The Centers for Medicare and Medicaid Services Innovation Center (CMMI) unveiled a radiation oncology alternative payment model (RO-APM) that will substantially change the way US radiation therapy services are reimbursed.

Several years ago, American Society for Radiation Oncology (ASTRO) leadership, with support from a broad cross section of the society's membership, made a strategic decision to embrace the opportunity for an alternative payment model for radiation therapy services to help support the next generation of clinical advancement in the specialty. Rather than burying our heads in the sand, ASTRO has taken a proactive approach that gives radiation oncology the best chance to provide the best care for our patients while maintaining fair and stable payments.

ASTRO believes that radiation oncology is well positioned to succeed under these new payment models. The Board decided that radiation oncology should lead the development and execution of value-based care for our specialty rather than leave it entirely to others to define the future for us. Nonetheless, ASTRO recognizes that such a dramatic shift will be welcomed by some and met with skepticism by others, and there will be significant challenges along the way. Therefore, it is important to provide context to help ASTRO members understand how the specialty got to this point and what comes next.

Support for Value-Based Payments 1 Health Care Payment Learning & Action Network

Measuring progress: Adoption of alternative payment models in commercial, Medicaid, Medicare Advantage, and Medicare Fee-For-Service programs. , 2 Feeley T.W.

Mota N.M. New marketplace survey: Transitioning payment models: Fee-for-service to value based care. There has been longstanding, bipartisan policymaker consensus that Medicare must change the method by which way health care services are paid by transitioning away from volume-based payment and toward value-based payment.The Affordable Care Act in 2010 prompted efforts by federal programs to move toward value-based payment, most notably via the creation of CMMI to develop and test new payment models that are intended to improve quality and reduce costs. In 2015, the Medicare Access and CHIP Reauthorization Act eliminated the problematic Sustainable Growth Rate and replaced it with the Quality Payment Program (QPP), including a 5% bonus for participating in alternative payment models. QPP accelerated the transition from fee-for-service to value-based payments for physicians and medical institutions that participate in either the Merit Based Incentive Payment System or Advanced Alternative Payment Models (APMs). Additionally, in July 2016, CMMI launched an effort to rein in cancer costs and improve quality with the implementation of the Oncology Care Model (OCM). Private payers have emulated this construct to varying degrees in exploring bundled payments or condition management payments for medical services.

Radiation Oncology Payments In Decline 3 Falit B.P.

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Roberts K.B. Integrated prostate cancer centers and over-utilization of IMRT: A close look at fee-for-service medicine in radiation oncology. 4 Thevenot L. Comment letter in response to Medicare Program; payment policies under the Physician Fee Schedule and other Part B Payment Policies for CY 2010; final rule with comment period. , 5 Thevenot L. Comment letter in response to Medicare Program; Revisions to payment policies under the Physician Fee Schedule, DME face-to-face encounters, elimination of the requirement for termination of non-random prepayment complex medical review and other revisions to Part B for CY 2013. , 6 Thevenot L. Comment letter in response to Medicare Program; revisions to payment policies under the Physician Fee Schedule, Clinical Laboratory Fee Schedule, Access to Identifiable Data for the Centers for Medicare and Medicaid Innovation Models & other revisions to Part B for CY 2015. 7 Thevenot L. Comment letter in response to Medicare and Medicaid Programs: Hospital outpatient prospective payment and ambulatory surgical center payment systems and quality reporting program proposed rule for CY 2014. , 8 Thevenot L. Comment letter in response to Medicare Program: Hospital outpatient prospective payment and other programs CY 2016. , 9 Thevenot L. Comment letter in response to Medicare Program: Hospital outpatient prospective payment and ambulatory surgical center payment systems and quality reporting program CY 2018 proposed rule. In the late 2000s, utilization of radiation oncology, most notably intensity modulated radiation therapy, was rising at a faster rate than any other specialty and drew scrutiny from Medicare officials looking to cut payments.The Center for Medicare and Medicaid Services (CMS) felt that the initially calculated professional expenses required to provide these services no longer matched current costs as technology evolved. Between 2009 and 2014 freestanding radiation oncology clinics experienced Medicare payment cuts of approximately 20%, even after additional proposed cuts were fended off by ASTRO's advocacy efforts.Additionally, hospital-based facilities have faced declines in reimbursement as the Comprehensive Ambulatory Payment Classification system has expanded, bundling more services and reimbursing them at lower rates.In the private insurance market, payers have also used prior authorization and restrictive coverage policies to regulate costs. In 2013, CMS requested a revaluation of the major radiation oncology treatment delivery codes and the image guidance codes—representing roughly half of Medicare payment for radiation therapy services under the fee schedule. Based on data derived directly from freestanding facility surveys analyzing current equipment expenses and personnel costs, updated and renamed treatment delivery and image guidance codes were valued through the standard process, namely the American Medical Association's Relative Value Update Committee, commonly known as the RUC. However, CMS elected not to accept the RUC-endorsed revised values in the 2015 Medicare Physician Fee Schedule for the freestanding facility setting, instead deferring any decision on changed reimbursements by establishing temporary “G” codes that held payment rates constant at 2014 levels for another year while a decision was finalized. As a side, technical note, CMS did accept the new code labels for reporting these services in the Hospitals Outpatient Prospective Payment System. 10 United States Department of Health and Human Services Report to Congress: Episodic Alternative Payment Model for Radiation Therapy Services. It was reasonable to anticipate that the field of radiation oncology would continue to experience further reimbursement cuts that might or might not be informed by accurate cost data. To avoid arbitrary downward cuts, ASTRO worked with Congressional leaders to stabilize payment by freezing rates on the G codes for at least another few years with the passage of the Patient Access and Medicare Protection Act (PAMPA) in 2015. PAMPA also required CMMI to report to Congress on the viability of an alternative payment model for radiation oncology.Thus, ASTRO had some limited time to work with CMS to address concerns with code valuations, and PAMPA provided the Society with an opportunity to engage with CMMI on the development of an RO-APM that would provide radiation oncologists with an opportunity to participate fully in the QPP, stabilize payment rates, and address concerns regarding the OCM. Radiation oncologists should not be lulled into a false sense of security by the relative stability of the years since PAMPA's passage and its subsequent 1-year extension in 2018. Because PAMPA expires at the end of 2019, the specialty must be proactive about securing the future long term. Stability is, at last, a real possibility—which is why ASTRO proposed a RO-APM and has communicated its views to CMMI on the model.

Why A Radiation-Specific Model? 11 Thevenot L. Comments in response to the Center for Medicare and Medicaid innovation oncology care model. The OCM initiates an episode of care at the point of starting chemotherapy or hormone therapy. The episode extends for a 6-month period and encompasses all Part A and Part B services, including radiation therapy. From the OCM's inception, ASTRO expressed concern that the model potentially disincentivizes the appropriate use of radiation therapy considering its associated costs are attributed to the total cost of care and can cause the medical oncologist not to meet the savings target defined in the OCM.Radiation oncologists who participate in the OCM have expressed concerns with the associated changes in practice patterns because of the potential detriment to cancer patients if high-value radiation therapy services are underused as a result. 12 Hubbard A. Radiation Oncology Alternative Payment Model (RO-APM). In an effort to develop a model specific to radiation oncology and provide input on the PAMPA-required report to Congress, ASTRO drafted a RO-APM in which radiation oncologists could participate voluntarily to ensure that it works for their patients. In April 2017, ASTRO submitted an APM concept paper to CMMI that emphasizes guideline-concordant care through bundled payments, paid prospectively, for the majority of disease sites treated with radiation.The ASTRO RO-APM would be available to both hospital and freestanding centers and meet the requirements for the Medicare Access and CHIP Reauthorization Act APM 5% bonus payment. The model would be voluntary so that practices could determine whether the model fits their practices and patients. This ASTRO RO-APM was not created in vacuum. It was the collaborative product of a broad cross-section of ASTRO members and close consultation with various other radiation oncology stakeholders. Radiation oncologists practicing in large and small hospitals and freestanding practices from across the country have contributed. The model ASTRO developed accommodates advances in technology and treatment techniques to support continued innovation. Now, the radiation oncology community needs to advocate vigorously for Medicare to adopt a model that aligns with our goals of fair and stable payments with incentives to improve quality and value.

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et al. Randmoized phase III noninferiority study comparing two radiotherapy fractionation schedules in patients with low-risk prostate cancer. 15 Moore A.

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Anderson N. Cost-containment in hypofractionated radiation therapy: A literature review. , 18 Gill B.S.

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et al. National cancer data base analysis of radiation therapy consolidation modality for cervical cancer: The impact of new technological advancements. Radiation oncology treatments continue to evolve. Most notably, the field is seeing a significant shift in how radiation therapy is delivered to patients as evidence-based shorter radiation treatment schedules are more widely adopted in clinics across the country.However, the current payment system disincentivizes the use of shorter fractionation schemes and other highly cost-effective treatments, such as brachytherapy.Value-based care is what patients deserve, and it is what we should strive to provide them. The existing fee-for-service system does not reliably incentivize delivery of the most cost-effective treatment. 19 Hunter D.

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Anderson N. Cost-containment in hypofractionated radiation therapy: A literature review. The new Medicare payment system ensures that practices not participating in APMs will have lower annual payment updates than those participating. Practices that avoid APMs will struggle, either financially through lower paymentor through additional burdens of quality reporting and prior authorization. ASTRO leaders have concluded that the best option moving forward for the specialty is an APM designed by and for radiation oncologists. ASTRO has spent a significant amount of time and resources to provide input and guidance in the development of the CMMI model, and the organization continues to devote resources to help members assess the APM launched by Medicare and understand how they will fare under the model. As the details of the CMMI model emerge, we hope ASTRO members will give us their perspectives on how the model could affect their practices and patient care. Then we will need to channel this input into advocacy that improves the CMS model into one that works well for all practices and supports high-quality radiation oncology care.

Article Info Publication History Footnotes Disclosures: none. Identification DOI: https://doi.org/10.1016/j.ijrobp.2019.07.002 Copyright © 2019 Elsevier Inc. All rights reserved. ScienceDirect Access this article on ScienceDirect