Workforce Innovation, Quality Improvement, and the Shift to Value-Based Radiation Oncology

ASTROnews has highlighted workforce trends in radiation oncology that are associated with quality improvement in their Summer 2024 edition. Due to rising radiation therapist shortages increasing from 7.2% in 2020 to 10.7% in 2022, departments need to reevaluate how to maintain staff in order to provide quality treatment centered on patient safety. ASTRO reported a significant increase in the remote dosimetry roles (6% since 2021), which has caused a shift in departments to accommodate remote roles through a structured communication channel, automated quality assurance processes, and flexible staffing models that are structured around continuity of care.¹

Machine calibration standards are also a concern due to the medical physicist retention and recruitment challenges that have risen in recent years. Calibration standards are a direct correlate to safety precautions that must be met in order to deliver quality care. The early career attrition and lack of advancement opportunities are affecting the quality assurance consistency across institutions. To combat these shortcomings, departments have invested in internal training programs, peer-led credentialing, and collaborative quality committees hoping to encourage engagement and maintain treatment integrity. The overarching goal of these large shifts is to have well-supported teams that are trained to uphold the standard of care that patients deserve and to keep up with the field’s demand for technological advancements.¹

Economic considerations and insurance are increasingly central to the evolution of radiation oncology as a field. In patient care settings, we are witnessing firsthand how this can influence clinical decision-making, technology use, and even patient access to care. The transition from fee-for-service to bundled and episode-based payment models, such as the Radiation Oncology Case Rate (ROCR), represents a shift in reimbursement. Historically, radiation oncologists billed per fractionation/duration of treatment. Today, there are increased incentives toward cost containment and value-based care. Recent analyses demonstrate that ROCR base rates result in an average 2% to 3% reduction in reimbursement compared with past years. This may disproportionately affect centers treating complex patients, particularly those in rural/freestanding settings. To combat this, there have been suggested modifications such as stage-based rate adjustments and shortened course duration for palliative radiation therapy (RT).²

Defining value-based care in radiation oncology requires comparing clinical benefit against direct vs indirect costs. Cost-effectiveness analysis and cost-utility analysis are increasingly used to inform overall treatment decisions. There is a shift toward the use of hypofractionated regimens, where higher doses of radiation are given over fewer sessions. This has been shown to reduce medical and nonmedical costs to patients while having comparable outcomes.³ In order to obtain robust data for new policy/practice, there needs to be an increase in the quality of economic evaluations, as well as stronger adherence.⁴

As a case, we can examine different reimbursement systems across Europe. Most countries utilize budget-based or fraction-based models. Only a small minority use episode-based payments. This variability leads to different incentives and resource allocations. RT represents a modest proportion of total cancer care expenditures, on average, only 7.8%. RT is a major pillar in cancer care, widely used, and is relatively low-cost per patient. Thus, scientific societies and legislators need to advocate for policies that both reflect the cost of evidence-based medicine and new innovative practices that allow for forward progression of the field.^5,6 This will allow all patients to continue to have equitable access to appropriate treatment as RT continues to evolve.