title: Proton beam therapy and accountable care: the challenges ahead.
abstract: OBJECTIVE
  Proton beam therapy (PBT) centers have drawn increasing public scrutiny for their high cost. The behavior of such facilities is likely to change under the Affordable Care Act. We modeled how accountable care reform may affect the financial standing of PBT centers and their incentives to treat complex patient cases.
  
  
  METHODS
  We used operational data and publicly listed Medicare rates to model the relationship between financial metrics for PBT center performance and case mix (defined as the percentage of complex cases, such as pediatric central nervous system tumors). Financial metrics included total daily revenues and debt coverage (daily revenues - daily debt payments). Fee-for-service (FFS) and accountable care (ACO) reimbursement scenarios were modeled. Sensitivity analyses were performed around the room time required to treat noncomplex cases: simple (30 minutes), prostate (24 minutes), and short prostate (15 minutes). Sensitivity analyses were also performed for total machine operating time (14, 16, and 18 h/d).
  
  
  RESULTS
  Reimbursement under ACOs could reduce daily revenues in PBT centers by up to 32%. The incremental revenue gained by replacing 1 complex case with noncomplex cases was lowest for simple cases and highest for short prostate cases. ACO rates reduced this incremental incentive by 53.2% for simple cases and 41.7% for short prostate cases. To cover daily debt payments after ACO rates were imposed, 26% fewer complex patients were allowable at varying capital costs and interest rates. Only facilities with total machine operating times of 18 hours per day would cover debt payments in all scenarios.
  
  
  CONCLUSIONS
  Debt-financed PBT centers will face steep challenges to remain financially viable after ACO implementation. Paradoxically, reduced reimbursement for noncomplex cases will require PBT centers to treat more such cases over cases for which PBT has demonstrated superior outcomes. Relative losses will be highest for those facilities focused primarily on treating noncomplex cases.
authors.affiliation: Department of Medicine, Brigham and Women's Hospital, Boston, MA 02115, USA. selnahal@partners.org
authors.forename: Shereef M
authors.initials: SM
authors.lastname: Elnahal
authors.forename: John
authors.initials: J
authors.lastname: Kerstiens
authors.forename: Richard S
authors.initials: RS
authors.lastname: Helsper
authors.forename: Anthony L
authors.initials: AL
authors.lastname: Zietman
authors.forename: Peter A S
authors.initials: PA
authors.lastname: Johnstone
mesh_terms: D060866:Accountable Care Organizations / Q000191:economics*; D002173:Cancer Care Facilities / Q000191:economics*; D002202:Capital Financing / Q000191:economics; D016543:Central Nervous System Neoplasms / Q000191:economics / Q000532:radiotherapy; D002648:Child; D003365:Costs and Cost Analysis / Q000191:economics / Q000379:methods; D003953:Diagnosis-Related Groups / Q000191:economics; D018588:Fee-for-Service Plans / Q000191:economics; D006801:Humans; D007182:Income; D008297:Male; D058991:Patient Protection and Affordable Care Act; D011471:Prostatic Neoplasms / Q000191:economics / Q000532:radiotherapy; D061766:Proton Therapy / Q000191:economics* / Q000295:instrumentation; D012051:Reimbursement Mechanisms / Q000191:economics*; D013997:Time Factors; D014481:United States