title: Doing poorly by doing good: the bottom line of proton therapy for children.
abstract: OBJECTIVE
  Proton beam therapy (PBT) is the most expensive form of radiation therapy in the United States. An area in which clear advantage has been modeled is the use of PBT for pediatric patients, although no publications deal with practice costs to PBT centers associated with a pediatric focus. Pediatric cases require longer treatment times and more staff members and incur higher supply and device costs. In addition to being more expensive to treat, the pediatric patients at the authors' center also present with Medicaid as their primary insurer at higher rates than adults. At their center, in the past 2 years, pediatric patients (<21 years of age) have constituted 32% of total patients treated. The authors present their cost experience in a PBT environment treating a large number of children.
  
  
  METHODS
  After approval was obtained from the local institutional review board, data relating to patients ≤21 years of age who started treatment during the period between November 1, 2011, and October 31, 2013, were reviewed. Direct expenses of devices and supplies used, billing for anesthesia, staffing, and direct operational costs (proton beam) were calculated to determine the direct cost to treat. Those direct costs were then compared with actual reimbursements received for those treatments. Additionally, gross operating costs per hour and gross average expenses per pediatric patient were calculated, and that cost was then compared with actual reimbursement.
  
  
  RESULTS
  The mission to preferentially treat pediatric patients involves accepting a loss for one-third of pediatric patients before allocating any overhead. After averaging gross expenses over total operating hours, 60% of the pediatric patients were found to be treated at a net loss.
  
  
  CONCLUSIONS
  Given insurance constraints and unique costs associated with the pediatric population, PBT centers devoted to children should not be expected to be markedly profitable. For centers that do choose to accept pediatric patients, those patients must be balanced with patients producing higher net reimbursement.
authors.affiliation: Department of Radiation Oncology, Indiana University School of Medicine, Indianapolis, Indiana; Indiana University Health Proton Therapy Center, Bloomington, Indiana. Electronic address: pajohnst@iupui.edu.
authors.forename: Peter A S
authors.initials: PA
authors.lastname: Johnstone
authors.affiliation: Indiana University Health Proton Therapy Center, Bloomington, Indiana.
authors.forename: John
authors.initials: J
authors.lastname: Kerstiens
mesh_terms: D000293:Adolescent; D002648:Child; D003365:Costs and Cost Analysis; D005260:Female; D006302:Health Services Research; D006801:Humans; D019458:Insurance Coverage / Q000706:statistics & numerical data; D008297:Male; D008484:Medicaid / Q000191:economics; D009369:Neoplasms / Q000532:radiotherapy*; D061766:Proton Therapy / Q000191:economics*; D013997:Time Factors; D014481:United States
keywords: Protons; health services research; pediatric cancer