Medicare Vexes Oncology Community’s Radiation Oncology Payment Model

WASHINGTON – The Biden administration’s Center for Medicare & Medicaid Innovation (CMMI) is currently in full swing with its radiation oncology model mandatory for Medicare payment, and physician groups are not happy with it.

“We are totally, categorically against mandatory models,” Ted Okon, MBA, executive director of the Community Oncology Alliance (COA), said on a phone call, quickly adding that does not mean his group is not supporting Medicare payment experimentation. reform. “At COA, we are so invested in oncology payment reform that no one can accuse us of wanting to delay the era of fee-for-service and not pushing payment reform. website; you will see a map of the United States with 35 different designs and practices participating in it. “

However, “mandatory models, by definition, violate the spirit of CMMI, which we fully support as a grand concept,” he continued. Instead of instituting a mandatory model, CMMI should stick to its original concept as outlined in the Affordable Care Act and “pilot [voluntary] phase one models and then turn them into larger phase two models, which should be done in collaboration with stakeholders… Mandatory models are like castor oil – they’re pushed down your throat. “

Three reasons to reform

The radiation oncology model began as a result of the Patient Access and Medicare Protection Act passed by Congress in December 2015, known as the Centers for Medicare & Medicaid Services (CMS) explained in a technical sheet on the model. The law required the Secretary of Health and Human Services to submit a report to Congress on “the development of an episodic alternative payment model” for radiation therapy services, CMS noted. the report was published in 2017 and listed three reasons why radiation therapy needed payment reform:

  • No site neutrality. Under Medicare’s fee-for-service system, Medicare pays a lower rate for radiation therapy (RT) provided in a free-standing community radiation therapy center than for the same therapy provided in an outpatient department of a hospital. “This difference in payment rates may cause Medicare providers and providers to provide radiation therapy services in one setting rather than another, even if the actual treatment and care received by Medicare beneficiaries for a given modality is. the same in both contexts, ”says the fact sheet. .
  • Driving volume over value. The incentives of the current fee-for-service system encourage clinicians to provide more services, rather than simply providing those with the most clinical value. “These incentives are not always aligned with what is clinically appropriate for the recipient,” CMS noted. “For example, for certain types of cancer, stages and characteristics of recipients, shorter RT treatment with more radiation per fraction may be clinically appropriate.”
  • Coding and payment issues. The agency “has determined that there are difficulties in coding and setting payment rates appropriately for radiation therapy services,” the fact sheet said. “These difficulties have resulted in pricing changes for these services under physician fee schedules (eg, payment reductions) and coding complexity both [the Physician Fee Schedule and the Hospital Outpatient Prospective Payment System]. “

Under the radiation oncology payment model, Medicare will “make forward-looking, episode-agnostic, and episode-neutral payments for 16 different cancer types,” according to CMS, which also said the model “is expected to improve. the experience of beneficiaries. by rewarding high quality patient-centered care; and by incentivizing high-value radiation therapy that translates into better patient outcomes. “

Delayed implementation

The model was originally scheduled to start on January 1, 2021, but was delayed until January 2022; it will require mandatory attendance from clinicians practicing in certain US Postal Service zip codes. RT providers in selected zip codes provide services representing about 30% of all act-eligible radiation therapy episodes nationwide, CMS said; a list of the postal codes concerned is available here.

Payments will be made in two parts: one at the start of therapy and one at the end of therapy; the amount will include reimbursement for RT services provided during a 90-day episode of care. Payments will include both a professional component for services provided by a physician and a technical component for services provided by non-physician personnel, as well as supplies and equipment.

Payment rates for each participant will be determined by a number of factors, including a national base rate, the participant’s case mix and the participant’s geographic location. In addition, CMS applies a “discount factor” – or payment reduction – of 3.75% for the professional component and 4.75% for the technical component in order to “reserve savings for Medicare and reduce cost sharing. by the beneficiaries “.

There will also be “holdbacks” for incorrect payments (1% for the professional and technical component), quality (2% for the professional component) and patient experience (1% for the technical component from 2023. ). Model participants can recover some or all of the holdbacks in various scenarios involving their clinical data reports and their quality and performance measurement reports, as well as patient surveys.

Disappointment on the discount factor

Radiation oncologists have expressed disappointment with various parts of the model, including the discount factor. “These discounts are problematic for several reasons,” said Constantine “Connie” Mantz, MD, radiation oncologist in Cape Coral, Fla. And president of health policy for the American Society for Radiation Oncology (ASTRO). On the one hand, the Medicare and CHIP Access Reauthorization Act (MACRA) of 2015 requires physicians joining advanced alternative payment models such as this to put a minimum of 3% of their income. at risk, not 3.75% or 4.75%, Mantz said. in a phone call.

Another problem is that “unlike other areas of medicine where costs are flexible, they are not in radiation therapy; they are extremely rigid,” Mantz continued. “We are committed to purchasing expensive equipment to install in our facilities and services, and these costs are fixed throughout the life of the equipment. If the payments change drastically, we have no way of adjusting to those changes through our operating expenses. “

This contrasts with medical oncology, “where a large portion of the expense … is in the drug inventory, and medical oncologists may decide that if reimbursement changes dramatically, they could just swap one set of drugs for another. , so they can cover their costs while treating the patients, “he added.” We can’t do that in radiation therapy, so we have very little flexibility in our costs. All the discounts, in especially those that go beyond what is absolutely necessary, create conditions of financial danger for these transactions. And so for these reasons, we would really like Medicare to consider reducing the discount factors to 3% as required by MACRA. “

Will the Biden administration listen to the concerns of the oncology community? Mantz has some hope that this will be the case. “The current administration has expressly stated that it intends to ensure that all government agencies address inequalities in services for disadvantaged groups, and in medicine, these patient groups are rural patients and minority groups, for whom there is already data showing that under the current fee -for the service, there are gaps in the provision of high-quality and high-value services to these patients, ”he said. declared. “So we believe that we can appeal to this stated goal of the current administration and request that some of these significant discounts can be at least partially corrected, so that suppliers can continue to improve their technical service offerings and deliver the standard. care needed to begin to close these gaps which are already observed among certain groups of patients. “

MedPage today emailed CMS asking for comment on this story, especially the concerns raised in a model summary written last year by ASTRO, including that the model oversampled rural oncology practices, had no positive payment incentives, and there was – when the summary was written – no waivers for small practices. Regarding possible rural oversampling, “the selection methodology is based only on Central Statistical Areas (CBSA), which are large geographic areas with an urban core,” the spokesperson said in an email. “Of the postal codes included in the CBSAs randomly selected to participate in the RO model, less than 6% are considered rural according to the most recent classification of rural-urban commuting areas, and among these postal codes, less than half include suppliers and suppliers of radiation therapy. . “

Regarding the lack of positive incentives, the spokesperson noted that “model participants can potentially earn a positive payment adjustment through the quality payment program, as the model is considered an advanced alternative payment model (APM ) and a merit-based incentive payment system (MIPS)) APM. Eligible clinicians who are professional participants and dual participants can potentially become eligible APM participants (QP) who earn a 5% APM incentive payment and are excluded from MIPS reporting requirements and payment adjustments. “

Regarding the hardship waiver, the spokesperson said the model “now includes a low volume exception for practices that fall below certain episode thresholds. In response to stakeholder comments, and to In light of the current public health emergency and several recent natural disasters, CMS is also proposing to adopt a policy of “extreme and uncontrollable circumstances.” This policy would provide flexibility to reduce the administrative burden of participating in the model, including understood the reporting requirements, and / or adjust the payment methodology if necessary. “

Last updated on August 10, 2021

  • Joyce Frieden oversees the coverage of MedPage Today in Washington, including articles about Congress, the White House, the Supreme Court, health professional associations and federal agencies. She has 35 years of experience in health policy. To pursue


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