Oncology: Proton Beam Therapy Reimbursement Takes a Leap

Proton beam therapy gets a 9% reimbursement increase for 2011.  This sounds great but you still need a lot of volume to cover a $150 million investment, not to mention ongoing costs.  Full capacity for a treatment center is estimated to be 2,000 to 3,500 patients per year, depending on the facility.  At first glance, that doesn’t seem like a lot of patients, but there are a lot of numbers to consider here.

With the new CMS payment level, reimbursement for simple treatments is now $1,031 (APC 664), up from $942 in 2010.  More complex treatments are reimbursed at a rate of $1,349 (APC 667), up from $1,232 in 2010.  Depending on the cancer, a protocol of 10 to 15 treatments may be required per patient.  This amounts to $10,000 to $20,000 per patient for the therapy alone, twice as much as a linear accelerator.  Planning and tracking should add another couple of thousand dollars.

So, what’s the patient getting for twice the costs?  Proton therapy’s benefits lie in its ability to destroy cancerous cells with sub-millimeter accuracy.  In a 2009 review, when comparing radiation doses to a retinoblastoma target, IMRT resulted in 96% coverage; proton beam therapy was able to cover 100% of the target.  The same study underlined that an advantage of proton beam therapy is that is does not harm healthy tissue.  Proton beam therapy resulted in only 10% of the dose going to healthy tissue.  In comparison, 25% dose going to healthy tissue using 3D-CRT and of 69% using IMRT.

Some time ago, I read an article in Forbes stating that with Medicare reimbursement, providers stand to make a pretty good profit with proton beam therapy, based on 40,000 treatments per year (2,000 to 3,000 patients).  As of 2010, there are only seven proton beam therapy centers in operation in the U.S. with four more under development.

I am pretty excited about this technology!  With outcomes like this and increasing reimbursement, no wonder there are four more centers underway right now.  PBT offers great potential and is a vastly underserved market.

James Laskaris, EE, BME
James Laskaris, EE, BME, Clinical Analyst — Mr. James Laskaris is a senior emerging technology analyst at MD Buyline and has been with the company since 1994. With over 30 years of experience in the healthcare field, Mr. Laskaris is the primary analyst of high-end OR technology. He also covers issues related to the legislative and reimbursement effect on healthcare and authors a bimonthly “Issues that Matter” publication. Mr. Laskaris received his biomedical engineering degree from Southern Illinois University. His work has been published in hfm Magazine, Radiology Manager and Healthcare Purchasing News.