Proposals for a new mandatory payment model for radiation oncology have been met with strong pushback from the medical community. The new model would cut payments for some high-value radiation treatment by 22% in order save an estimated $160 million.
The changes, proposed by the Centers for Medicare & Medicaid Services (CMS) to their Radiation Oncology (RO) Model, have been challenged primarily by the American Society for Radiation Oncology (ASTRO), but by other groups as well.
These excessive reductions will jeopardize access to lifesaving radiation therapy services for Medicare beneficiaries at a time when the US healthcare system needs “all doors open” to treat patients with cancer, says ASTRO.
The proposed cuts are scheduled to take effect January 1 and will be mandatory for the 30% of providers that will be randomly selected to participate.
The timing could not be worse, says the Community Oncology Alliance (COA). “How can payment be ratcheted down on a vital aspect of cancer in the middle of a pandemic?” said Ted Okon, MBA, executive director of COA. “What was CMS thinking? These are extreme circumstances, and this is so ill-timed and so tone deaf that it just takes my breath away.”
He pointed out that with hospitals being overrun with COVID-19 patients, community practices have to keep their doors open to treat patients. “This is an extended public health emergency, and a variant can reignite the surge,” said Okon. “CMS should be asking practices what they can do to help them —and not trying to make drastic cuts.”
Okon is also concerned that as a result of the pandemic, “we are going to be seeing more advanced cancers, which are more difficult and expensive to treat, and radiation therapy is going to come into play,” he said. “These are serious and unintended consequences, and CMS needs to come out of their [Washington] DC bubble and see what’s really going on.”
The timing of the rollout is particularly precarious, given the financial upheaval caused by the COVID-19 pandemic, agrees Constantine Mantz, MD, ASTRO’s Health Policy Council vice-chair.
“Medicare’s proposed cuts unfortunately compound the enormous financial challenges imposed by the COVID-19 pandemic on physicians and their practices,” said Mantz. “Radiation oncology is particularly at risk given its dependence on expensive treatment equipment to deliver cancer care.”
The high costs of maintaining this equipment remain the same whether the equipment is used or not. “This means that fewer patients being seen during the pandemic combined with these steep reimbursement cuts in the near future risk the continued viability of many centers and their ability to provide lifesaving cancer treatment,” he said.
ASTRO Calls on Congress to Intervene
ASTRO has asked President Biden and Congress to intervene immediately on not only the Radiation Oncology model but the severe cuts that were proposed for the 2022 Medicare Physician Fee Schedule.
“The RO Model, which was last updated in the 2022 Medicare Hospital Outpatient Prospective Payment System Proposed Rule, would cut payments for radiation therapy services by 3.75% for physicians and 4.75% for facilities,” said Mantz. “This cut would be in addition to an 8.75% cut to radiation oncology in the 2022 Medicare Physician Fee Schedule Proposed Rule.”
As a result, the physicians and facilities that are required to participate in the RO Model are facing steep declines in Medicare reimbursement. “This amounts to well over 10% for their patients covered by Medicare next year,” Mantz told Medscape Medical News.
The Radiation Oncology Model
The goal of the RO Model is to test a change in the way radiation therapy services are paid — from the current “fee-for-service” payments” to prospective, site-neutral, modality-agnostic, episode-based payments that incentivize physicians to deliver higher-value care. It requires mandatory participation of practices.
The Center for Medicare and Medicaid Innovation published a final rule in September 2020 that established the RO Model, which was to begin on January 1, 2021. However, because of the ongoing COVID-19 pandemic, the start of the RO Model was delayed until July 1, 2021, and subsequently, the Consolidated Appropriations Act, 2021, included a provision that prohibits implementation of the RO Model before January 1, 2022.
Further changes to the RO model were proposed last month, which included some slight revisions to the discount factor. But ASTRO points out that these revisions did not address numerous concerns raised by both the radiation oncology community and a broad coalition of medical provider groups, patients, hospitals, health systems, and bipartisan members of Congress.
The new model would provide an alternative to the traditional fee-for-service payments. Instead, the payments are prospective and episode-based, and based on the cancer diagnosis. It would cover radiation therapy that is administered during a 90-day episode, and would meet the included cancer type criteria described in the final rule.
The RO model would use “site-neutral payment” by establishing a common, adjusted national base payment amount for the episode, regardless of the setting where it is administered.
The episode payments would be divided into professional and technical components to allow the current claims systems for the Physician Fee Schedule (PFS) and the Outpatient Prospective Payment System (OPPS) to be used to adjudicate claims as well as to maintain consistency with existing business relationships.
Another aspect is that the model links ‘payment’ to ‘quality’ using reporting and performance on quality measures, clinical data reporting, and patient experience as factors when determining payment to RO participants. Finally, providers will be randomly selected and participation is mandatory.
Okon feels that the idea of a mandatory model is wrong. “They are going to be taking 30% of practices to participate in an experiment,” he said. “Mandatory means that you can’t get enough people to participate so it is mandated to force them into it.”
Mantz also noted that the model is going to have a widespread impact on a wide range of issues. “Sharply reduced reimbursement for radiation therapy services under the RO Model is expected to delay, if not prevent, the equipment upgrades and other improvements that are necessary for practices to continue to provide high-quality, high-value cancer care.
“These problematic barriers to access advanced treatment technology also come at a critical time for radiation oncology, in that we already are seeing more difficult-to-treat cancers and caring for patients with more advanced-stage diseases due to delayed diagnoses during the peak of the pandemic last year.”
In addition, the RO model, in its current inception, is expected to further widen existing gaps in access to cancer care, disproportionately harming patients from marginalized groups (eg, poor patients, medically underserved patients).
“For example, ASTRO analyses have demonstrated that patients in rural areas currently face significantly reduced access to stereotactic radiotherapy and lifesaving brachytherapy treatments compared to patients in urban areas,” said Mantz. “It’s difficult to imagine that these serious health inequities could even begin to be addressed with the aggregate payment cuts imposed by the RO model.”
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