By Geraldine Jacobson, MD, MBA, MPH, FASTRO, ASTRO Chair; Connie Mantz, MD, FASTRO, Health Policy Council Chair; and Catheryn Yashar, MD, FASTRO, Health Policy Council Vice-chair

On June 23, ASTRO’s Board of Directors approved pursuing legislation to create a new Radiation Oncology Case Rate (ROCR) payment program under traditional Medicare, which would:

• Change radiation oncology payment from per fraction to per patient.
• Reverse decade-long declines in Medicare payments.
• Usher in a new era of stable payments, higher quality care, and reduced disparities.

ROCR represents a bold initiative to reverse disastrous Medicare payment trends. ASTRO believes ROCR is our best chance to secure long-term rate stability and continue to deliver cutting-edge care to patients close to home. ASTRO is seeking feedback on ROCR with the goal of securing broad support from the radiation oncology community before advancing this legislative proposal in Congress.

Background:

Medicare spends less on all radiation oncology treatments than it spends on just three top cancer drugs; yet radiation oncologists treat more than twice the number of beneficiaries. Despite its high value, radiation oncology has faced more payment cuts than nearly all other specialties through a combination of direct cuts and policy proposals that shift resources from specialty care to primary care. More cuts are likely to come.

The Facts:

• Medicare has cut RadOnc payments by more than 20% over the last 10 years.
• Practice costs are rising, as equipment and staff are getting more expensive.
• More Medicare beneficiaries are receiving radiation therapy.
• The current payment system penalizes the use of shorter treatment regimens.
• The CMS RO Model failed due to excessive payment cuts and administrative burden.

Without stable payments, access to care and quality will suffer and the field will struggle.

Radiation therapy is primed to make great gains for cancer patients, but the current Medicare payment system is prohibiting the investments necessary to achieve those goals. ASTRO refuses to let the status quo of cuts and failure of the RO Model stand in the way of radiation oncologists who are committed to providing greater value to their patients. The specialty needs to look forward and act now.

ASTRO has invested significant time and resources in developing this new Medicare payment system for radiation oncology. Developed by ASTRO’s Health Policy Council physician leaders from various practice settings and with the help of expert consultants, the ASTRO Board approved ROCR as a proposal in June after numerous versions were evaluated and analyzed.

Several practices, including private practices (freestanding and hospital based) and academic centers, modeled ROCR using the tool linked below and determined ROCR was favorable in comparison to expected Medicare fee-for-service payments.

Why ROCR?

Because it:

• Addresses the instability of the current payment systems;
• Aligns financial incentives with clinical guidelines;
• Ensures use of quality assurance and improvement standards;
• Reduces disparities by helping underserved patients initiate, access and complete treatments;
• Uses a more simplified approach than the CMS RO Model;
• Unifies payment that levels the playing field across care delivery settings;
• Updates payments annually based on medical inflation trends.

ROCR has precedent in past payment reforms for capital intensive health care services, such as End Stage Renal Disease, which is paid on a prospective basis.

ROCR Ins and Outs

• All radiation oncology practices participating in Medicare.
• Professional and technical services paid under Medicare physician fee schedule and hospital outpatient prospective payment system for 15 common cancer types.
• External beam modalities and associated services.
  • Conventional, IMRT, SRS, SBRT

• Services delivered in inpatient hospitals, ASCs, PPS-exempt cancer hospitals.
• Medicare Advantage and commercial insurance payments.
• New Technology and Services (without Cat 1 CPT codes).
  • i.e., Adaptive RT
• Services without national Medicare prices.
  • Proton therapy, surface guidance
• Lower volume services.
  • Protons, brachytherapy, radiopharmaceuticals

Excluded technology and services potentially eligible for inclusion in future years.

How does ROCR work?

1. Payment rates and RVUs are derived from “M code” case rates published by Medicare in 2022 for technical and professional payments for 15 cancer types.
   1. ASTRO’s consultants validated the accuracy of these unified payment rates.
   2. Half of the payment will be paid at the start of the radiation treatment.
   3. Final payment will be made at the end of the course of treatment.
2. Applies annual inflationary payment updates.
   1. Professional payments updated by the Medicare Economic Index.
   2. Technical payments updated by the Hospital Inpatient Prospective Payment System market basket update.
3. Applies a savings adjustment, which is phased in over five years. 
   1. Savings adjustment would reduce Medicare radiation oncology spending by slightly more than $200 million over five years, which is about 1% of total Medicare spending on radiation oncology each year or about $17,500 per practice, per year.
   2. Savings are needed for Congress to even consider ROCR.
   3. Savings are primarily derived from technical payments.
      1. ASTRO estimates ROCR’s level of savings to be less than what is likely to happen if current payment and hypofractionation trends continue.
4. Provides a Health Equity Achievement in Radiation Therapy (HEART) payment of $500 per patient to technical payments to cover transportation services for underserved patients.
   1. Triggered by using a standardized screening question and billing code.
5. Provides a technical payment incentive to earn/maintain practice accreditation, which is well accepted by radiation oncology clinics for assessing and improving quality of care.
   1. First three years, accredited practices receive a .5% positive payment adjustment.
   2. After three years, practices would receive a -1.0% adjustment for lack of accreditation.
6. Applies geographic adjustments and the federally mandated cut of 2%, per current law.

What’s next?

Practices are encouraged to use the modeling tool to compare payments under ROCR to trended fee-for-service payments. Tell us how your practice would perform under ROCR.

• Keep in mind that the tool does not account for additional expected Medicare payment cuts under the fee schedule and the continued impact of increasing hypofractionation on technical revenues.

Review the full ROCR report, technical analysis and modeling tool. We want to hear from you — please send us your feedback via email to Health Policy.

Read the draft letter to Congress and if you agree with ROCR, indicate your practice or organizational support by filling out this form.

By Jennifer Jang, ASTRO Communications

ASTRO is excited for the 2023 ASTRO Annual Meeting to be held this October 1-4 in beautiful San Diego. The meeting’s theme, “Pay it Forward: Partnering with Our Patients,” is intended to keep at the meeting’s forefront the central role of human interaction and generosity toward building a better future. A premium feature of the Annual Meeting is the Presidential Symposium, which will spotlight the year’s theme and explore different facets of radiation oncology based on it, from patient perspectives to clinical trials.

ASTRO President Jeff Michalski, MD, MBA, FASTRO, pointed out that a key role for this meeting is to provide the platform for sharing emergent discoveries from clinical trials. In light of this year’s theme, he emphasized that these trials are “only made possible by patients who very much believe in ‘paying it forward,’” and that findings are shared and pushed further through productive conversations.

The Presidential Symposium will include multiple deep dives into numerous aspects of clinical trials. To start, Session I will focus on Clinical Trial Design and be introduced by Dr. Michalski, and James Dignam, PhD, NRG Oncology Statistics and Data Management Center, will moderate the session. It will focus on how novel trial designs can be more efficient and effective, exploring the means to reduce the number of enrollees and shorten the time to obtain meaningful results. Statistical design will be explored, along with a look at how NCI is developing an innovative clinical trial unit.

Session II will cover Diversity in Clinical Trials and be moderated by Eleanor Walker, MD, Henry Ford Health System. Speakers include Karen Winkfield, MD, PhD, Electra Paskett, PhD, Chanita Hughes-Halbert, PhD, and Desirée A. H. Walker. This session will focus on the necessity of clinical trials to have a diverse enrollment along with a diverse study team, with patient perspectives from those who have participated in radiation clinical trials.

Honing in on the meeting’s theme, Session III will explore Patient Perspectives, and Bryan Hwang, MD, Mountain View Center, and Barbara Barclay, a patient advocate, will co-moderate. This session will provide a unique learning opportunity, as patients and patient advocates share their stories and experiences from clinical trials. Advocates will share how they appreciate being approached about clinical trials or their research into trials. Dr. Hwang, a radiologist, was a patient of Quynh-Thu Le, MD, FASTRO, Stanford Cancer Institute, and participated in RTOG 0615 for the treatment of his NPC.

Then, zooming out, Session IV will look at International Trial Reports, and will be moderated by Mitchell Machtay, MD, FASTRO, Penn State University. The session will focus on the future strategy of Cooperative Group Trials with an emphasis on radiation oncology around the world. Winette van der Graaf, MD, PhD, European Organization for Research and Treatment of Cancer (EORTC), Professor Trevor Leong, Trans-Tasman Radiation Oncology Group (TROG Cancer Research), May Abdel-Wahab, International Atomic Energy Agency (IAEA), and Quynh-Thu Le, MS, FASTRO, NRG Oncology, will share their experiences in this exciting session.

Upon considering each of these sessions, Dr. Michalski noted that the Annual Meeting serves as a key learning opportunity, as attendees have a chance to understand how the field is evolving upon hearing the latest reports on clinical trial investigations and to participate in that evolution.

Special thanks to each of our presenters in the Presidential Symposium. Join us for the Presidential Symposium sessions and all that the Annual Meeting has to offer — register by June 29 for the Early-bird rate!

By John Buatti, MD, FASTRO, Vice-Chair, Science Council and Chair, RPT Work Group

ASTRO’s RPT Work Group has been leading efforts since 2018 to promote radiation oncologists as key leaders in the burgeoning field of radiopharmaceuticals (RPTs). To this end, in March 2023, ASTRO hosted more than 40 individuals, including academic and community practice physicians, physician scientists and industry, to engage in a dialogue between radiation oncologists and industry thought leaders about key strategic issues and opportunities related to RPTs. There was excellent engagement from participants and several priority areas emerged from the conversation:

• Supply Chain Issues. The challenges of creating and distributing RPTs once an agent is approved for therapy is a global concern. Structural and regulatory barriers were reviewed and the need for broad investment in infrastructure and engagement with government agencies was supported.


• Dosimetry. There was agreement that better understanding of dosimetry is important to achieving the optimal therapeutic potential of RPTs. However, much remains to be learned and consensus guidance is needed on key aspects of dose response both for tumor and normal tissues.


• Rational Trials Design. Another important theme that emerged was the importance of trials. This discussion included questions such as whether animal studies are valuable in the context of RPTs and whether removal or liberalization of dose limits for Phase 1 trials should be considered instead of dose extrapolation from EBRT.


• Educational Needs. Another theme that was discussed was the need to educate various stakeholders on issues related to effective practices. Better understanding by regulatory agencies and other health care disciplines about appropriate risks regarding radiation dose limits and level setting on acceptable toxicities with RPT development is needed. Failure to educate relevant stakeholders may limit the application of these highly effective agents and is a concern for industry as they bring more agents to market.

Industry leaders indicated that they would be interested in learning more about how to leverage the existing infrastructure in RO departments both to improve standardization for dosimetry and for clinical trials. To help support research, ASTRO is assembling a list of centers interested in participating in clinical trials with RPTs. If your practice currently participates in RPT and in NIH or NCTN trials and would be interested in opening industry-funded RPT trials, please contact ASTRO staff.

In addition to this inaugural stakeholder discussion, in the first half of 2023, ASTRO offered the RPT Masterclass as an add-on to the Refresher Course, with over 100 members taking advantage of this opportunity. The winter issue of ASTROnews was dedicated to RPTs, providing members with firsthand accounts on how to set up a program and gain authorized user status, patient-centered treatments and emerging advances. ASTRO also submitted comments to the International Accreditation Committee (IAC) on its proposed standards for RPTS specifically asking that the standards be modified to:

• Address patient care and management;


• Allow radiation oncologists to be the medical director of an RPT practice; and


• Allow therapy medical physicists to be the technical director of an RPT practice.

ASTRO is also in the process of updating our APEx standards for accreditation and we have posted those proposed changes, including standards to evaluate practices that offer RPTs for public comment. Please  review the proposed standards and provide your feedback.

In April, ASTRO surveyed the chairs of academic practices and learned that almost half (45%) of academic centers either have or are in the process of developing a multidisciplinary clinic for RPTs. ASTRO strongly supports multidisciplinary care and our Framework for Patient-Centered Care describes an idealized way to manage patients receiving RPT. This framework was developed to incorporate the strengths of both radiation oncologists and nuclear medicine physicians. A multidisciplinary approach requires enhanced coordination and collaboration among appropriately qualified personnel with diverse expertise in image acquisition, image interpretation, quantitative imaging, dosimetry calculation, radiation quality assurance and safety as well as oncology care and RPT-induced sequelae and response assessment. There is ample opportunity for our specialty to work alongside nuclear medicine physicians to realize the potential of these new agents.

The RPT Work Group continues to creatively advance the field of RPTs and radiation oncology’s role. If you have suggestions for other activities ASTRO can support to promote this field, please email me via ASTRO staff.