When the Centers for Medicare & Medicaid Services (CMS) began exploring the concept of an episode-based payment methodology for radiation oncology services in 2014, oncology providers immediately expressed their concerns. They were wary about the real-world feasibility of such a payment model and the adverse consequences it could have on patient care.
Then in 2020, the CMS announced the Radiation Oncology (RO) model, which they created to test whether making site-neutral payments to physician practices, including free-standing radiation therapy centers, would enhance quality of care while reducing Medicare spending.
CMS stated that “under the current fee-for-service payment structure, Medicare pays providers and suppliers for each individual service they perform. Additionally, Medicare pays differently for radiotherapy depending on where the patient is receiving care.”
According to the CMS, the RO model will focus on value-based care by creating simpler, more predictable payments that incentivize cost-efficient and clinically effective treatments to improve quality and outcomes.
"The latest clinical evidence suggests that shorter courses of (radiation therapy) for certain types of cancer would be equally effective and could improve the patient experience, potentially reduce costs for the Medicare program and lead to reductions in beneficiary cost-sharing," the CMS said.
Radiation Oncology leaders disagree.
New model a financial risk and hindrance to innovation?
"This places too much risk and burden on providers with little opportunity for reward in the form of shared savings, especially in light of the significant investments required," the American Hospitals Association said in response to CMS’s announcement.
Providers believe the RO model will expose them to undue financial risk and especially at a time when all hospitals and practice centers are feeling the effects of the COVID-19 pandemic, including decrease in revenue, decline in patient volumes, and reduction in staffing.
"The proposed Medicare payment policy set to start on January 1, 2021, would cause significant additional financial challenges for radiation oncology practices as they enter the new year. Despite many practices already experiencing revenue declines of 20-30% due to the COVID-19 pandemic, CMS is still pushing ahead with large additional cuts for radiation oncology and other specialties," said Thomas J. Eichler, MD, FASTRO, Chair of the ASTRO Board of Directors.
In a September 2019 article published in Modern Healthcare, providers and suppliers also speculated that the RO Model payment schedule could lower the financing of new technologies and equipment, thus hampering access to groundbreaking types of care and stifling innovation.
One such innovation mentioned was Proton Therapy. Proton Therapy, which uses a beam of protons instead of x-rays to destroy cancer cells, is one of the newest and, thus, most expensive forms of radiation therapy a patient can receive.
Under the 2019 proposed RO Model, the CMS would reimburse providers at the same rate for proton therapy as it does for all other types of radiation treatment. Providers of this therapy posit that rather than improving the quality of patient treatments, the new payment model could expose patients to more radiation and increase their risk of developing cancer in the future.
"By establishing payment rates that reimburse all modalities the same, CMS, by its own logic, is financially incentivizing providers to use the cheapest modalities which also tend to be those that deposit the greatest amount of radiation in healthy tissue," said Provision CARES Proton Therapy Center of Knoxville Florida. "This entirely ignores side effects and potential secondary cancer profiles, running afoul of the desire to improve quality and patient care."
In that same article, the New York Proton Center called the RO Model reimbursement rates "woefully inadequate" and that the changes could put patients at risk.
Recent changes to the RO model don’t appease providers
CMS initially set the implementation date for the RO Model as January 1, 2021, however the Consolidated Appropriations Act of 2021 included a provision that moved the implementation date to January 1, 2022, due to the ongoing COVID-19 pandemic.
In a July 19th announcement, CMS proposed additional changes to the RO Model as outlined in an article on Auntminie.com:
- The RO Model would start on January 1, 2022, with a five-year "performance period" that would end in December 2026.
- The model's baseline period would change from 2016-2018 to 2017-2019.
- The discount for the professional component would be lowered to 3.5% and the technical component to 4.5%.
- Brachytherapy would be removed from the RO Model, and it would still be paid on a fee-for-service basis.
- Cancer inclusion criteria would be revised, and liver cancer treatments would be removed from the RO Model.
- An "extreme and uncontrollable circumstances" policy would be adopted, which would adjust the payment methodology under certain circumstances.
- Certain outpatient departments would be excluded from participation in some parts of the model.
Although these revisions were intended to address numerous concerns put forward by oncology providers and several professional associations, CMS still seems to have missed the mark.
In an excerpt from their July 2021 press release, ASTRO leadership makes it very clear that the most recent changes are not sufficient:
"The cuts to providers in the Radiation Oncology Model substantially exceed those in other models and, astoundingly, became more severe between the proposed and the final iterations from CMS," said Dr. Eichler.
"We are concerned that these mandatory cuts will financially jeopardize practices' ability to deliver optimal care during the five-year demonstration period, especially as we continue to face a public health emergency. Unfortunately, CMS’ failure to listen to our recommendations has turned a model with great potential to improve patient care into one that we’re seriously worried will undermine patient care."
Eichler also questioned why CMS targeted radiation oncology for payment cuts when cancer incidence rates are rising, following the delayed screenings seen during COVID-19.
“By proposing to cut high-value radiation treatments by as much as 22% and proceeding with more than $160 million in reductions under the RO Model, CMS is jeopardizing the ability of the nation’s radiation therapy professionals to continue to provide essential care for their patients now and in the future.”
He also added, “Access to life-saving cancer treatments will suffer, and the viability of clinics already reeling from the pandemic will be at considerable risk if these proposals are finalized.”
“Access to radiation therapy for people with cancer is under attack.”
Eichler pointed out that in two consecutive weeks, the Centers for Medicare and Medicaid Services (CMS) singled out radiation oncology for payment cuts that put access to cancer care for Medicare beneficiaries in peril – at a time when cancer incidence rates are rising due to delayed screenings caused by the COVID-19 pandemic.
By proposing to cut high-value radiation treatments by as much as 22% and proceeding with more than $160 million in reductions under the Radiation Oncology Model (RO Model), Eichler stats, “CMS is jeopardizing the ability of the nation’s radiation therapy professionals to continue to provide essential care for their patients now and in the future. Access to life-saving cancer treatments will suffer, and the viability of clinics already reeling from the pandemic will be at considerable risk if these proposals are finalized.”
Next steps for Radiation Oncology providers
Hospitals, physician practices, the radiation oncology community, and professional associations, such as ASTRO and the American College of Radiology (ACR) made public pleas to CMS, Congress, and even President Biden to intervene on their behalf.
ASTRO released a statement urging leaders in Washington “to immediately intervene on the flawed RO model and proposed Medicare Physician Fee Schedule cuts.” They are requesting additional support and action “to blunt CMS’ draconian cuts and reform the RO model.”
In their statement ASTRO reiterates their commitment to working with CMS to find a solution to value -based care that does not impact quality of care:
“ASTRO remains committed to value-based care and to constructively engaging with CMS on reasonable ways to improve these policies. We are eager to help President Biden achieve his goal of ending cancer as we know it, and we are developing promising approaches to reduce health care disparities in cancer treatment. These difficult policy challenges require investments in our human and technological cancer care infrastructure that would be virtually impossible under the current proposals. Massive cuts such as those proposed by CMS will set us back, not move us forward, and ASTRO will vigorously oppose these threats to radiation oncology and our patients.
To better understand the potential impact on your facility, use the tools and resources below:
ASTRO RO Model Professional Component Workbook (downloadable Excel worksheet)
ASTRO RO Model Technical Component Workbook (downloadable Excel worksheet)