Too Much, Too Fast: Providers Push Back on CMS’ Final RO Model

Editor’s Note: After this article went to press, CMS announced that the Radiation Oncology Model will be delayed until July 1, 2021. For more, read here​ .

A new alternative payment model (APM) for radiation oncology (RO) has drawn fire from providers, who say a mandatory shift to bundled payments in the middle of a pandemic is unfair.

Transitions cost money, and many have none to spare. CMS Administrator Seema Verma vowed full steam ahead when she finalized the RO Model on September 18, claiming the change that takes effect January 1, 2021, would save $230 million over 5 years and likely mean lower out-of-pocket costs for Medicare beneficiaries.¹

“Today, Medicare payment for radiotherapy is based on the number of treatments a patient receives and where they receive it, which can lead to spending more time traveling for treatment with
little clinical value,” she said in a statement.¹

Radiation oncologists have been bracing for a move to a bundled payment model for a while. But they say the timing—in the wake of staffing shortages caused by the coronavirus disease 2019 (COVID-19) pandemic—could not be worse. The American Society for Radiation Oncology (ASTRO) argues that the planned start date is too aggressive for a model that would be mandatory for 30% of providers, and the group said it would go to Congress to seek relief.²

“The transition to value-based payment will require significant practice changes and investments to comply with the model’s requirements. ASTRO strongly urges CMS to significantly delay the start date rather than foster unnecessary chaos and burden for the practices this model is designed to support,” the group said in a statement.²

The American College of Radiology echoed these concerns.³

The RO Model was in the works well before COVID-19, as CMS has been determined to create a payment structure that is site neutral and rewards outcomes, not how many times a patient
receives radiation. Historically, payments have been doled out bit by bit, giving providers an incentive to keep treating and billing. CMS argues that evidence shows “for some cancer types and beneficiary characteristics, a shorter course of [radiotherapy] treatment with more radiation per fraction may be clinically appropriate.”⁴

Elements of the RO Model
The RO Model calls for bundled payments over a 90-day episode of care, which would go to radiotherapy providers who treat 1 of 16 cancer types. CMS said it would require participation from
physicians in randomly selected geographic areas covering 30% of all current Medicare fee-for-service episodes (the initial proposal was 40%). The model has a 5-year performance period that would run through December 31, 2025.⁴

According to a CMS fact sheet, the episode payments would be split into 2 components: the professional and technical pieces, which would allow the existing claims systems for the Physicians’
Fee Schedule (PFS) and the Hospital Outpatient Prospective Payment System (OPPS) to be used to pay claims.

A chief mission of the model, according to CMS, is to emphasize “site-neutral payment by establishing a common, adjusted national base-payment amount for the episode, regardless of the setting where it is furnished.”⁴

Payment will be linked to quality through performance measures, clinical data reporting, and patient experience factors. The model allows providers to meet Advanced APM requirements under the Quality Payment Program. Beneficiaries must be notified their provider is taking part in the RO Model.

Model Pricing and COVID-19
The RO Model calls for participant-specific payments that take into account a mix of national base rates, trend factors, and “adjustments for each participant’s case mix, historical experience, and geographic location.” CMS then applies a complex system of discount factors. But CMS will be basing 90% of the payment on a practice’s historical payments from 2016 to 2018, even though an ASTRO survey released in May found that 85% of members reported a decline in visits due to COVID-19, by an average of one-third.⁵

“While these volume declines won’t impact the historical experience data, they likely will impact other aspects of the model, most notably the payment adjustment that accounts for case mix, as we
expect more patients to present with more complex disease due to delayed screening. These issues will likely confound at least the first year of CMS’ evaluation of the model,” Dave Adler, vice president for Advocacy, ASTRO, told Evidence-Based Oncology™ (EBO) in an email.

“Skewed results in the first evaluation report would start the program off on the wrong foot and jeopardize the future of the model. This is an important reason to delay the model until after the pandemic.”

EBO asked if the amounts of bundled payments in the early part of the model could be under valued, as most experts predict a wave of patients with advanced cancers will be diagnosed in late 2020 or early 2021 due to missed screenings. Adler said this is possible. In their statement, ASTRO providers said they remained committed to working toward a value-based payment model, but under the current circumstances they believe a voluntary phase is needed first.

“ASTRO has worked with CMS and bipartisan legislators for several years toward a viable payment model for radiation oncology that would support stable and fair payments, drive adherence to nationally recognized clinical guidelines, and improve patient care,” the statement said. “We are hopeful that CMS and Congress are open to reconsidering a start date that would be realistic and not derail this unique opportunity.”²

Adler said ASTRO will seek a delay of implementation until July 1, 2021—and potentially later if the pandemic persists—and to reduce the discount factor payment cuts to 3%. This would put the discount factor cuts in line with other models from CMS, he said.

Lower Out-of-Pocket Costs?
CMS’ details suggest that along with bundled payments to providers, the current 20% coinsurance paid by beneficiaries would be configured differently. “Since CMS applies a discount to each
component of the bundled payment, the agency expects that beneficiary cost sharing would be, on average, lower relative to what typically would be paid under Medicare’s fee-for-service system,” the fact sheet states.⁴

The model covers 16 diagnoses that account for the vast majority of solid tumor cancers: anal cancer, bladder cancer, bone metastases, brain metastases, breast cancer, cervical cancer, central nervous system tumors, colorectal cancer, head and neck cancer, liver cancer, lung cancer, lymphoma, pancreatic cancer, prostate cancer, upper gastrointestinal cancer, and uterine cancer.⁴

References
1. CMS announces innovative payment model to improve care, lower costs for cancer patients. News release. CMS. September 18, 2020. Accessed September 18, 2020. https://www.cms.gov/newsroom/pressreleases/
cmsannouncesinnovativepaymentmodelimprovecarelowercostscancerpatients
2. ASTRO responds to CMS Radiation Oncology Model: implementation delay and more reforms needed. News release. ASTRO. September 18, 2020. Accessed September 18, 2020. https://www.astro.org/NewsandPublications/NewsandMediaCenter/NewsReleases/
2020/ASTROrespondstoCMSRadiationOncologyModelImp
3. ACR joins ASTRO in urging CMS and Congress for changes to RO Model. News release. ACR. September 21, 2020. Accessed September 23, 2020. https://www.acr.org/AdvocacyandEconomics/AdvocacyNews/
AdvocacyNewsIssues/IntheSept262020Issue/
ACRJoinsASTROinUrgingCMSandCongressforChangestoROModel
4. Radiation Oncology (RO) Model fact sheet. CMS. September 18, 2020. Accessed September 18, 2020. https://www.cms.gov/newsroom/factsheets/radiationoncologyromodelfactsheet
5. ASTRO survey: fewer patient visits despite enhanced COVID19 safety measures for radiation oncology clinics. News release. ASTRO. May 20, 2020. Accessed September 23, 2020. https://www.astro.org/NewsandPublications/NewsandMediaCenter/
NewsReleases/2020/ASTROsurveyFewerpatientvisitsdespiteenhanced