Why Bundled Payments Could Drive Innovation: An Example From Interventional Oncology

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1 Health Policy Original Contribution Why Bundled Payments Could Drive Innovation: An Example From Interventional Oncology By Joseph R. Steele, MD, MMM, A. Kyle Jones, PhD, Elizabeth P. Ninan, PA, MBA, Ryan K. Clarke, MHA, Bruno C. Odisio, MD, Rony Avritscher, MD, Ravi Murthy, MD, and Armeen Mahvash, MD The University of Texas MD Anderson Cancer, Houston, TX Abstract Some have suggested that the current fee-for-service health care payment system in the United States stifles innovation. However, there are few published examples supporting this concept. We implemented an innovative temporary balloon occlusion technique for yttrium 90 radioembolization of nonresectable liver cancer. Although our balloon occlusion technique was associated with similar patient outcomes, lower cost, and faster procedure times compared with the standard-of-care coil embolization technique, our technique failed to gain widespread acceptance. Financial analysis revealed that because the balloon occlusion technique avoided a procedural step associated with a lucrative Current Procedural Terminology billing code, this new technique resulted in a significant decrease in hospital and physician revenue in the current fee-for-service payment system, even though the new technique would provide a revenue enhancement through cost savings in a bundled payment system. Our analysis illustrates how in a fee-for-service payment system, financial disincentives can stifle innovation and advancement of health care delivery. Introduction Innovation has transformed industries ranging from personal computers to air transportation. Some have questioned whether innovation-driven transformation can be achieved in health care delivery in the United States under the current fee-forservice payment system. In this article, we describe an innovative interventional radiology radioembolization technique that is both less expensive and faster than the conventional technique. At the same time, the new technique is equally safe. However, this new technique has failed to gain widespread acceptance. A careful financial analysis has indicated that this lack of acceptance may be a consequence of the substantial loss of physician and hospital revenue that results when the new technique is adopted in the current fee-for-service payment system. In contrast, if this new technique were to be introduced in a bundled payment system, the cost savings realized would lead to margin enhancement, making it more likely that the new technique would be adopted. Innovation in Health Care Richard Lyons, the Dean of the Haas School of Business at the University of California Berkeley, coined a simple definition of innovation: Fresh thinking that creates value. 1(p2) In health care we often discuss three types of innovation: disruptive, accretive, and sustaining. Disruptive innovation is the replacement of complex, expensive products and services with simpler, less expensive solutions. Originally described by Bower and Christensen in 1995 as disruptive technologies, 2 a term Christensen and Raynor later replaced with disruptive innovations, 3 these new products, methods, or services are often unanticipated and may threaten the viability of companies and institutions profiting in the conventional paradigm. Innovation in health care is more often accretive innovation, 4 which is characterized by the addition of newer technology to existing technology, or sustaining innovation, whereby current technology is incrementally improved and sold for higher profits. 5 Christensen and Raynor 3 describe how sustaining technologies advance faster than consumer adoption; an example of this phenomenon is the ever-increasing number of unused features available on consumer electronics. Examples of sustaining innovation in health care include imaging equipment with higher resolution and speed, surgical devices with minor performance enhancements, and medical therapies with small comparative clinical benefits. Factors that limit innovation in health care include a lack of outcomes measurement, regulatory burdens, communication breakdowns, siloed management and care delivery, and economic misalignment. In the current third-party fee-for-service payment system, patients and providers are relatively insensitive to price insured patients pay a small percentage of their total health care costs, and providers are reimbursed based on services rendered. This price inelasticity of demand often results in an environment in which patients drive innovation that improves their care, and providers drive innovation that increases their remuneration, predominantly through utilization of high-margin procedures that are the result of sustaining innovations. Furthermore, because patients pay only a fraction of the total costs of their care, patients are subject to a moral hazard, desiring more and better services than payers are willing to provide. This environment can lead to conflicting incentives for patients, providers, payers, and suppliers. Bundled Payments In an attempt to better align incentives among patients, providers, and payers, improve quality, and reduce costs, alternatives MARCH 2015 jop.ascopubs.org e199

2 Steele et al to the current fee-for-service payment system have been proposed. One such alternative is the bundled or episode-based payment model. While bundled payments can take a number of forms, the basic concept is that of a single payment that is shared among all providers (of services covered under Medicare parts A and B) for a procedure or medical condition over a specific period of time, the global period. Consider the example of a total hip arthroplasty: a single payment would be expected to cover all related medical services from the initial evaluation through the operative period and immediate postoperative period. A number of pilot studies using bundled payments have been performed: Centers for Medicare and Medicaid Services Center of Excellence demonstrations in 1991, 1996, and 2001, 6 the Heart Bypass Demonstration from 1991 through 1994, 7 and most recently the Acute Care Episode demonstration in Decreases in costs, lengths of stay, and Medicare payments have been reported. 8 However, not all pilot projects have met with success. The Health Care Incentives Improvement Institute has initiated the PROMETHEUS (Provider Payment Reform for Outcomes, Margins, Evidence, Transparency, Hassle Reduction, Excellence, Understandability, and Sustainability) bundled payment experiment. Thirteen bundles were created, and pilot sites were allowed to choose the bundles in which they participated. As of May 2011, no site had been successful because of numerous points of contention between providers and payers. 9 Innovative Technique for Yttrium 90 Radioembolization As the incidence of nonresectable primary and metastatic liver cancer increases, patients and providers have sought additional therapeutic options. One such option is intra-arterial brachytherapy (radiotherapy). One form of intra-arterial brachytherapy is yttrium 90 (Y-90) radioembolization, a minimally invasive regional therapy in which radioactive microspheres are infused into the liver. Although the liver derives blood supply from both the hepatic arteries and the portal vein, growing tumors obtain most their blood supply from the hepatic arteries. The Y-90 radioembolization procedure consists of at least two outpatient sessions: a diagnostic session followed by a treatment session. During both sessions, a small angiographic catheter is inserted into the femoral artery and advanced under x-ray fluoroscopy guidance through the body into the hepatic artery. 10 The patency of the vascular anatomy is adequately mapped, and a surrogate radioactive particle that can be imaged using a nuclear medicine camera is administered to mimic treatment delivery. During the treatment session, radioactive Y-90 microspheres are injected in the hepatic arteries that perfuse the tumor. One potential complication of Y-90 radioembolization is accidental distribution of the radioactive microspheres outside the liver, most commonly into the stomach or proximal small intestine. This is a consequence of the multiple paths of communication that exist between the hepatic artery and the GI arteries. Such a complication may result in inflammation or ulceration of the GI tract. 11 Thus, interventional radiologists have gone to great lengths and expense to avoid infusing radioactive microspheres into the GI tract. The current standard technique for preventing infusion of radioactive Y-90 microspheres into the GI tract during radioembolization involves inserting small metal coils in communicating arteries. 12,13 During the diagnostic session, small branching vessels that supply the stomach and small intestine are aggressively sought out, catheterized, and embolized (occluded) using small catheters, guidewires, and platinum coils. This technique has a number of drawbacks. The embolization process can be extremely challenging and time-consuming, resulting in increased radiation exposure to the patient and physician since the procedure is performed under x-ray fluoroscopy guidance. The disposable supplies necessary to occlude the small vessels are expensive. Most importantly, this technique is not technically feasible in all cases. 14,15 Once the branch vessels are safely occluded, the patient can return for the therapeutic session, during which the Y-90 microspheres are injected directly into the liver through a catheter. In one-third of cases, despite pretreatment embolization, new vessels develop or previously occluded vessels are found to be patent at the time of treatment. 16 This requires further embolization and has been shown to result in a higher rate of GI ulceration. A potentially disruptive innovation in Y-90 radioembolization was reported during the initial clinical trials of radioactive glass microspheres almost 20 years ago and was adapted from a similar technique first described almost 30 years ago. 17,18 The investigators found that it was not necessary to permanently occlude all the branch vessels leading to the stomach and small intestine to safely deliver radioactive microspheres to the liver; instead, the use of an inexpensive catheter with an occlusive balloon could achieve the same results by altering arterial flow dynamics. This balloon occlusion technique temporarily reverses the blood flow in branch vessels supplying the stomach and small intestine during transarterial embolization. 18 Similar to how a dammed river finds new routes through which to flow, when the hepatic artery is occluded by the balloon, the flow in the branches that feed the stomach and intestine is reversed and begins to flow toward the liver (Figure 1). Thus, any radioactive microspheres injected through the catheter proximal to the reversed branches flow toward the liver. This phenomenon occurs because of the rich collateral blood circulation of the stomach and small intestine. At our institution, this balloon occlusion technique has been used since 2010 with more than 80 patients undergoing Y-90 radioembolization planning and treatment, and the technical outcomes and complication rates have been similar to those with the standard-of-care coil embolization technique. 19 Because the dose calculations are standardized with each of the Y-90 techniques, the technical end point of complete dose administration without complication is conceptually similar to complete dose administration of system chemotherapy. The proportion of prescribed activity delivered (73% for coil embolization v 76% for balloon occlusion) and the median activity delivered (45.0 mci for coil embolization v 46.6 mci for balloon occlusion) were similar for the two techniques. In addi- e200 JOURNAL OF ONCOLOGY PRACTICE VOL. 11, ISSUE 2

3 Why Bundled Payments Could Drive Innovation Coil Method B C A Liver Catheter Coils Particles GDA RGA Balloon Method D E CHA Balloon Figure 1. Comparison of coil embolization and balloon occlusion techniques for yttrium 90 (Y-90) radioembolization for treatment of nonresectable liver cancer. (A) Typical hepatic arterial anatomy. Oxygenated blood flows via the common hepatic artery (CHA) toward the liver, antegrade via the right gastric artery (RGA) to the stomach, and antegrade via the gastroduodenal artery (GDA) to the duodenum. (B, C) Coil technique. First, vascular microcoils are used to permanently occlude the RGA and GDA (B). Then Y-90 microspheres are injected into the proper hepatic artery (C). Reflux and inadvertent deposition of microspheres into the stomach and small bowel is unlikely because the RGA and GDA are now occluded. (D, E) Balloon occlusion technique: First, a balloon catheter is inflated in the CHA, resulting in reversal of flow in the RGA and GDA (D). Then Y-90 microspheres are injected (E). The risk of reflux is low because of the reversed, retrograde blood flow in the RGA and GDA. tion, our rates of complete dose administration are similar to those for other institutions. 20 Some of the safety concerns with use of this technique include the potential for vascular injury from the use of the occlusion balloon and the additional possibility of nontarget microspheres deposition causing GI ulceration. Our review of 97 diagnostic and treatment angiograms demonstrated no evidence of vascular injury on follow-up angiography or contrast enhanced cross-sectional (computed tomography, magnetic resonance imaging) imaging. Also in the initial 50 patients treated with this technique, we demonstrated that no GI ulcerations were attributed to microsphere deposition in the GI tract. 19 This is less than GI ulceration rates in the literature. 11 In our experience, the balloon occlusion technique has proven to be faster, to be less expensive, and to require less radiation than the coil embolization technique. 21 We have presented our data at the Society of Interventional Radiology Annual Meeting in 2012 and ,23 However, to our knowledge, the balloon occlusion technique has not been adopted in any other clinical practice in the United States. This raises the question: why has a technique presented almost 30 years ago and demonstrated to be safe, effective, and faster and less expensive than the standard-of-care technique not been adopted by the interventional radiology community? An informal survey of interventional radiologists revealed that some operators question the safety of the balloon occlusion technique, while others are not comfortable with changing an effective practice. Additionally, the absence of marketing may contribute to poor provider adoption. For example, a much newer alternative to the balloon occlusion technique, use of an antireflux catheter (Surefire Medical, Westminster, CO), has been marketed specifically for the safe administration of Y-90 microspheres. 24 This catheter provides advantages similar to those of the balloon catheter but is far more expensive (by more than $2000). Despite the high cost, this product has achieved successful market penetration. 25 Financial Impact of Switching From Coil Embolization to Balloon Occlusion One potential reason for the lack of widespread adoption of the balloon occlusion technique is the negative financial impact of using this technique. We explored this concept by conducting a financial analysis of the impact of switching from coil embolization to balloon occlusion, in which we compared procedural steps along with their associated Current Procedural Terminology (CPT) billing codes. Procedural time saved using the balloon occlusion technique was financially valued based on whether additional cases could be performed (Fig 1). In the scenario of additional demand for interventional procedures, added revenue was calculated using a weighted average of Medicare payments for the regular case mix, per hour, per procedure room. In the scenario without additional demand, there was no additional revenue, and procedure time reduction was measured as cost savings. Revenue from interventional radiology services is derived from two sources: professional charges, for services provided MARCH 2015 jop.ascopubs.org e201

4 Steele et al Table 1. Comparison of Procedure Revenue Between the Coil Embolization Technique and the Balloon Occlusion Technique for Yttrium 90 Radioembolization for Nonresectable Liver Cancer in a Fee-for-Service Payment Model Payment Method With Additional IR Procedure Demand Without Additional IR Procedure Demand Fee for Service in procedure reimbursement (9,647) in procedure reimbursement (9,647) in supply cost 1,138 in supply cost 1,138 in labor and overhead 0 in labor and overhead 440 in reimbursement utilizing additional 45 min/d 2,163 in reimbursement utilizing additional 45 min/d 0 (6,346) (8,069) Bundle in procedure reimbursement 0 in procedure reimbursement 0 in supply cost 1,138 in supply cost 1,138 in labor and overhead 0 in labor and overhead 440 in reimbursement utilizing additional 45 min/d 1 in reimbursement utilizing additional 45 min/d 0 1,138 1,578 Abbreviations: IR, interventional radiology. by the physician, and technical charges, billed by the hospital. Revenue capture in this financial analysis was calculated based on widely used contracted payment schedules instead of charges, as hospital and physician charges, disposable equipment costs, and payments for services are extremely variable. The amount billed for a service and the payment received for the service usually differ. In an effort to insure consistency, the revenue model used in this work was constructed using the following reference sources and assumptions: 1. Revenue A. Payments to hospital: Medicare Part A, Centers for Medicare and Medicaid Services 2013 Hospital Outpatient Prospective Payment System for Harris County, Texas (Data Supplement) B. Payments to physicians and midlevel providers: Medicare Part B, Centers for Medicare and Medicaid Services 2013 Physician Fee Schedule for Harris County, Texas (Data Supplement) C. Added revenue from procedure time saved: Using 12 months of historical data from our institutional radiology information system, a regular case mix was created. Using a weighted average of Medicare Part A and Medicare Part B payments, over a 50-hour work week, an hourly revenue value was calculated Table 2. Financial Implications of Changing From the Coil Embolization Technique to the Balloon Occlusion Technique in a Fee-for Service and a Bundled Payment Model Reimbursable Services With Coil With Balloon Diagnostic preprocedure visit $ $ Diagnostic procedure $20, $11, Diagnostic nuclear medicine procedure $1, $ Treatment procedure $20, $20, Treatment nuclear medicine procedure $2, $2, Total procedure reimbursement $45, $35, Two scenarios are evaluated: one in which there is additional demand for interventional procedures, the other in which no such demand exists. 2. Costs A. Disposable supply costs: Premier group purchasing organization B. Labor costs and total compensation (Appendix Table A1, online only) i. Nursing and technical staff: local market averages 29% fringe benefits ii. Physicians: Medical Group Management Association market averages for interventional radiology 29% fringe benefits C. Overhead and supporting costs (Appendix Table A1) i. Total compensation 70% Compared with the coil embolization technique, the balloon occlusion technique decreased the mean diagnostic session time by 10 minutes and the mean treatment session time by 37 minutes. The procedure cost savings for the balloon occlusion technique were calculated by summing the total costs for the disposable supplies that are required for coil embolization but not balloon occlusion, including catheters, wires, and coils. When no additional demand existed, the total cost savings also included the absolute difference in labor and overhead costs between the coil embolization and balloon occlusion techniques owing to the time saved with the balloon occlusion technique. The analysis of the coil embolization and balloon occlusion procedures demonstrated a significant difference in total reimbursement, defined as physician payment plus hospital payment. The analysis showed that cost and revenue differences between the two techniques are highest during the diagnostic session on the first procedure day. The standard-of-care technique involved transcatheter coil embolization and allowed for billing of CPT code With the balloon occlusion technique, this code cannot be billed. In a fee-for-service payment system, elimination of this step and its associated CPT code decreases revenue by $9,647. However, because coils, microcatheters, and microwires are not routinely used during the diagnostic session for the balloon occlusion technique, disposable equipment costs decreased by $1, Furthermore, use of balloon occlusion rather than coil embolization saves a com- e202 JOURNAL OF ONCOLOGY PRACTICE VOL. 11, ISSUE 2

5 Why Bundled Payments Could Drive Innovation bined 47 minutes between the diagnostic and treatment sessions, which results in a labor and overhead savings of $ (Table 1). To appreciate the financial impact of changing from the coil embolization technique to the balloon occlusion technique, two variables must be considered, the payment system and the demand for interventional procedures. In a fee-for-service payment system with demand for additional interventional procedures, transitioning to the balloon technique results in a decrease of net income by $6,346. If no demand exists and additional cases cannot be performed during the additional 47 minutes, the decrease in net income worsens to $8,069. Conversely, in a bundled payment system with demand for additional interventional procedures, net income increases by more than $1,138. A more accurate valuation cannot be obtained since the model cannot calculate a weighted average of an undefined bundled amount of the additional interventional procedures done during the saved 47 minutes. In a bundled payment system without demand for additional interventional services, net income increases by $1,578 (Table 2). Discussion This case study illustrates that in a fee-for-service payment environment, innovation that results in more efficient care may also result in lost revenue. Because much innovation in health care simplifies processes, innovation may eliminate steps from which revenue can be derived in a fee-for-service payment model. In the example of balloon occlusion for Y-90 radioembolization, the end result was a decrease in total reimbursement ranging from $6,346 to $8,069 per patient, which at a medical center performing 50 to 100 Y-90 radioembolizations annually will result in a noticeable negative fiscal change. In contrast, in a bundled payment model, the revenue for an episode of care is fixed. If an episode of care for Y-90 radioembolization included the pre-evaluation, diagnostic session, treatment session, and 30 days of follow-up, providers would be motivated to deliver high-quality care at the lowest cost. Assuming all quality benchmarks are met, every dollar saved is additional profit. Under this model, the cost savings of more than $1,138 per patient would result in additional profit for the provider, and the balloon occlusion technique would be more likely to be adopted. Bundled or episode-based payments will better align patients, providers, and payers. This type of payment reform, when combined with outcomes-driven data reporting, encourages and fosters high-value health care innovation. Acknowledgment Previously presented as a poster at the ASCO Quality Care Symposium, San Diego, CA, November 1-2, Authors Disclosures of Potential Conflicts of Interest Although all authors completed the disclosure declaration, the following author(s) and/or an author s immediate family member(s) indicated a financial or other interest that is relevant to the subject matter under consideration in this article. Certain relationships marked with a U are those for which no compensation was received; those relationships marked with a C were compensated. For a detailed description of the disclosure categories, or for more information about ASCO s conflict of interest policy, please refer to the Author Disclosure Declaration and the Disclosures of Potential Conflicts of Interest section in Information for Contributors. Employment or Leadership Position: None Consultant or Advisory Role: None Stock Ownership: None Honoraria: Joseph R. Steele Research Funding: None Expert Testimony: None Patents, Royalties, and Licenses: None Other Remuneration: None Author Contributions Conception and design: Joseph R. Steele, Aaron Kyle Jones, Ravi Murthy, Armeen Mahvash Administrative support: Elizabeth Priya Ninan Collection and assembly of data: Joseph R. Steele, Elizabeth Priya Ninan, Ryan Kristopher Clarke, Bruno Calazans Odisio, Armeen Mahvash Data analysis and interpretation: Joseph R. Steele, Aaron Kyle Jones, Rony Avritscher, Ravi Murthy, Armeen Mahvash Manuscript writing: Joseph R. Steele, Aaron Kyle Jones, Elizabeth Priya Ninan, Ryan Kristopher Clarke, Bruno Calazans Odisio, Rony Avritscher, Ravi Murthy, Armeen Mahvash Final approval of manuscript: Joseph R. Steele, Aaron Kyle Jones, Elizabeth Priya Ninan, Ryan Kristopher Clarke, Bruno Calazans Odisio, Rony Avritscher, Ravi Murthy, Armeen Mahvash Corresponding author: Joseph R. Steele, MD, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Houston, TX 77030; jsteele1@mdanderson.org. DOI: /JOP ; published online ahead of print at jop.ascopubs.org on January 20, References 1. Vaitheeswaran V: Something new under the sun: A special report on innovation. The Economist October 13, Bower JC, Christensen CM: Disruptive technologies: Catching the wave. Harvard Bus Rev January February Christensen CM, Raynor ME: The Innovator s Solution: Creating and Sustaining Successful Growth. Boston, MA, Harvard Business School Press, 2013, p Zimlichman E, Levin-Scherz J: The coming golden age of disruptive innovation in health care. J Gen Intern Med 28: , Hwang J, Christensen CM: Disruptive innovation in health care delivery: A framework for business-model innovation. Health Aff (Millwood) 27: , Draper A: Managing bundled payments. Healthc Financ Manage 65: , Miller HD: From volume to value: Better ways to pay for health care. Health Aff (Millwood) 28: , Sood N, Huckfeldt PJ, Escarce JJ, et al: Medicare s bundled payment pilot for acute and postacute care: Analysis and recommendations on where to begin. Health Aff (Millwood) 30: , Hussey PS, Ridgely MS, Rosenthal MB: The PROMETHEUS bundled payment experiment: Slow start shows problems in implementing new payment models. Health Aff (Millwood) 30: , Salem R, Lewandowski RJ, Sato KT, et al: Technical aspects of radioembolization with 90Y microspheres. Tech Vasc Interv Radiol 10:12-29, Murthy R, Brown DB, Salem R, et al: Gastrointestinal complications associated with hepatic arterial yttrium-90 microsphere therapy. J Vasc Interv Radiol 18: , quiz 562, 2007 MARCH 2015 jop.ascopubs.org e203

6 Steele et al 12. Salem R, Thurston KG: Radioembolization with 90yttrium microspheres: A state-of-the-art brachytherapy treatment for primary and secondary liver malignancies Part 2: Special topics. J Vasc Interv Radiol 17: , Kennedy A, Nag S, Salem R, et al: Recommendations for radioembolization of hepatic malignancies using yttrium-90 microsphere brachytherapy: A consensus panel report from the Radioembolization Brachytherapy Oncology Consortium. Int J Radiat Oncol Biol Phys 68:13-23, Dudeck O, Wilmhelmsen S, Ulrich G, et al: Effectiveness of repeat angiographic assessment in patients designated for radioembolization using yttrium-90 microspheres with initial extrahepatic accumulation of technitium-99m macroaggregated albumin: A single center s experience. Cardiovasc Intervent Radiol 35: , Barentsz MW, Vente MA, Lam MG, et al: Technical solutions to ensure safe yttrium-90 radioembolization in patients with initial extrahepatic deposition of (99m)technetium-albumin macroaggregates. Cardiovasc Intervent Radiol 34: , Abdelmaksoud MH, Hwang GL, Louie JD, et al: Development of new hepaticoenteric collateral pathways after hepatic arterial skeletonization in preparation for yttrium-90 radioembolization. J Vasc Interv Radiol 21: , Andrews JC, Walker SC, Ackermann RJ, et al: Hepatic radioembolization with yttrium-90 containing glass microspheres: Preliminary results and clinical follow-up. J Nucl Med 35: , Nakamura H, Tanaka M, Oi H: Hepatic embolization from the common hepatic artery using balloon occlusion technique. AJR Am J Roentgenol 145: , Mahvash A, Odisio BC, Avritscher R, et al: Temporary balloon occlusion of the common hepatic artery during Y90 radioembolization planning and treatment in patients with patent hepatoenteric collaterals. J Vasc Interv Radiol 25:S87-S88 (suppl 3), Chao C, Dagli M, Mondschein J, et al: Effect of substituting 50% isovue for sterile water as the delivery medium for SIR-SPHERES: Improved dose delivery and decreased incidence of stasis. J Vasc Interv Radiol 25:S89 (suppl 3; abstr 187), Black Jones AK, Mahvash A, et al: Impact of a novel balloon occlusion technique on fluoroscopy time and radiation dose during Y90 radioembolization. J Vasc Interv Radiol 25:S205 (suppl 3), Mahvash A, Shreyaah S, Chasen B, et al: Balloon-catheter occlusion technique for adminstration of Y90 microspheres in patients with patent hepatoenteric arteries. J Vasc Interv Radiol 25:S67-S68 (suppl 3; abstr 161), Mahvash A, Zaer N, Shaw, et al: Temporary balloon occlusion of the common hepatic artery for administration of yttrium-90 resin microspheres in a patient with patent hepatoenteric collaterals. J Vasc Interv Radiol 23: , van den Hoven AF, Prince JF, Samim M, et al: Posttreatment PET-CT-confirmed intrahepatic radioembolization performed without coil embolization, by using the antireflux Surefire Infusion System. Cardiovasc Intervent Radiol 37: , Morshedi MM, Bauman M, Rose SC, et al: Yttrium-90 resin microsphere radioembolization using an antireflux catheter: An alternative to traditional coil embolization for nontarget protection. Cardiovasc Intervent Radiol [epub ahead of print July 3, 2014] e204 JOURNAL OF ONCOLOGY PRACTICE VOL. 11, ISSUE 2

7 Why Bundled Payments Could Drive Innovation Appendix Table A1 Time-Driven, Activity-Based Costing Analysis of the Physician, Technologist, and Nurse Required for Y-90 Hepatic Radioembolization Characteristics US $ % Salary Interventional radiology tech 72,500 Clinical nurse 72,000 Radiology: diagnostic invasive compensation* 371,318 Fringe Classified fringe benefits 29 Faculty fringe benefits 29 Total compensation Staff compensation 186,405 Faculty compensation 479,000 Overhead/supporting costs Overhead 70 Total expense, compensation overhead Expense per year 1,131,189 Expense per day Expense per hour Expense per minute 9.35 NOTE. Salaries were based on market averages for Harris County, Texas (technologist and nurse), and Medical Group Management Association Reports (physician); fringe and overhead percentages are those commonly used at our institution; assumptions include 180 eight-hour working days per year. * Medical Group Management Association: Academic Practice Compensation & Production 2013 report based on 2012 data. MARCH 2015 jop.ascopubs.org e205