RO-APM: What we know, what we don’t and what it all means

By Anne Hubbard, MBA, ASTRO's Director of Health Policy

On February 12, the Centers for Medicare and Medicaid Services (CMS) issued a transmittal to Medicare Administrative Contractors related to the implementation of a radiation oncology alternative payment model (RO-APM).  This is the surest indication since HHS Secretary Alex Azar’s comments last fall that a RO- APM is on the way. The transmittal, posted briefly by mistake and then pulled down, included just a few details about the model that likely raised more questions than provided answers.

What we know

According to the transmittal, the RO-APM will be applicable in both hospital-based and freestanding settings, so it effectively replaces the Medicare Physician Fee Schedule (MPFS) and Hospital Outpatient Prospective Payment System (HOPPS) for practices participating in the model. The model provides prospective payment for a 90-day episode of care that includes separate PC/TC payments for radiation oncology services. The separate PC/TC payments are made in two installments. The first payment is issued at the beginning of the episode of care when a participant bills one of the new RO-Model specific HCPCS codes assigned to one of 17 disease sites and one of two RO-Model modifiers (PC and TC). The second installment will be issued at the conclusion of the episode. The PC payments are made to the radiation oncologist (identified by NPI/TIN) and cover delivery of care for 17 different cancer types. The model is expected to be mandatory for randomly selected Core-Base Statistical Areas (CBSA).

What we don’t know

While the directive provided us with a glimpse of the model’s design, there is still plenty we don’t know about the RO-APM. While it’s clear the intention is to apply the model in both freestanding and hospital-based settings, it is unclear how payments will be made to those freestanding practices that bill globally (no PC/TC split). We also don’t know what is included in the list of 17 disease sites, but a clue may be found in information CMMI shared at a May 2017 radiation oncology stakeholder meeting.

Making sure the RO-APM meets Advanced APM requirements, so participating physicians can enjoy the 5 percent bonus as prescribed in the Medicare Access and CHIP Reauthorization Act of 2015, will be critical. Based on the limited information in the transmittal, it is unclear whether nominal risk requirements will be met. Most importantly, we don’t know how the payment methodology is being constructed. How the Agency plans to establish benchmark and target prices, as well as whether there will be a blend with national averages, will be very important considerations. Since the model is prospectively paid, there is no reconciliation of payment and no clawback for overspending, which have proven to be burdensome for other models. There is also a lack of information on quality measures and electronic health records certification requirements that are also important to obtain Advanced APM status.

Finally, the mandatory component is still unclear. While CMS states that they plan to mandate participation in selected CBSAs, we don’t know how many CBSAs will be on that list, thus we don’t know just how many practices will be required to participate.  On the flip side, will practices not required to participate be allowed to opt-in to potentially achieve the 5% bonus?  The other big question associated with mandatory participation is whether it will be immediate or phased in. If other mandatory models serve as an indicator, a phased in approach is possible.

What it all means

While there are plenty of unknowns, it is clear that CMS is committed to rolling out a RO-APM and it’s coming fast. We anticipate that many of the unknown aspects of the model will be revealed when CMS issues a notice of proposed rulemaking (NPRM) describing the model. Not only will that answer many of our questions, it will also give us an opportunity to thoughtfully react to the proposal and engage with the Agency on any necessary changes that should be implemented before the model is finalized.

Once the model is issued through the regulatory process, ASTRO will assess the model, review the implications of the proposed rule and provide comments to CMMI on potential modifications that need to be considered before moving forward. Ultimately, we want to ensure that the RO-APM allows radiation oncologists an opportunity to actively participate in an advanced APM that rewards them for delivering high quality care; stabilizes payment rates across practice settings; and ensures patient access to appropriate radiation oncology services.

Radiation oncology practices should look closely at the transmittal and ASTRO’s proposal to help prepare for a likely dramatic change in the way Medicare pays for radiation therapy services.

Posted: February 14, 2019 | with 0 comments
Filed under: Blog, CMS, Medicare

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