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Concerns About the Real-World Impact of CMS’ Radiation Oncology Model

Authored by

Association of Community Cancer Centers

Citation

J Clin Pathways. 2020;6(10):26-27.

ACCCWhile the Association of Community Cancer Centers (ACCC) supports the Center for Medicare and Medicaid Innovation (CMMI) Radiation Oncology (RO) Model’s concept and the transition to value-based care, ACCC has serious concerns1 about the mandatory model, which is slated for launch July 1, 2021.

CMMI’s aim for the RO Model is “to improve the quality of care for cancer patients receiving radiotherapy and move toward a simplified and predictable payment system.”2 Unfortunately, the finalized Model is unlikely to accomplish either of these goals. ACCC, together with the American Society for Radiation Oncology (ASTRO)3 and other stakeholders, continues to urge that CMMI reevaluate components of the Model and postpone the pilot program’s start.

Significant Concerns

Stakeholders continue to question: (1) the timing for launch of the mandatory 5-year pilot; (2) whether the Model will yield a stable, predictable payment system; and (3) the impact of the Model on participating providers and their patients. In an interview for this column, Director of Policy at ASTRO, Anne Hubbard, MBA, provided additional perspective on these issues.Quote 1

Timing. As 2020 draws to a close, the country is struggling with the SARS-CoV2 pandemic and its effects on health care delivery as well as its toll on providers, patients, and our society. After months of uncertainty and disruption, is 2021 the time to launch a new mandatory (for some) alternative payment model (APM) for radiation oncology?

“One of the things we’ve learned during this COVID-19 Public Health Emergency,” said Ms Hubbard, “is that radiation oncology practices have experienced revenue declines of upwards of 30%, and we’re hearing from practices who have said our patient volumes are down, our revenues are down, and now 950 of these practices are being compelled to participate in an APM that doesn’t recognize that they are already in financial straits due to COVID. It could potentially put a number of those practices over the edge.”

Payment methodology. An overriding question is whether the Model’s reimbursement methodology is, in fact, “a move toward a simplified and predictable payment system.” Both ASTRO3 and ACCC have voiced concerns about the significant cuts associated with the Model’s discount factors and withholds. Both organizations urged that the discount factor cuts be set at 3% or lower, in keeping with MACRA, which created a 3% nominal risk requirement for advanced APMs. However, in the final rule, these were only marginally lowered to 3.75% and 4.75%, for the professional component and technical component, respectively.

In addition, there are significant unknowns. ASTRO remains concerned that with a July 1, 2021 start date, “if the agency is not able to identify practices as advanced APMs by meeting the qualified participant status thresholds for their Medicare spend or their Medicare patients who are in an advanced APM, then that could potentially result in another cut on top of the existing payment methodology that has the discount factor reductions and the withholds,” Ms Hubbard explained. “By not addressing the qualified advance APM participant status component, with a July 1 start date, many practices won’t achieve that status and they don’t benefit from the 5% APM bonus.” And what happens to the trend factor for next year—based on the Medicare Physician Fee Schedule (MPFS)—remains to be seen, she cautioned
(Note: Final 2021 MPFS not issued as of article in-press date).

As the RO Model stands, the Professional Component trend factor update is based on the Medicare Physician Fee Schedule, which, as proposed for CY2021, results in a 6% cut for radiation oncology.4 For those in the RO Model, this would mean an additional 3% cut. “It actually creates a situation where model participants are in an even worse position because of what is going on outside the model,” noted Ms Hubbard. “One of the tenets for developing an APM for radiation oncology has always been to establish rate stability,” she said. “This is another area where we are saying to the agency: ‘Put guardrails around the trend factor, so if there are significant cuts outside of the model, they are not going to be disruptive for those practices that are inside the model.’”

Improved Patient Care?

Finally, how might this model improve “quality of care” for patients receiving radiation therapy? As a consequence of the COVID-19 pandemic, many people have delayed cancer screenings and may have opted to delay treatment. Concerns about the impact on future cancer volumes, later-stage diagnosis, and outcomes have been raised by National Cancer Institute Director Norman Sharpless, MD,5 among others. The RO Model will only apply to Medicare fee-for-service patients, but the potential exists as the Model is currently structured for it to create a greater financial burden for patients. The Model develops an episode-based payment by disease site. This means that a prostate cancer patient in the “episode” time frame will pay the same coinsurance amount regardless of the cancer stage or complexity of care provided. “So, you may have an early-stage prostate cancer patient who will be paying more for care inside the model because the bundle includes the cost of care for more complex patients,” said Ms Hubbard. “And the reverse is also true. You might have a very complex prostate patient who is paying less than they would outside the model,” she said. “But overall, that’s a shift in financial responsibility that should not be borne by the patient.”

Take Action Now

ACCC urges programs identified for RO Model participation to support ASTRO efforts to collect data to tell the story of the real-world impact this mandatory pilot will have on radiation oncology programs and patients in 2021 and beyond. ASTRO has created tools that enable radiation oncology providers to estimate the Model’s effect on projected revenue for 2021 compared with 2019. ACCC has made these workbooks available on its website at accc-cancer.org/advocacy.

References

1. Association of Community Cancer Centers. Letter to Alex Azar, Secretary, U.S. Department of Health and Human Services, and Seema Verma, Administrator, Centers for Medicare & Medicaid Services. October 13, 2020. Accessed November 29, 2020. https://www.accc-cancer.org/docs/documents/advocacy/accc-ro-model-final-rule-letter-from-dr--oyer.pdf?sfvrsn=ea32f7c0_2

2. Centers for Medicare & Medicaid Services. Center for Medicare and Medicaid Innovation. Radiation Oncology Model. Updated October 20, 2020. Accessed November 29, 2020. https://innovation.cms.gov/innovation-models/radiation-oncology-model

3. American Society for Radiation Oncology. Letter to Brad Smith, Deputy Administrator and Director, Center for Medicare and Medicaid Innovation. July 22, 2020. Accessed November 29, 2020. https://www.astro.org/ASTRO/media/ASTRO/News%20and%20Publications/PDFs/ROModelCOVIDletter.pdf   

4. Centers for Medicare & Medicaid Services. Physician fee schedule, CY 2021 physician fee schedule proposed rule with comment period. August 4, 2020. Accessed November 29, 2020. https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched

5. Cavallo J. How delays in screening and early cancer diagnosis amid the COVID-19 pandemic may result in increased cancer mortality. ASCO Post. September 10, 2020. Accessed November 29, 2020. https://ascopost.com/issues/september-10-2020/how-delays-in-screening-and-early-cancer-diagnosis-amid-the-covid-19-pandemic-may-result-in-increased-cancer-mortality/

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