions per treatment course. To the extent that MRgRT enhances our ability to safely deliver
ultra-hypofractionated treatments, further cost savings from wide MRgRT implementation are likely
to ensue. While some published studies found MRgRT 5 fraction SBRT to be more costly than CTbased treatment,15 further reducing the number of fractions delivered is another possible method for
improving its cost-effectiveness.14 Such fraction-reducing treatment paradigms are currently under
prospective evaluation in prostate cancer 28, 29 as well as other disease sites.30, 31, 32, 33 The underlying
rationale for studies such as these is sound, given that MRgRT has already demonstrated incremental
improvements in both patient-and physician-reported toxicity profiles of ultra-hypofractionated
radiation therapy.34 Moreover, ultra-hypofractionated treatment courses may mitigate patient financial
toxicity through less missed work, reduced caregiver burden, and fewer travel-related expenses, among
other components,35, 36, 37, 38 and shorter treatment courses may even have positive environmental
impacts as well.39, 40 Furthermore, there are factors specific to the CTgRT process, such as the need
for the procedural insertion of fiducial markers for certain disease sites,41 which are not required
with MRgRT, thereby creating additional opportunities for cost savings and improvements in patient
outcomes. Finally, MRgRT most often requires both CT and MRI simulations for planning in its current
state.42 When the treatment planning process can omit CT simulation, which is potentially the case with
synthetic CTs,16, 43, 44, 45 the costs of MRgRT can be improved even further.
Also fundamental to a treatment's value is how it is incorporated into healthcare insurance coverage
and reimbursement policies, and indeed, changes in our billing and coding paradigms are critical for
making MRgRT cost-effective as well. Such an undertaking must balance the often-competing interests
of payers, patients, the centers investing in MRgRT capabilities, as well as the healthcare system overall.
Despite the significant innovations offered by MRgRT, the current billing and coding nomenclature
neither distinguishes nor does it differentially reimburse for MRgRT or the process by which it is used
in adaptive treatment delivery.46, 47 The reflex may be to simply plug these novel treatment delivery
processes into the pre-existing adaptive billing lexicon. However, the current coding structure for
adaptive radiation therapy is based on legacy adaptive radiation planning and thus does not sufficiently
account for the radically different processes utilized in MRgRT adaptive planning. This is especially
important to consider under the proposed radiation oncology-alternative payment model (RO-APM),48
where adaptive MRgRT may be susceptible to reduced reimbursement relative to its infrastructure costs
in the setting of bundled payments.49 Continued thought and discussions are needed on how to best
account for the different processes introduced by MRgRT in the billing and coding nomenclature in
order to maximize the benefit of this technology for all financial stakeholders.
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