Radiation Oncology: Alternative payment model (and alternative thought process, too?)

Once in a while, I am tempted to write a long-form on specific issues that have far-reaching consequences as it requires a thorough analysis. I cannot claim any expertise on the American healthcare barring write a generic perspective on these complex issues as I face them in my medical practice.

I was tagged by one of the prominent Twitter users for their collaborative podcast on the upcoming changes in the payment models for radiation therapy. There was a no-holds barred perspective from one of the subject experts, and I respect their refreshing candor. Therefore, the following represents my “non-American perspective” on the upcoming changes in payment model for Medicare/Medicaid patients.

However, first listen to the podcast, if you haven’t heard it as yet:

I can only highlight the key areas where I believe that it will affect the radiation oncology practise and see a significant impact.

  1. Short course fractionation has taken the “world by storm”- it has become apparent in the covid era and there were several “guidelines” that appeared for “covid struck departments”. Hypofractionation is making inroads from the near dead in its earlier avatar. The conventional fractionation was touted as “safer” but there have been elegant debates about the applicability of LQ model on extreme fractionation too. The changed payment model would put more emphasis on the stereotactic delivery techniques. The long-term effects of stereotactic radiation require careful validation.
  2. The authority overseeing the mode of payments wants to see the DVH data and the requisite EMR data. The guest on podcast show had mentioned about the big data coming in the mainstream.
  3. Ongoing issues related to financial toxicity.
  4. Importance of palliative care and a discussion around high costs associated with “end-of-life-care”.

How these will shift the market towards an implied behavior for improving the quality of healthcare and radiation oncology?

A banal representative image of EMR

I’ll start with the EMR data. Unless there is a method to open up the EMR (and ongoing compliance issues with the ingress and egress of confidential data), the unstructured information from the EMR entries will be difficult to navigate. Unless there is a methodology to put in templates for follow up. (Hint: As part of my prospective PhD, I had created a draft outline for an EMR focused on Oncology. I would have developed it, save that there were ongoing issues with the ownership of intellectual property. None of it materialized, though).

I have seen some EMR entries in North America and they are unreliable, even from the perspective of long-term data and lack of standardisation. I don’t think it would be feasible to “reset” the market for the EMR data entries, but there are ways to migrate to newer formats while keeping the older ones in an archive for retrieval. However, the associated costs are not trivial and I can imagine the CIO getting peptic ulcers, merely by having a thought about migration.

How will the DVH be analysed? Excel sheets? I am not sure.

The larger issue that I have been pushing and have escaped the scrutiny is that we need quantification of mature data and the symptom tracking. One of my earlier project was based on Telegram chat application to get the instant feedback on symptoms and run studies in real time with ping notifications and an opportunity to interact with the same in the clinic.I had created a bot to display information on the expected side effects and also simple voice messages that could be delivered to emphasize compliance to management of radiation induced side effects.

Besides, the proposed system may simplify the approach towards the existing cancer patients. Hopefully, whole brain radiation will be resurrected in its favor, rather than the esoteric conceptional ideas of “hippocampal” sparing. I remain on the fence for the qualitative deterioration of patients, and there is no need to introduce additional complexity for patients based on rather spurious claims. None of the psychometric tests are easier to administer in the clinic and require additional manpower to get it off the ground. A well controlled/funded “trial” might have the resources to pull it off but in busy clinics, it remains an impractical solution. Therefore, they are good enough to preach in fancy glitzy conferences but useless in real life.Do I foresee the shift back to whole brain radiation therapy protocols, then? Unlikely, based on this blog post!

Proton therapies remain on the fence and I have seen huge tomes for marketing: are they beneficial? I am wading into rough territory here because there is likely to be a lot of hand wringing about the impact on pediatric tumors. The large cooperative groups are working towards “elimination” of radiation therapy from treatment protocols because they feel that “targeted therapies” and “newer chemotherapy” is better suited for growth spurts. Never mind the fact that they have propagated pure lies about the impact of radiation on “secondary tumors” and I still see the nonsense popping up on my Twitter stream. It is because the reported literature is NOT supported my molecular data on impact of chemotherapy on oncogenes and pathogenesis of secondary tumors later in the life. The point here is- what is the economic cost that we are willing to endure?

Cancer, for a vast majority of patients, is a lifestyle problem. There has been enough research done to show that lack of physical activity and smoking causes it. The risk persists in ex-smokers. Which remains more economically beneficial? Preventive strategies by taxing cigarettes, for example? Or treating patients with a toxic cocktail of chemotherapy and “biologicals”?

Therefore, the impact of this payment model will be felt in many subtle ways- a complete realignment for the quality of healthcare delivery wherein, hopefully, a better quantification of data and means to follow up. For a vast majority of patients diagnosed with cancer, the associated “fears” are for immediate needs- arranging finances, putting kids through college, employment issues for taking time off work, and generally this upsets the routine for most. Besides, there is a general dissatisfaction with the complexity of procedures and a complete “foreign sounding technical ideas”- how much can a clinician explain so it is really understood by the patients and their caregivers?

As I have been writing on my blog and elsewhere, we need better research in radiobiology; especially related to the impact of fractionation on normal tissues and associated molecular profiles. Instead, what I end up seeing is a shift towards a combination of radiation with various biologicals (which may or may not act in specific ways). The interaction of radiation with chemotherapy is still less understood, and we have made none significant advance beyond the conceptual ideas of the 70s.

Protons don’t represent an advance or “innovation” but a serendipitous discovery about the heavy particles for “cancer” cure. Besides, the dosimetric advantages for radiation delivery (volumetric arc therapies/ DIBH) don’t represent the “cutting edge” of treatments and is a grossly mistaken concept.

Do you what matters the most to the patients? Empathy. We have a clear understanding that the life course care off. An emphasis on palliative care by providing an excellent quality of life where patient remains functional till the end. An adequate pain relief through the judicious use of opioids.

At a subtler level, I think this is a clarion call for all of us (as radiation oncologists) to remind ourselves about the importance of Hippocratic oath and primum-non-nocere. First, do no harm. Let’s join our hands together to shun the complexity and make it simpler for the patients to negotiate the toughest challenges in their lives. Let’s go back to the roots of the profession and remind ourselves that we shouldn’t allow “technology” or the “reimbursement” codes to dictate the course of treatment.