Economic Impact of IMRT
with modest socio-economic
comments
Michael Gillin,
Gillin, Ph.D.
Chief of Clinical Physics
The Inverse, the Converse, and
the Perverse
Eli Gladstein, M.D.
•• Cost
Cost Considerations
Considerations Negative
Negative
•• “It
“It should
should be
be obvious
obvious to
to all
all that
that IMRT
IMRT is
is
expensive
expensive in
in terms
terms of
of (1)
(1) the
the space,
space,
hardware,
hardware, and
and software
software that
that are
are required;
required; (2)
(2)
the
involved in
in preparation
preparation of
of plans
plans and
and
the time
time involved
execution
execution of
of treatment;
treatment; (3)
(3) the
the manpower
manpower
available
available to
to carry
carry out
out such
such planning
planning and
and
treatment;
treatment; and
and (4)
(4) the
the expenditures
expenditures that
that go
go
along
along with
with all
all of
of those
those resources.”
resources.”
Health Care Costs
•• NCI
NCI estimated
estimated that
that in
in 1994
1994 cancer
cancer care
care represented
represented
5%
5% of
of all
all health
health care
care costs
costs or
or $41B
$41B of
of the
the
approximate
approximate $834B.
$834B. One
One rough
rough estimate
estimate is
is that
that
approximately
approximately 10%
10% of
of cancer
cancer care
care costs
costs are
are spent
spent
on
on radiation
radiation oncology
oncology or
or approximately
approximately $5B
$5B
•• In
In the
the 2000’s,
2000’s, Medicare
Medicare costs
costs for
for Radiation
Radiation
Oncology
Oncology represent
represent approximately
approximately 8%
8% of
of the
the
Medicare
Medicare expenditures
expenditures or
or approximately
approximately $9B.
$9B.
•• 2002:
2002: ACS
ACS estimates
estimates $60.9B
$60.9B spent
spent on
on cancer
cancer care,
care,
which
which means,
means, after
after applying
applying the
the 10%
10% rule,
rule,
approximately
approximately $6B
$6B on
on radiation
radiation oncology.
oncology.
Intensity-Modulated Radiation
Therapy: The Inverse, the
Converse, and the Perverse
Eli Gladstein, M.D.
•• Seminars
Seminars in
in Radiation
Radiation Oncology,
Oncology, Vol
Vol 12.
12. No
No
33 (July)
(July) 2002
2002
•• “The
“The present
present euphoria
euphoria surrounding
surrounding IMRT
IMRT is
is
difficult
difficult to
to dissect.
dissect. IMRT
IMRT has
has been
been heavily
heavily
touted
touted by
by both
both vendors
vendors and
and investigators,
investigators,
although
although actual
actual clinical
clinical data
data for
for analysis
analysis
have
have so
so far
far been
been sparse.”
sparse.”
Health Care Costs
2000 Consumers Union
• 1996 7.9% of household income was
spent on health care
• 2000 8.6% of household income was
spent on health care
• 44 million uninsured
• In 1998 18.4% of the people under 65
years old were uninsured.
Radiation Oncology Costs
• As a rough estimate, it appears that
radiation oncology costs in the early
2000’s are between $5B to $10B per
year.
•• Less
Less than
than half
half of
of this
this amount
amount is
is paid
paid to
to UT
UT
MDACC.
MDACC.
1
Radiation Oncology Costs
•• Costs
Costs vs.
vs. Charges
Charges -- An
An important
important
distinction
distinction
•• What
What must
must an
an institution
institution charge
charge per
per hour
hour
or
or per
per treatment
treatment to
to collect
collect its
its costs
costs for
for
providing
providing external
external beam
beam radiation
radiation
treatments?
treatments?
•• What
What is
is the
the charge
charge per
per hour
hour to
to collect
collect
costs
costs for
for providing
providing external
external beam
beam
planning?
planning?
Cost Accounting: Perez
•• 1991
1991 Project
Project -- aa procedure
procedure level
level cost
cost
accounting
accounting system
system of
of all
all of
of the
the costs
costs
involved
involved in
in providing
providing radiation
radiation oncology
oncology
services
services
•• Cost
Cost type:
type: direct
direct variable
variable (labor
(labor and
and
supplies),
supplies), direct
direct fixed
fixed (equipment),
(equipment), indirect
indirect
variable
variable (medical
(medical records),
records), indirect
indirect fixed
fixed
(building
(building -- exam
exam rooms
rooms and
and offices,
offices,
administration,
administration, computers,
computers, etc.)
etc.)
Cost Accounting: Perez
Average time per patient
1991
Activity
CMD
CT
65 min
PhD
Complex Ex Beam 47 min
Interm. Ex. Beam
21 min
Cont. Med. Physics 4.4 min
3.4 min
Cost Accounting in Radiation
Oncology: A ComputerBased Model for
Reimbursement
Carlos A. Perez, M.D. et al.
Int J. Radiation Oncology Biol. Phys.
Vol. 25, 895-906, 1993
895
895-906,
Cost Accounting: Perez
Average MD time per patient
1991
Activity
Activity
•• Consultation
Consultation Complex
Complex
•• Consultation
Consultation Interm
Interm
•• Sim.
Sim
Sim.. Complex
Complex
•• Rx
Rx Planning
Planning Complex
Complex
•• Review
Review dosimetry
dosimetry
Minutes
Minutes
67
67
54
54
50
50
45
45
88
Cost Accounting: Perez
Cost per procedure
1991
Activity
MD
Professional
Planning
Technical
Sim. Interm.
$188
$640
Rx Planning/
Isodose Complex
$147
$618
2
Cost Accounting: Perez
Technical cost per Rx procedure
1991
Rx Interm.
$182
Rx Complex
$220
Gyn Implant
$1557
A Comparison of Two
Methods for Estimating the
Technical Costs of External
Beam Radiation Therapy
James A. Hayman,
Hayman, M.D. M.B.A. et al.
University of Michigan
Estimating the Technical Costs
of External Beam Radiation
Therapy
Estimating the Technical Costs
of External Beam Radiation
Therapy
•• 1997
1997 Data
Data
•
•
•
•
•
•• Cost
Cost Effective
Effective Analysis
Analysis (CEA)
(CEA) estimates
estimates the
the
additional
additional cost
cost per
per unit
unit benefit
benefit associated
associated
with
with the
the use
use of
of aa given
given intervention
intervention as
as
compared
compared to
to the
the most
most reasonable
reasonable
alternative
alternative strategy
strategy
•• Int.
Int. J.
J. Radiation
Radiation Oncology
Oncology Biol.
Biol. Phys.
Phys. 47,
47,
461-467, 2000
461
461-467,
2000
Estimating the Technical Costs
of External Beam Radiation
Therapy
•• Four
Four typical
typical treatment
treatment approaches:
approaches:
–– Simple
Simple palliative
palliative -- 66 MV
MV single
single field,
field, simulation
simulation
–– Complex
Complex palliative
palliative -- 10
10 MV
MV POP,
POP, simulation,
simulation,
blocking
blocking
–– Breast
tangents ++ electron
Breast --tangents
electron boost,
boost, simulation
simulation
–– Prostate
-field ++ CT
44-field
Prostate -- 35
35 Fx’s
Fx’s 10
10 MV
MV 4CT simulation
simulation
Cost-toCost
to-Charge Ratios (CCR)
Cost-to-Charge
Institution’s annual operating costs
CCR for therapeutic radiology 0.4542
Cost Accounting Systems (CAS)
CAS uses a bottom up approach to
estimate the cost of labor, capital
equipment, and overhead necessary
to provide a particular service.
Estimating the Technical Costs
of External Beam Radiation
Therapy
Activity
CCR Cost Est. CAS Cost Est.
Palliative – S
$1285
$1195
Palliative – C
$2345
$1769
Curative Breast
$6757
$4850
Curative
Prostate
$9453
$7498
3
Estimating the Technical
Costs of External Beam
Radiation Therapy
• The underlying cause of the
difference between the two methods
was primarily due to the estimated
cost of delivering a daily treatment.
Comparing the costs of
radiation therapy and radical
prostatecomy for the initial
treatment of early-stage
prostate cancer
Burkhardt et al. (ACR)
J Clin
-75
20(12):2869
Clin Oncol
Oncol 2002 20(12):286920(12):2869-75
Comparison of Two
Institutions
MIR
U
MIR
U of
of Michigan
Michigan
•• 1991
•• 1997
1991
1997
•• Rx
fx •• Rx
$221/
Rx Complex
Complex $221/fx
$221/fx
Rx Complex
Complex
•• CCR
CAS
CCR
CAS
•• $256/fx
fx** $200/fx
fx**
$256/
$200/
$256/fx*
$200/fx*
•• *Estimated
cost
*Estimated cost of
of CT
CT
study
study $500
$500
Comparing the costs of
radiation therapy and radical
prostatecomy
• 1992 and 1993 Medicare approved
payment amounts
• Direct medical costs
• Patients 65 and older and coded by the
Surveillance, Epidemiology, and End
Results (SEER) Registry
Comparing the costs of radiation
therapy and radical
prostatecomy
Modeling Direct Costs for
RT Rx
Average
Average direct
direct
medical
medical costs
costs
•• External
External beam
beam RT
RT
•• $14,048
$14,048 (95%
(95% CI,
CI,
$13,765
$13,765 to
to $$14,330)
$$14,330)
•• Assuming
Fx’s
Assuming 35
35 Fx’s,
Fx’s,,
then
then the
the average
average
direct
direct medical
medical cost
cost
per
per fraction
fraction is
is $400.
$400.
Item
Initial
Item
Initial Costs
Costs
$150,000
Rx
$150,000
Rx Room
Room
(600
(600 sq.ft
sq.ft at
at
2
$250/ft
$250/ft2))
Accelerator
$2,000,000
Accelerator
$2,000,000
Maintenance
Maintenance
22 RTT’s
RTT’s
0.5
0.5 Physicist
Physicist
Approximate
Approximate direct
direct
cost
cost per
per hour
hour
Average
Average direct
direct
medical
medical costs
costs
•• Radical
Radical
prostatectomy
prostatectomy
•• $17,226
$17,226 (95%
(95% CI,
CI,
$16,891
$16,891 to
to $17,560)
$17,560)
Cost
Cost per
per Year
Year
$25,000
$25,000
$300,000
$300,000
$200,000
$200,000
$150,000
$150,000
$62,500
$62,500
$350
$350
4
Modeling Direct Costs for
RT Rx
Direct
Direct costs
costs per
per hour
hour $350
$350
•• Overhead
50%
Overhead
50%
•• Total
$525
Total
$525
•• Collection
50%
Collection rate
rate
50%
•• Charge
$1,050
Charge per
per hour
hour
$1,050
for
for aa Rx
Rx room
room
•• Charge
Charge per
per Rx
Rx
$262
$262
(4
(4 patients/hour)
patients/hour)
Modeling Direct Costs for RT
Planning
Item
2
Room,
Room, 225
225 ft
ft2 at
at
22
$200
ft
$200 ft
Planning
Planning System
System
Software
Software support
support
$300,000
$100,000
$50,000
$100,000
$62,500
$150
Approximate
Approximate
direct
direct cost/hour
cost/hour
Average Treatment Times
MIR*
$150
$150
50%
50%
$225
$225
50%
50%
$450
$450
•
•
•
•
$2,250
$2,250
* J. Michalski M.D. Target Delineation
Symposium, January, 2003
Average Treatment Times
UT MDACC
Prostate
Prostate
•• Conventional
Conventional
10
10 min
min
•• 3D-CRT
15
3D
3D-CRT
15 min
min
•• IMRT
IMRT -- SMLC
SMLC
20
20 min
min
Cost per year
$6,500
Dosimetrist
Dosimetrist
0.5
0.5 Physicist
Physicist
Modeling Direct Costs for RT
Planning
Direct
Direct costs
costs per
per hour
hour
•• Overhead
Overhead
•• Total
Total
•• Collection
Collection rate
rate
•• Charge
Charge per
per hour
hour
for
for aa Rx
Rx room
room
•• Charge
Charge per
per Plan
Plan
(5
(5 hours/plan)
hours/plan)
Initial Cost
$45,000
Head
Head and
and Neck
Neck
•• Conventional
Conventional
15
15 min
min
•• 3D-CRT
20
3D
3D-CRT
20 min
min
•• IMRT
IMRT -- SMLC
SMLC
25
25 min
min
Conventional
3D CRT
IMRT - MiMiC
IMRT - SMLC
10 min
18 min
30 min
19 min
Average Treatment Times
UT MDACC
•• At
At the
the risk
risk of
of stating
stating the
the obvious
obvious with
with aa
simple
simple model,
model, ifif the
the treatment
treatment time
time is
is
doubled
doubled between
between conventional
conventional treatments
treatments
and
and IMRT
IMRT treatments,
treatments, as
as is
is the
the case
case at
at UT
UT
MDACC,
MDACC, the
the cost
cost of
of delivering
delivering such
such
treatments
treatments will
will double
double
•• Treatment
Treatment room
room time
time is
is expensive.
expensive.
5
Average Planning Times*
UT MDACC
Prostate
•
•
•
*
Conventional
3D-CRT
3D
3D-CRT
IMRT-DMLC
IMRT
IMRT-DMLC
3.0 hours
6.0 hours
8.0 hours
Treatment
Treatment planning
planning times
times are
are very
very difficult
difficult to
to
estimate.
estimate.
Time
Time == Time(definition
Time(definition of
of task,
task, learning
learning curve,
curve, specific
specific
patient,
patient, etc.)
etc.)
Planning
Planning time
time has
has decreased
decreased as
as aa result
result of
of the
the use
use of
of
aa template
template and
and the
the electronic
electronic chart.
chart.
Survey of Physics Time per
Patient Procedure
•• 2001
2001 survey
survey data
data from
from 30
30 institutions
institutions (11
(11
academic
academic and
and 19
19 community
community or
or free
free standing)
standing)
•• Average
Average qualified
qualified medical
medical physicist
physicist hours
hours per
per
patient
patient for
for IMRT
IMRT -- 12 hours.. This
This is
is divided
divided
between
between planning
planning and
and QA
QA
•• Reimbursement
Reimbursement versus
versus Effort
Effort in
in Medical
Medical Physics
Physics
Practice
Practice in
in Radiation
Radiation Oncology,
Oncology, Herman,
Herman, Mills,
Mills,
and
Gillin
and Gillin,
Gillin,, JACMP,
JACMP, March
March 2003
2003
Physics Time per IMRT
Patient
•• Two
Two independent
independent surveys
surveys indicate
indicate that
that on
on
the
the average
average physicists
physicists are
are spending
spending 12
12
hours
hours per
per patient.
patient.
•• The
The cost
cost of
of physics
physics time
time depends
depends upon
upon
the
the assumption
assumption of
of the
the number
number of
of hours
hours
worked
worked per
per week.
week.
•• Assuming
Assuming $50/hr
$50/hr for
for physics
physics time,
time, then
then
the
the cost
cost of
of physics
physics effort
effort per
per IMRT
IMRT patient
patient
is
is approximately
approximately $600.
$600.
Average Planning Times*
UT MDACC
Head and Neck
•• 3D
3D CRT
CRT
Initial
2.0
Initial effort
effort
2.0 days
days
Rework
Rework effort
effort 1.5
1.5 days
days
•• IMRT
Initial
3.0
IMRT
Initial effort
effort
3.0 days
days
Rework
Rework effort
effort 2.0
2.0 days
days
One
One accepted
accepted plan
plan per
per week
week from
from aa
CMD
CMD for
for H&N.
H&N.
** Times
Times are
are difficult
difficult to
to estimate,
estimate,
but
but UT
UT MDACC
MDACC is
is averaging
averaging between
between two
two
to
dosimetist
to three
three plans
plans per
per week
week per
per dosimetist.
dosimetist..
Survey of Physics Time per
Patient Procedure
Abt 2003 Survey
• Procedure Median QMP Total Time
hours
• 77315 Complex
0.83
• 77301 IMRT
5.53
• 77370 Consultation 5.60
• 773xx IMRT
Consultation
6.00
Staffing Patterns Abt 2003
Overall
Com Hosp Academic Phys Con
Patients
1080
816
1500
MD’s
4.0
2.8
7.5
1.5
Physicists 3.5
2.0
5.4
1.3
CMD/Jr P
2.5
1.9
4.0
1.3
Phy Asst
0
0
1
0
RTT’s
7.0
6.0
10.5
3.8
465
6
Staffing Patterns Abt 2003
Overall
Com Hos
Academic Phy Con
Patients
1080
816
1500
465
Patients/
Physicist
309
408
278
358
Estimated Added Cost for IMRT
at UT MDACC
•• Corvus
Corvus Planning
Planning System(s)
System(s) $40K/yr/system
$40K/yr/system
99 clinical
clinical systems
systems
•• MiMiC
$90K/yr
MiMiC (Used
(Used for
for << 33 years)
years)
$90K/yr
•• QA
$20K/yr
QA Equipment
Equipment
$20K/yr
•• MLC’s
MLC’s ?
? Also
Also used
used for
for 3D
3D CRT
CRT
•• QA
$125K/yr
QA Specialists
Specialists 22 FTE/yr
FTE/yr
$125K/yr
Perform
Perform routine
routine QA
QA which
which is
is required
required for
for
every
every patient.
patient.
UT MDACC IMRT
Are the added costs recovered?
•• This
This is
is very
very difficult
difficult to
to know
know for
for sure
sure
•• Substantial
Substantial charges
charges are
are generated
generated
•• If
If the
the added
added expenses
expenses are
are $1M/year,
$1M/year, and
and if
if
the
the service
service is
is offered
offered on
on 55 Rx
Rx units,
units, then
then an
an
additional
additional $100/hr/machine
$100/hr/machine must
must be
be
collected,
collected, so
so $200/hr
$200/hr must
must be
be billed
billed
•• Charge
Charge per
per hour
hour per
per machine
machine has
has increased
increased
by
by >> 20%for
20%for IMRT
IMRT services.
services.
IMRT Start Up Costs
•• MCW
MCW
•• Physics
Physics
commissioning
commissioning time
time
11 yr
yr
•• Planning
Planning system
system
$170K
$170K
•• QA
QA Equipment
Equipment $20K
$20K
•• Delivery
Delivery System
System
$0
$0 -- Existing
Existing
equipment
equipment used
used
•• UT
UT MDACC
MDACC
•• Physics
Physics
commissioning
commissioning time
time
11 -- 22 yrs.
yrs.
•• Planning
Planning systems
systems
>$500
>$500
•• QA
QA Equipment
Equipment $20K
$20K
•• Delivery
Delivery Systems
Systems
>$300K
>$300K -- Mimic
Mimic
purchased
purchased
Estimated Added Cost for IMRT
at UT MDACC/Year
• Planning Computers:
$360K
99 ea
ea xx $40K
$40K
• Labor
Labor
$640K
$640K
(2
(2 QA
QA specialists,
specialists, 11 additional
additional engineer,
engineer,
22 additional
additional dosimetrists,
dosimetrists, 22 additional
additional physicists)
physicists)
Total
$1M+
$1M+
Rough
Rough estimate
estimate of
of the
the additional
additional costs
costs above
above
existing
existing costs
costs for
for IMRT.
IMRT.
2003 Medicare Payments for
HOPPs
APC
APC
Description
Description
Payment
Payment Rate
Rate
0300
0300
Level
Level I,I, RT
RT
$82.37
$82.37
0301
0301
Level
Level II,
II, RT
RT
$164.73
$164.73
IMRT
IMRT
$400
$400
0305
0305
Level
Level II,
II, RT
RT Prep
Prep
$190.51
$190.51
0310
0310
Level
Level III,
III, RT
RT Prep
Prep
$712.51
$712.51
IMRT
IMRT Dose
Dose Plan
Plan
$875
$875
7
UT MDACC Costs versus
2003 Medicare Payment
Schedule
• Medicare
$875
Medicare IMRT
IMRT Planning
Planning
• H&N Planning Labor Costs
5 days of CMD time
$2,000
• H&N Planning Computer
Costs/week
$1,000
• $3,000 vs $875
• More efficiency is needed, e.g.
Economic Considerations
•• Is
Is the
the added
added cost
cost in
in terms
terms of
of time
time in
in the
the
treatment
treatment room,
room, time
time in
in the
the planning,
planning, time
time
in
in QA,and
QA,and additional
additional equipment
equipment required
required
by
by IMRT
IMRT reimbursed
reimbursed by
by Medicare
Medicare 2003
2003
rates?
rates?
•• Possibly,
Possibly, depending
depending on
on time
time spent
spent
delivering
delivering treatment
treatment and
and time
time spent
spent in
in
planning
planning
Socio-Economic
Considerations
UT MDACC Planning Activity
Socio-Economic Considerations
UT MDACC Planning Activity
Appropriate use of technology
January,
January, 2003
2003 Plans
Plans
•• Complex
Complex 200
200 47%
47%
•• 3D
175
3D
175 40%
40%
•• IMRT
55
IMRT
55 13%
13%
February,
February, 2003
2003 Plans
Plans
•• Complex
Complex 170
170 45%
45%
•• 3D
170
3D
170 45%
45%
•• IMRT
40
IMRT
40 10%
10%
Socio-Economic
Considerations
UT MDACC Planning Activity
Appropriate use of technology, April, 2003
•
•
•
•
•
•
IMRT Plans per Service
CNS
4%
GU
46%
GYN
13%
H&N
29%
THORACIC
8%
Appropriate use of technology
March,
March, 2003
2003 Plans
Plans
•• Complex
Complex 175
175 47%
47%
•• 3D
155
3D
155 42%
42%
•• IMRT
40
IMRT
40 11%
11%
April,
April, 2003
2003 Plans
Plans
•• Complex
Complex 170
170 42%
42%
•• 3D
175
3D
175 44%
44%
•• IMRT
55
IMRT
55 14%
14%
Socio-Economic Considerations
••
The
The appropriate
appropriate allocation
allocation of
of cancer
cancer care,
care,
which
-effectiveness or
cost
which is
is based
based upon
upon costcost-effectiveness
or
efficacy,
is
a
very
challenging
exercise.
efficacy, is a very challenging exercise. In
In aa
1992
1992 JAMA
JAMA article
article Eddy
Eddy identified
identified the
the 44
toughest
toughest problems:
problems:
1.
1. Defining
Defining an
an understandable
understandable benefit,
benefit, e.g.
e.g. lives
lives
saved
saved
2.
2. Dealing
Dealing with
with inadequate
inadequate information
information
3.
3. Measuring
Measuring the
the costs
costs of
of care
care
4.
4. Defining
Defining the
the treatment
treatment efficacy
efficacy outside
outside of
of aa
clinical
clinical trial,
trial, i.e.
i.e. clinical
clinical trial
trial results
results may
may not
not
transfer
transfer directly
directly to
to the
the community
community setting
setting
8
Socio-Economic Considerations
Socio-Economic Considerations
•• Possibly
Possibly yes,
yes, if
if the
the patient
patient is
is aa healthy
healthy 60
60
year
year old
old male
male who
who is
is expecting
expecting to
to work
work for
for
another
another 10
10 years
years and
and whose
whose life
life
expectancy
expectancy is
is approximately
approximately 20
20 years
years
•• For
For the
the purposes
purposes of
of discussion,
discussion, assume
assume that
that IMRT
IMRT
long
-CRT outcomes,
3D
long term
term outcomes
outcomes are
are equal
equal to
to 3D3D-CRT
outcomes,
but
but have
have aa 50%
50% lower
lower complication
complication rate
rate for
for prostate
prostate
cancer
cancer patients
patients with
with Gleason
Gleason 77 and
and PSA
PSA << 15
15
•• Also
Also assume
assume that
that the
the technical
technical treatment
treatment costs
costs for
for
IMRT
-CRT, $10K
3D
IMRT are
are double
double than
than of
of 3D3D-CRT,
$10K to
to $20K
$20K
•• Possibly
Possibly no,
no, if
if the
the patient
patient is
is aa 75
75 year
year old
old
whose
whose life
life expectancy
expectancy is
is less
less than
than 55 years
years
•• From
-economic perspective,
socio
From aa sociosocio-economic
perspective, can
can the
the added
added
cost
cost to
to lower
lower the
the complications
complications be
be justified?
justified?
Economic Burden of Cancer
Cost of Illness
Socio-Economic
Considerations
•• Consider
Consider aa H&N
H&N patient,
patient, who
who is
is receiving
receiving
IMRT.
IMRT.
•• Assume
Assume the
the cost
cost of
of IMRT
IMRT over
over 3D
3D CRT
CRT is
is
1.3
1.3 times
times greater.
greater.
•• If
If the
the principle
principle benefit
benefit to
to the
the patient
patient is
is
continued
continued saliva
saliva product
product and
and ifif there
there is
is aa 11
in
in 22 chance
chance of
of this
this benefit,
benefit, can
can the
the added
added
cost
cost (>$4K)
(>$4K) be
be justified?
justified?
•• IfIf Yes,
Yes, should
should the
the patient,
patient, as
as opposed
opposed to
to
insurance,
insurance, be
be expected
expected to
to pay
pay for
for this
this additional
additional
cost?
cost?
Economic Burden of Cancer
ACS Data
• 2002 NIH estimates overall annual
cost of cancer:
– Direct
– Morbidity Costs
Costs
– Mortality
Mortality Costs
Costs
$60.9B
$15.5B
$95.2B
IItt is
is interesting
interesting to
to note
note that
that the
the largest
largest
component
component in
in the
the cost
cost of
of cancer
cancer is
is the
the cost
cost of
of
productivity
productivity due
due to
to premature
premature death.
death.
••
••
••
Direct
Direct cost:
cost: medical
medical procedure
procedure and
and services
services
Morbidity
cost:
lost
income
due
Morbidity cost: lost income due to
to disability
disability
Mortality
Mortality cost:
cost: lost
lost income
income due
due to
to premature
premature
death
death
•• From
-economic perspective,
socio
From this
this sociosocio-economic
perspective, time
time
in
in terms
terms of
of years
years lived
lived represents
represents money
money and
and
it
it is
is easier
easier to
to justify
justify high
high costs
costs if
if there
there is
is aa
longer
longer life
life expectancy
expectancy with
with aa higher
higher quality
quality of
of
life.
life.
Economic Burden of Cancer
•• In
In 1997
1997 four
four cancer
cancer sites,
sites, lung,
lung, prostate,
prostate,
breast,
breast, and
and colon/rectum
colon/rectum accounted
accounted for
for
52%
52% of
of the
the estimated
estimated new
new cancers
cancers and
and
55%
55% of
of the
the estimated
estimated cancer
cancer deaths.
deaths. The
The
relative
relative 55 year
year survival
survival rates
rates are
are 93%
93% for
for
prostate,
prostate, 86%
86% for
for breast,
breast, 61%
61% for
for
colorectal
colorectal and
and 14%
14% for
for lung.
lung.
•• Will
Will IMRT
IMRT make
make aa significant
significant survival
survival
contribution
contribution to
to any
any of
of these
these sites
sites besides
besides
prostate
prostate with
with its
its 93%
93% 55 year
year survival?
survival?
9
Socio-Economic Considerations
IMRT and Mesothelioma
30 Gy Yellow, 50 Gy Blue
•• The
The potential
potential economic
economic gains
gains from
from any
any
new,
new, effective
effective cancer
cancer therapy
therapy are
are
substantial
substantial
•• For
For example,
example, aa 2%
2% increase
increase in
in the
the cure
cure rate,
rate,
10,000
10,000 lives,
lives, could
could save
save $1B
$1B (1/75
(1/75 of
of the
the
total
total cost
cost of
of cancer
cancer care
care in
in 2000),
2000), assuming
assuming
that
that the
the cost
cost of
of care
care for
for these
these patients
patients as
as
their
their disease
disease progresses
progresses through
through end
end of
of life
life
is
is $100,000
$100,000
Socio-Economic Considerations
• One fundamental economic fact that
perseveres in cancer management is
that an expensive cure is far less
costly in the long run than a treatment
failure.
Socio-Economic
Considerations
•• “…
-adjusted
quality
“… we
we could
could save
save more
more qualityquality-adjusted
years
years of
of life
life -- five
five times
times as
as many
many in
in this
this
example
example -- ifif mammograms
mammograms were
were done
done
every
every two
two years
years and
and the
the money
money saved
saved was
was
spent
spent on
on giving
giving every
every woman
woman aa
colonoscopy
colonoscopy every
every 55 to
to 10
10 years.
years. But
But at
at
the
the present
present time,
time, more
more women
women get
get annual
annual
mammograms
mammograms than
than ever
ever get
get screened
screened for
for
colon
colon cancer.”
cancer.”
Socio-Economic
Considerations
• Houston Chronicle June 8, 2003
Milton Weinstein
Weinstein -- Kaiser
Kaiser
Professor of Health Policy and
Management at Harvard School of
Public Health
• “We now ration health care, so why
not do it rationally?”
• Quality-adjusted life years - QALYs
Quality
Quality-adjusted
Socio-Economic
Considerations
• The New York Times NATIONAL
Sunday, June 8, 2003. White House
Memo - Richard Stevenson
• “After signing his third tax cut into
law last month and plunging into
Middle East peacekeeping this past
week, Mr. Bush is now making
Medicare his focus. …”
10
Socio-Economic
Considerations
•• When
When will
will Medicare
Medicare apply
apply aa QALY’s
QALY’s
analysis
analysis on
on the
the treatment
treatment of
of patients
patients with
with
lung
lung cancer?
cancer?
•• Stage
Stage III
III Lung
Lung Cancer
Cancer -–– workup
workup includes
includes multiple
multiple CT
CT exams
exams and
and
now
now PET.
PET.
–– Treatment
Treatment may
may soon
soon include
include an
an IMRT,
IMRT,
gated,
gated, guided
guided with
with multiple
multiple image
image sets
sets
treatment
treatment with
with protons.
protons.
–– Survival
Survival << 10%
10%
11