2639 - Modeling of Out-of-Pocket Costs across Medicaid and Medicare Plans of Standard-of-Care External Beam Radiation Therapy vs. Radiosurgery for Symptomatic Metastatic Spine Cancer

V. S. Wu¹, M. Khlopin², and S. McClelland III³; ¹University Hospitals Seidman Cancer Center, Case Western Reserve University, Department of Radiation Oncology, Cleveland, OH, ²University Hospitals Cleveland Medical Center Department of Radiation Oncology, Cleveland, OH, ³Case Western Department of Radiation Oncology, Cleveland, OH

Purpose/Objective(s): The choice between stereotactic body radiation therapy (SBRT) and external beam radiation therapy (EBRT) for spine metastases depends on several factors including the size and location of the metastases, the overall health and prognosis of the patient, the presence of other treatment modalities, and the goals of treatment. There remains limited evidence regarding the influence of insurance coverage on out-of-pocket (OOP) expenses for patients receiving different modalities of radiation and fractionation. This study seeks to assess costs across various insurance plans, thereby improving clarity and understanding of treatment expenses. Materials/Methods: We utilized the NCCN guidelines and expert experience to determine the standard treatment protocol for symptomatic metastatic spine cancer. OOP costs were calculated based on the sum of annual deductibles, treatment costs, and copays based on three public insurance plans: Original Medicare, Medigap Plan G, and Medicaid. All costs were calculated over a two-year time horizon (not adjusted for inflation), and all treatment and work-ups were assumed to have taken place at an Ohio hospital. EBRT was defined as 1 fraction (8 Gy x 1), 5 fractions (4 Gy x 5), or 10 fractions (3 Gy x 10).

Results: RT-specific treatment charges include on-treatment radiation oncologist visits, treatment planning, simulation and verification, RT delivery, on-treatment visits, and follow-up visits. Given that Medicare beneficiaries face an OOP cost of 20% for Medicare Part B claims approved procedures after the annual $240 deductible, patients are faced with $807.01, $871.51, $959.69 for EBRT 1 fraction, 5 fractions, and 10 fractions, respectively, after 2 years. Medicare beneficiaries are faced with an OOP charge of $1,127.03, $1,444.92, $1,762.82, and $2,398.60 for SBRT 1, 2, 3, and 5 fractions, respectively. Under Medigap Part G, patients are only responsible for the annual deductible, given no medication charges under Medicare Part D. These patients are faced with a total charge of $480 after 2 years, regardless of radiation modality and fractionation. Medicaid beneficiaries face no OOP expenses as all expenses are covered with no cap, regardless of treatment option.

Conclusion: SBRT remains a more costly treatment modality compared to EBRT, regardless of the number of fractions. Under Medicare, single-fraction EBRT has OOP financial toxicity 19% less than 10-fraction EBRT, 40% than single-fraction SBRT, 79% less than two-fraction SBRT, and 197% less than five-fraction SBRT at two-years post-treatment. These findings indicate that for spinal metastases patients with limited prognosis unlikely to benefit from the superior durability of SBRT (PMID 35675854), the reduced OOP financial toxicity of EBRT may be preferrable to optimize quality of life. By understanding these cost differences, patients and their healthcare providers can work together to determine the best treatment option for each patient from a clinical and financial perspective.