# Pay per course of radiotherapy, not per session, so short courses are not penalised

Source: https://onco.cc/ideas/idea-fund-course-based-radiotherapy-payment/  
OnCo record `idea-fund-course-based-radiotherapy-payment` (Idea). Data CC BY-NC 4.0, attribute "Data from OnCo (onco.cc)"; commercial use needs a licence.

## TL;DR

Hospitals are paid for each radiotherapy session, so a proven five-session course earns less than an unproven twenty-five-session one. Paying per course removes the reason to give more treatment than needed.

## Summary

Payers move from per-fraction to episode-based or per-course payment for radiotherapy, with the price set by indication and independent of fraction number, and with a quality bonus for adherence to evidence-based fractionation guidelines. Randomised trials (FAST-Forward, CHHiP, PACE-B, the Dutch and Canadian hypofractionation trials) have shown that shorter courses are equivalent for breast and prostate cancer, yet uptake lags for years in fee-for-service systems. The US Radiation Oncology Model was designed on this principle; implementing it widely, and in other countries, aligns payment with evidence and frees capacity.

## Fields

- Kind: Idea
- Last checked: 2026-09-08
- Hypothesis: Course-based payment raises the use of guideline-concordant hypofractionation for breast and prostate cancer by at least 20 percentage points within two years in affected systems, with no measurable change in outcomes or toxicity.
- Rationale: Uptake of hypofractionation is far higher in capitated or salaried systems (UK, Canada) than in fee-for-service settings, indicating payment, not evidence, drives practice. Episode payment is a standard tool for aligning incentives and requires no new evidence.
- Proposed test: Compare hypofractionation rates and outcomes before and after episode-based payment in a payer region against a matched fee-for-service region.
- Maturity: being-tested-at-scale
- Actor: payer

## Sources

- Bottleneck evidence (Surgery and radiotherapy cure most, get least): Sullivan et al., Global cancer surgery (Lancet Oncology Commission 2015): https://doi.org/10.1016/S1470-2045(15)00223-5

## Connected records

- ideas: [Core-funded radiotherapy trials infrastructure with central quality assurance](https://onco.cc/ideas/idea-fund-radiotherapy-trials-infrastructure/), [Payers fund trials of cheaper, shorter or lower-dose versions of expensive treatments](https://onco.cc/ideas/idea-fund-payer-funded-pragmatic-trials/)
- cancers: [HR-positive / HER2-negative breast cancer](https://onco.cc/cancers/breast-hr-positive/), [Prostate cancer](https://onco.cc/cancers/prostate/)
- technologies: [IMRT / IGRT (modern external beam)](https://onco.cc/technologies/imrt-igrt/), [SBRT / SABR (stereotactic radiotherapy)](https://onco.cc/technologies/sbrt/)
- bottlenecks: [Incentives reward me-too drugs and marginal gains](https://onco.cc/bottlenecks/b-incentive-misalignment/), [Surgery and radiotherapy cure most, get least](https://onco.cc/bottlenecks/b-surgery-radiation-innovation/)
- key papers: [Global cancer surgery: delivering safe, affordable, and timely cancer surgery](https://onco.cc/key-papers/paper-sullivan-lancet-oncol/)

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