Objective : Only 36% of Medicare patients diagnosed with hepatocellular carcinoma (HCC) receive cancer-directed therapy. Among them, transarterial chemoembolization (TACE) is utilized 10 times more frequently than ablation for these patients. Creation of a HCC-based bundled payment model may improve overall treatment utilization, use of potentially curative treatments, and patient outcomes. However, the true costs of locoregional therapies are poorly understood. Therefore, the purpose of this study was to use time-drive activity-based costing (TDABC) to estimate and compare the costs of TACE, yttrium-90 radioembolization (Y-90) and ablation for HCC treatment.
Methods : In this HIPAA-compliant, IRB-approved study, three observers prospectively recorded the utilization time for staff members and equipment used to treat ten HCC patients with TACE, Y-90, and ablation procedures. The observers also recorded consumable supplies used in each procedure. TDABC process maps captured patient flow from admission to discharge, and the total duration of each phase of care was determined with prospective measurements. Capacity cost rates (cost per minute) were calculated for all staff members and fixed equipment. Capacity cost rates were multiplied by the average utilization duration per resource to determine the average cost of that resource for each procedure.
Results : Ablation total costs, from admission to discharge, were $3,813, which was 75% of the $5,097 cost for TACE, and 18% of the $20,745 cost of Y-90. The cost for an ablation increased from $3,288 to $4,245 for one vs. two lesions treated and $4,461 for three lesions treated with one probe vs. $4,986 for three lesions treated with two probes. The cost for a TACE increased from $5,097 to $5,296 for non-selective (lobar) vs. selective TACE. Consumables were the greatest cost contributor across all three procedures and accounted for 63% of ablation, 57% of TACE, and 91% of Y-90 costs. Of note, each procedure has a single consumable that accounted for a substantial portion of the overall procedure cost, namely ethiodized oil for TACE (30%), Y-90 resin microspheres for Y-90 (81%), and the probe for ablation (41%).
Conclusions : Our analysis, using a bottom-up costing approach, shows that ablation costs are significantly less than those of TACE and Y-90. Replication of these methods at other institutions may allow for the creation of a representative national or regional bundled payment model to improve utilization of locoregional therapies for patients with HCC.