© 2010 Universitair Ziekenhuis Gent

Innovative Radiotherapy Techniques

Time-Driven Activity-Based Costing

Yolande Lievens, MD, PhD

Radiation Oncology

University Hospital Gent

UNAMEC – November 5th 2014

the aim of radiotherapy:

improve local control, survival and quality of life

technologic advances:

equitoxic dose escalation vs. reduced side effects

Tumour control

Effe

ct

Tumour Dose

Normal tissue damage

Dose escalation Increase the tumour dose

for the same dose to the healthy tissues

Decrease toxicity (ALARA) Reduce the dose to the healthy tissues

for the same tumour dose

2D RT 60Gy/2Gy

3D-CRT 66-70Gy/2Gy

IMRT >70Gy/2Gy

SBRT 60Gy/20Gy

Fang et al. IJROBP 2006 Lagerwaard et al. IJROBP 2008

Liao et al. IJROBP, 2009

Veldeman et al. Lancet Oncology 2008

It’s always too early to evaluate a technology, until, suddenly, it’s too late!

Buxton’s Law

development RCT unethical? Widespread use still avoidable?

Effectiveness?

exte

nt

clin

ical

use

t premarket emerging diffusing established obsolete

Perform

ance &

safety

Co

st calculatio

n?

CEA

- BIA

investment

Fin

anci

ng

in silico studies Phase I-II

in selected centres

* Patient

Assessment

Imaging for RT

Planning

Treatment

Planning

Pre-Treatment Review

and Verification

Treatment

Delivery

Post –Treatment

Completion

On-Treatment Quality

Management

* Equipment and

Software Quality

Management

x N Fractions

AAPM process map, Ford et al.

x times ART (Adaptive RT)

preparation

3D-CRT IMRT SBRT

delivery

IGRT Image-Guided RT

more complex treatments

more time

more resources capital investments

sophisticated equipment

buildings

human resources treatment

maintenance

more costly

Ploquin and Dunscombe, R&O 2008

historical evolution of the cost of radiation therapy over 20 years

corrected for inflation and exchange rates

what we want for our patients

what society wants for all patients

maximise health within a given budget minimise cost per life year gained

early availability of new and promising treatments

high-tech, high cost, high reimbursements (?)

« The difference between the reimbursement in the United States and most European health care systems

has been proposed as a contributing factor in explaining the slower introduction of IMRT in European centres.

Although favourable reimbursement may ensure

cost-effectiveness from a departmental perspective, it clearly does not guarantee cost-effectiveness

from the society or the health service point of view. »

Bentzen IJROBP 2004

ideally reimbursement should

cover the costs adapt to technology evolution endorse quality account for effectiveness

Belgian radiotherapy reimbursement

no correlation to costs lags behind on technology evolution does not support quality is not related to effectiveness

Hulstaert et al, Rapport 198 KCE 2013

reimbursement for SBRT ?

what is

the (level 1) evidence?

the cost?

the value for money?

the budgetary impact?

coverage with evidence development

Innovative radiotherapy techniques

Define the indications

Define the costs to be covered

Define the evidence generation

Evidence generation and follow-up

In close collaboration with the radiotherapy departments

NIHDI

KCE

CR

Technique Cancer Indication Safety monitoring

(clinical trial )

APBI Breast (low risk group only) No**

APBI Breast (medium risk) Yes

Intraoperative boost Breast No**

SBRT Lung No

SBRT Prostate Yes

SBRT Renal Yes

SBRT Pancreatic Yes

SBRT Head & Neck Yes

SBRT Primary Hepatic Yes

SBRT Hepatic Metastases No

SBRT Spinal and paraspinal No

SBRT Oligometastases (other) Yes

SBRT Lung Metastases No

SBRT Lymph Node Metastases Yes

Kaplan and Porter, Harvard Business Review 2011

microcosting

gross costing

time and motion studies

detailed resource use analysis

bottom up

sensitivity & precision

complexity & cost

total budget allocated

to specific services

top down

simplicity & low cost

lack of sensitivity

microcosting

gross costing

bottom up

top down

treatments

radiotherapy resources

personnel equipment buildings overhead

“1st stage cost drivers” “resource drivers”

e.g. time percentages

“2nd stage cost drivers” “activity drivers”

number of activities… time

direct allocation

indirect allocation using cost drivers

resource costs

cost-objects

activities

time-driven Activity-Based Costing

consumables

activities consume resources to produce products

Lievens et al. IJROBP, 2003 Van de Werf et al. R&O, 2012

Out of scope

Treatment cost

DIRECTINDIRECT

Personnel MaterialEquipment

RT patient related activities RT support act.

Intake consultation

Medical review

…

APBI -brachytherapy

SBRT – lung –5 fractions

…

Overhead

OtherEquipment

Maint. & QA

Material

Time driven

Activity consumption Per fraction

Non-RT, care

activities

Non- care activities

RT patient related

RT support

Mark-up % on

treatment cost

80% fraction

20% patient

56.6%

Hulstaert et al, Report 198 KCE 2013

0

2000

4000

6000

8000

10000

12000

14000

16000

3 4-6 7-10

Co

st

(€)

N of fractions

Free breathing - center A

Free breathing - center B

Free breathing - center C

Free breathing - center D

Free breathing - center E

Free breathing - center F

Gating - center G

Gating - center H

Tracking - center I

Tracking or Free breathing - center J

Hulstaert et al, Report 198 KCE 2013

average cost SBRT: 6,221€

Hulstaert et al, Report 198 KCE 2013

4-year provisional financing of SBRT

prospective evaluation

real-life setting

Which departments?

Which indications?

Which technology?

What standards of care?

What outcome?

What budget?

Hulstaert et al, Report 198 KCE 2013

7 304

5 116 5 134

6 378 6 400

7 289 7 522

8 418 8 519 8 701

9 561

-

1 000

2 000

3 000

4 000

5 000

6 000

7 000

8 000

9 000

10 000

Average A B C D E F G H I J

Co

st

per t

reatm

en

t (€)

Prostate IMRT 33-40 fractions

Hulstaert et al, Report 198 KCE 2013

-

500

1 000

1 500

2 000

2 500

3 000

3 500

4 000

4 500

A B C D E F G H I J

Eq

uip

me

nt

+ p

ers

on

ne

l c

os

t p

er

tre

atm

en

t (€

)

Average cost per process step for all external radiotherapy treatments

First patient contact Simulation Delineation Planning

Treatment delivery End of treatment Adaptative RT

Most Important Input Parameters RadiationTreatments

Country for Cost Evaluation: South Africa Fractionation Schedules long (> 25)

intermediate

(11-25) short (<11)

Currency Used for Results: Rand

Distribution of Fractionation

Schedules 20% 10% 70%

Patient Number: 3000 Treatment Using Blocks 60% 30% 10%

Treatment Using Immobilization 50% 30% 5%

Personnel Time

Radiation

Oncologist

Medical

Physicist

Senior

Radiation

Technologist

Junior

Radiation

Technologist Nurse Administrative Personnel

Patient-Related

EBRT Time 55% 70% 85% 100% 75% 75%

Total Overhead 45% 30% 15% 0% 25% 25%

Equipment Anticipated Cobalt Orthovoltage Linac Simulator TPS Mould Room

Number of

Equipment 2 1 4 2 3 1

Proportional

Use of

Equipment 30% 10% 60% 85% 15% 60%

Amort. 24%

Maint. 54%

Salaries 22%

Total Operating Costs

1703 3309 4325 3882

10334

18136

,0

5000,0

10000,0

15000,0

20000,0

25000,0

Short Intermediate Long

Cost per Treatment Type

Inclusive Departmental Overhead

Building & Equipment Cost Personnel Cost

Most Important Input Parameters RadiationTreatments

Country for Cost Evaluation: South Africa Fractionation Schedules long (> 25)

intermediate

(11-25) short (<11)

Currency Used for Results: Rand

Distribution of Fractionation

Schedules 20% 10% 70%

Patient Number: 3000 Treatment Using Blocks 60% 30% 10%

Treatment Using Immobilization 50% 30% 5%

Personnel Time

Radiation

Oncologist

Medical

Physicist

Senior

Radiation

Technologist

Junior

Radiation

Technologist Nurse Administrative Personnel

Patient-Related

EBRT Time 55% 70% 85% 100% 75% 75%

Total Overhead 45% 30% 15% 0% 25% 25%

Equipment Anticipated Cobalt Orthovoltage Linac Simulator TPS Mould Room

Number of

Equipment 2 1 4 2 3 1

Proportional

Use of

Equipment 30% 10% 60% 85% 15% 60%

94% 89%

67%

98%

83% 93%

51% 62%

57%

98%

63% 70%

0%

20%

40%

60%

80%

100%

120%

Radiation Oncologist Medical Physicist Senior RadiationTechnologist

Junior RadiationTechnologist

Nurse AdministrativePersonnel

Personnel Utilization Total Time EBRT Time Only

AVAILABILITY equipment & staffing

guidelines reimbursement

NEEDS translation CCORE utilisation

to Europan countries

ACTIVITY-BASED COSTING at the national level

in European countries

ECONOMIC EVALUATION at the national level

in European countries HERO-project

National Societies

National Societies

CCORE

National Societies

CCORE

IAEA National Societies

ESTRO Clinical

Committee

a wider scope, the (near) future • Breast reconstruction techniques after mastectomy: description and costing of the medical subcomponents (HTA Study 2014-25)

• New Generation Sequencing panel tests in oncology

• Cost of medical imaging techniques (MRI/CT/… )

• …

adapt (part) of the nomenclature review hospital financing based on actual costs

Take-home messages Rapid evolution of radiotherapy, reimbursement inadequate Need for correct cost data, for reliable effectiveness data Coverage with evidence development TD-ABC used in several radiotherapy settings TD-ABC is a possible model to support market access of innovative medical technologies in Belgium

Thank you for your attention !

Thanks to

the Belgian Health Care Knowledge Centre Frank Hulstaert & Caroline Obyn Anne-Sophie Mertens & Dries Van Halewyck

the Belgian Cancer Registry and the RIZIV-INAMI

Jan Verstraete & Evelyn van de Werf Barbara Vanderstraeten

the IAEA Vic Levin, Branislav Jeremic, Eduardo Zubizerrato

the ESTRO-HEROes Cai Grau, Noémie Defourny, Peter Dunscombe & Chiara Gasparotto