OBJECTIVES

Brachytherapy (BT) is an underutilized component of standard-of-care for locally advanced cervical cancer in the US. Emerging evidence implicates under-reimbursement but is incomplete, relying on survey-based data and lacking indirect costs. This study sought to compare the cost of definitive cervical cancer radiotherapy from the hospital’s perspective with current and proposed (under the anticipated bundled payment model) reimbursement using time-driven activity-based costing (TDABC).

METHODS

Process maps were created for the entire care cycle and divided into external beam radiotherapy (EBRT), including 3D-conformal radiotherapy (3DCRT) or intensity-modulated radiotherapy (IMRT), and high-dose BT boost. Capacity cost rates (CCRs) were derived for each resource, including personnel, space, equipment, and consumables, using national data where available. Indirect costs were also obtained. A representative 66-patient cohort was assembled, and timestamps obtained from the medical record. Current Medicare reimbursements were derived from Current Procedural Terminology (CPT) codes. Proposed rates were derived from figures published by Centers for Medicare and Medicaid Services.

RESULTS

The direct cost of radiotherapy was $17,272, with personnel, space and equipment, and consumables constituting 58%, 39%, and 4% respectively. Indirect costs were $7,030 and total costs $24,302. BT (total=$14,575; direct=$10,359) was costlier than either 3DCRT (total=$9,045; direct=$6,428) or IMRT (total=$9,802; direct=$6,967). These costs were higher than previously estimated via survey-based TDABC (direct cost only: BT=$8,609; EBRT=$4,090). MRI-based planning added $1,367 in direct costs. Compared to current Medicare reimbursement rates, 3DCRT, IMRT, and BT margins were -$274, $6,766, and -$7,822. Compared to the bundled payment base rate ($23,080), the margin for the complete care cycle was -$1,211.

CONCLUSIONS

TDABC was used to calculate the true cost of definitive cervical radiotherapy. Patient timestamps and inclusion of indirect costs resulted in higher estimates than previous. Current fee-for-service and proposed bundled payment models under-reimburse BT and may spur reliance on cross-subsidization and disincentivize provision of standard-of-care nationwide.