The Study: This pragmatic analysis takes a look at the variability in Medicaid reimbursements among states. A typical course of hypofractionated breast radiation was used as a template comprised of 16 fractions of 3D conformal whole breast radiation with daily respiratory tracking for a breath-hold technique and a 5 fraction electron boost to the lumpectomy cavity. The authors were able to dig up Medicaid reimbursement rates for the associated CPT codes from publicly available resources to produce a telling table outlining the typical CPT codes used for this course and the average fee for service across the country. As expected with most any analysis of Medicaid, there was wide variability in reimbursement across states. The range for the total course went from as low as $2900 in New Hampshire (live free or die!) to upwards of $15,000 in Delaware. While some of the difference was one of price, another major deviation was whether services were reimbursed at all. For instance, 77387 that which covers daily respiratory tracking is only reimbursed by roughly 40% of states (there’s a nice map to see where your state falls). This all matters for many reasons, not least of which is that such variability could have downstream effects on the availability of the latest techniques—or radiation at all, for that matter—for vulnerable patient populations.
Bottom Line: Medicaid fees for typical radiation services vary widely among states, including as much as a 5-fold difference for a typical course of breast radiation. | Agarwal, Int J Radiat Oncol Biol Phys 2019