Health Services Research

PV QA 3 - Poster Viewing Q&A 3

TU_37_2965 - Variations in Medicaid Payment Rates for Radiation Oncology

Tuesday, October 23
1:00 PM - 2:30 PM
Location: Innovation Hub, Exhibit Hall 3

Variations in Medicaid Payment Rates for Radiation Oncology
A. Agarwal1, and L. B. Marks2; 1University of North Carolina - Chapel Hill, Chapel Hill, NC, 2Lineberger Comprehensive Cancer Center, University of North Carolina Hospitals, Chapel Hill, NC

Purpose/Objective(s): Medicaid fee schedules are determined individually by each State in the US. We herein quantify the magnitude of differences in Medicaid-based reimbursement between states for routine hypo-fractionated whole breast radiation. Further, we assess if these differences mirror inter-state variations in Medicaid-based fees for non-radiation therapy-related care.

Materials/Methods: Current Procedures Terminology (CPT) codes associated with delivery of 4,272 cGy to the whole left breast in 267 cGy fractions, with a tumor bed boost of 1,000 cGy in 200 cGy fractions, using 3D conformation radiation therapy and respiratory motion management, were identified. All radiation oncology codes from the day of treatment planning and simulation to the final fraction of treatment were included. The Medicaid fee-for-service reimbursement rates were accessed through state-specific online Medicaid websites. If an individual state had different reimbursement rates for the same CPT code (e.g. based on facility type or location), a simple average was calculated. Because some states did not reimburse for respiratory motion management, total reimbursements with and without were computed. Data are presented using simple descriptive statistics. The Kaiser Family Foundation (KFF) publishes a Medicaid-to-Medicare fee index that measures each state’s Medicaid physician reimbursement relative to Medicare reimbursement. KFF calculates the index by comparing rates for 27 common medical services. We computed the Pearson’s Correlation Coefficient between the state-specific radiation-oncology data, and the KFF data, to assess their degree of correlation.

Results: 44 of the 50 states had complete fee-for-service data available for each radiation oncology CPT codes. Within these 44 states, the total reimbursements (including respiratory motion management) ranged from $4,519 – $18,581 (median $7,242); standard deviation $2,801. The total reimbursements (excluding respiratory motion management) ranged from $3,831 – $15,218 (median $6,727); standard deviation $2,252. The Pearson’s Correlation of Coefficient between hypo-fractionated breast radiation and general Medicaid reimbursement is 0.55 (p<0.001), indicating a statistically significant moderately positive correlation.

Conclusion: There are marked (four fold) inter-state variations in total Medicaid reimbursements for routine breast cancer treatments. These large inter-state variations may affect availability of radiation oncology services (especially in rural locations with fewer providers) and utilization rates. In addition, reimbursement differences can have important implications for determinations of cost effectiveness, as well as future efforts for payment reform. The variation in the Medicaid radiation oncology fees is reflective of broader interstate variations, and the large differences in reimbursements need to be acknowledged and considered in future work in these areas.

Author Disclosure: A. Agarwal: Executive Committee Member; Association of Residents in Radiation Oncology. L.B. Marks: None.

Ankit Agarwal, MD, MBA

Disclosure:
Employment
UNC Chapel Hill: Resident Physician: Employee

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