ASTRO Identifies Initial Concerns With RO Model

By Dave Adler, Vice-President, Advocacy

ASTRO leaders, staff and consultants have been analyzing closely the radiation oncology alternative payment model (RO Model) unveiled July 10 and have identified several preliminary key issues.

ASTRO has hired an analytics firm to help analyze the model, but we are still weeks away from getting a clearer picture on whether CMS priced the RO model episodes appropriately and what impact the various model parameters will have on ASTRO members and patients. Analyzing the complex and comprehensive model is a massive undertaking with a rapidly approaching comment deadline of September 16.

While ASTRO is just beginning to digest the model, here are some preliminary perspectives:

  • Stable Payments, Higher Quality. ASTRO is pleased that the Centers for Medicare and Medicaid Services (CMS) is moving forward with a model that provides an opportunity for some radiation oncologists to participate in value-based care arrangements, and we see some strong potential for it to achieve our goals of incentivizing higher quality care and stabilizing payments in the long term. The model construct overall will help drive more guideline concordant care, and ASTRO is committed to working constructively with CMS and Congress to improve the model before it’s implemented.
  • Mandatory Participation. The model would be mandatory for more than 1,000 radiation oncology practices, which is a significant concern. While ASTRO understands CMS rationale for making the model mandatory, we believe the model should at least start as voluntary until we better understand how it works. Should CMS persist with a mandatory model, 40% of episodes is unwarranted and far beyond what is needed to adequately evaluate the model while still achieving savings.
  • Opt Out/In. If the model is mandatory, there should be consideration of a hardship exemption for practices to opt out and an opportunity for practices that want to participate to opt in to the model. Both can be done without compromising the evaluation of the model or savings. Radiation oncology practices deserve an opportunity to choose whether to test their participation in value-based care arrangements.
  • Timing. It’s very difficult to imagine that more than 1,000 practices will be notified in early November of their required participation and then start in the model on January 1, 2020. Participating in the model will take far more effort than flipping a switch. CMS should delay implementation until at least April 1, 2020, or consider a rolling start.
  • Discounts and Withholds. While the prospective payment is a positive, the discount factors of 4% and 5%, respectively for professional and technical payments, combined with additional withhold requirements for quality (2%), incorrect payments (2%) and, in the future, patient experience (1%), seem excessive and could create cash flow issues for many practices, particularly those with small margins, and undermine the value of prospective payments. In addition, we’re concerned that the adjustments could disadvantage efficient practices.
  • APM Incentive Payment. The 5% Advanced APM incentive payment would apply only to professional component services, despite technical payments being subject to the discounts and withholds. According to the Medicare Access and CHIP Reauthorization Act (MACRA) definition of “professional covered services,” the APM incentive payment should apply to payments based on the physician fee schedule, which should include freestanding technical payments. CMS is waiving that requirement due to concerns about a shift in site of service. CMS should find an approach that allows for the incentive payment to be applied to these technical payments, as MACRA intended.
  • Episode Payment. We must carefully assess how CMS is calculating the episode-based national payment rates and numerous adjustments to ensure that these payments are fair for a diverse group of radiation oncology practices and different modalities. While some national base rates appear reasonable, others seem low. In particular, we need to better understand whether the base rates properly account for certain common procedures, such as brachytherapy as a boost to external beam treatments, and referrals to other radiation oncologists for specialized services.
  • Innovation. The model does not seem to account for the adoption of new technology and new service lines during the term of the model and beyond. This needs further examination, as it could stifle innovation in a rapidly advancing field. There should be consideration of an adjustment to the episode or paying fee-for-service (FFS) for new technology/service lines until there’s enough cost data to incorporate into the episode payment.
  • Quality. We believe the selection of quality measures is appropriate, and we are particularly pleased with the emphasis on a patient safety organization that collects radiation oncology specific information.
  • Compliance Burden. It’s likely that CMS is underestimating the burden on participating practices, particularly in terms of collecting additional clinical data and monitoring information. It will be critical that CMS only collects what it absolutely needs and does so in the least burdensome way, particularly if the Agency is forcing practices to take on this additional burden by mandating participation.
  • All Payer. The model is Medicare FFS only and not an all-payer model. It’s not clear to us why it’s limited in this way. We are concerned about the proliferation of different models among different payers and the confusion and difficulty this will cause for radiation oncology practices.
  • Site Neutral. We need to further examine the way CMS is proposing to create national base rates for episodes in a site-neutral manner to ensure an even-handed approach that does not disadvantage freestanding or hospital-based clinics.

ASTRO is looking for input from members and radiation oncology stakeholders on these issues and others. Please send your suggestions to healthpolicy1@astro.org.

In addition, ASTRO has begun engaging congressional leaders and radiation oncology’s legislative champions to inform them of the model and ASTRO’s initial concerns, and to consider next steps to improve the RO Model before it’s finalized in November.

Posted: July 24, 2019 | with 4 comments
Filed under: Health policy

Jeff Michalski
In many large practices, patient care is shared by more than one radiation oncologist. This may be for special procedures, such as brachytherapy, or it could be for care being offered closer to a patient's home. The proposed model discusses withholding payment for patient's that transfer care but how is this to apply to a shared care situation amongst a group of RO practitioners?
8/20/2019 3:49:06 PM

Randi Kudner
Dr Luh, thank you for your comments. The quality measures do present 2 MIPS measures that are not consistently used by radiation oncology practices, depression screening and advanced care plan. These measures have their own specific issues, however they are both relevant to holistic patient care. The pain measure and treatment summary measures were both developed by ASTRO. While we do have some concerns about the list, we understand the need to have measures at the beginning of the model that are not already topped out.
The proposed rule does lay out additional data collection which is specifically intended for measure development. CMS hopes to use this data to identify trends that cannot be observed in claims.
Please reach out with any additional questions or concerns.
7/29/2019 2:37:26 PM

Join Luh
Three of the 4 quality metrics selected for quality reporting are NQF and MIPS measures that are not specific to radiation oncology. For an RO APM, there should be several radiation oncology relevant measures that are actually meaningful for quality improvement. CMS admits there are no outcomes measures in radiation oncology, although by definition an APM is required to have one. The MIPS quality category is already deficient in RO specific measures. This proposed quality category in the RO APM is not much of an improvement.
7/28/2019 8:21:19 PM

It appears that the National Base rates in the proposed model are based on the hypofractionation protocols that ASTRO has been pushing (based largely on subjective assessments of toxicity in phase 3 studies from Europe & Canada where there is strong incentive for limiting fractions & non randomized US trials wiith limited followup). If adopted they will result in substantial revenue loss for most.
Arbitrarily selecting rad oncs for involuntary inclusion also seems discriminatory & subject to legal challenge.
7/25/2019 4:11:15 PM

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