Retrospective analysis of characteristics associated with higher-value radiotherapy episodes of care for bone metastases in Medicare fee-for-service beneficiaries

Objectives The Centers for Medicare & Medicaid Services' newly enacted Radiation Oncology Model (' RO Model') was designed to test the cost-saving potential of prospective episode-based payments for radiation treatment for 17 cancer diagnoses by encouraging high-value care and more efficient care delivery. For bone metastases, evidence supports the use of higher-value, shorter courses of radiation (≤10 fractions). Our goal was to determine the prevalence of short radiation courses (≤10 fractions) for bone metastases and the setting, treatment and patient characteristics associated with such courses and their expenditures. Design Using the RO Model episode file, we evaluated receipt of ≤10 fractions of radiotherapy for bone metastases and expenditures by treatment setting for Medicare fee-for-service beneficiaries during calendar years 2015-2017. Using unadjusted and adjusted regression models, we determined predictors of receipt of ≤10 fractions and expenditures. Multivariable models adjusted for treatment and patient characteristics. Results There were 48 810 episodes for bone metastases during the period. A majority of episodes for ≤10 fractions occurred in hospital-outpatient settings (62.8% (N=22 715)). After adjusting for treatment and patient factors, hospital-outpatient treatment setting remained a significant predictor of receiving ≤10 fractions (adjusted OR 2.03 (95% CI 1.95, 2.12; p<0.001) vs free-standing). The greatest adjusted contributors to total expenditures were number of fractions (US-3424 (95% CI US-3412 to US-3435) for ≤10 fractions vs >10; p<0.001) and treatment type (including US7716 (95% CI US7424 to US8018) for intensity modulated radiation therapy vs conventional external beam; p<0.001). Conclusions A measurable performance gap exists for delivery of higher-value bone metastases radiotherapy under an episode-based model, associated with increased expenditures. The RO Model may succeed in improving the value of bone metastases radiation. Increasing the capacity of free-standing centres to implement palliative-focused services may improve the ability of these practices to succeed under the RO Model.