By Constantine Mantz, MD, FASTRO, Chair ASTRO Health Policy Council, and Anne Hubbard, ASTRO Director of Health Policy
On November 7, the Center for Medicare and Medicaid Innovation (CMMI) issued Person-Centered Innovation – An Update on the Implementation of the CMS Innovation Center’s Strategy. The “update” report builds on the October 2021 Innovation Center Strategy Refresh document by establishing baselines and targets for each of the following five key objectives:
- Drive accountable care.
- Advance health equity.
- Support innovation.
- Address affordability.
- Partner to achieve system transformation.
CMS also introduced a strategy to improve access to high-quality integrated specialty care focused on four key areas:
- Enhance transparency in clinician performance.
- Continue deployment of episode payment models that align with ACOs and primary care, including mandatory models.
- Support specialists to further embed primary-care focused models.
- Create incentives within population-based models to encourage specialty care integration.
According to the document, CMMI plans to assess data shared in current specialty and population-based models and programs and determine how it can be refined and enhanced to support greater coordination and integration between primary and specialty care. The Agency specifically points to the Comprehensive Joint Replacement (CJR) Model, Bundled Payments for Care Improvement (BPCI) Advanced and Enhanced Oncology Model (EOM) as examples of episode-based payment models that can be used to align incentives between specialists, primary care and Accountable Care Organizations (ACOs).
Additionally, the Agency highlights recent modifications to the BPCI-Advanced model that are designed to maintain momentum among providers and health systems that are participating in that program. Specific modifications include a two-year extension of the model and a reduction of the discount factor from 3% to 2%, as well as a reduction in the Peer Group Trend Factor Adjustment from 10% to 5%. CMMI hints that it will be releasing a new mandatory episode-based payment model that builds on the lessons learned from the BPCI, BPCI-Advanced and the CJR models. The Agency does not provide any details about this new mandatory initiative other than to say that it believes a mandatory approach can improve and standardize care for beneficiaries across hospital-based and post-acute care transitions, while also avoiding risk selection in participation decisions. The Agency also underscores its commitment to models that focus on special patient populations, including patients with cancer, with the implementation of the EOM in July 2023.
Finally, CMMI is seeking opportunities to create financial incentives for specialists to affiliate with population-based payment models, allowing more specialists to move toward value-based payment. This includes establishing incentives that allow for greater management and integration of specialty care within population-based models.
Implications for Radiation Oncology
The update represents a renewed interest in episode-based payment models. This is a shift from the prior Strategy Refresh document, which indicated that the Agency was focused on the establishment of broader total cost of care (TCOC) and ACO concepts. Since the issuance of the Strategy Refresh document, and the subsequent introduction of the REACH Model, which was an ACO concept, the Medicare Payment Advisory Commission (MedPAC) and the Physician Focused Technical Advisory Committee (PTAC) have raised questions regarding the implications of broader approaches to value-based payment. These discussions have included interest in exploring episode-based approaches for distinct components of care that can be nested within broader value-based payment programs. These discussions seem to have not only influenced the document but also given CMMI an opportunity to consider revisions to existing episode-based payment models that incentivize participation, such as the BPCI-Advanced payment methodology revisions that reduce financial risk.
While it is disappointing that the Agency remains committed to mandatory models, the focus on revising payment methodologies to incentivize participation is a positive development. Additionally, CMMI’s renewed interest in episode-based payment and integration of specialty care into broader value-based payment initiatives indicates that, while the RO Model has been indefinitely delayed, the Agency is establishing a pathway for similar concepts to be implemented. This underscores the importance of continuing ASTRO’s efforts around payment reform, particularly related to episode-based payment model development approaches that stabilize payment, protect access to care and ensure appropriate use of radiation therapy in the treatment of cancer.
For more information about the program, CMMI will be hosting a Specialty Care Strategy Listening Session on December 1, 2022, at 1:00 p.m. Eastern time. This event will cover the following topics:
- Overview of CMS Innovation Center Specialty Care Models and the rationale for focusing on specialty care integration.
- Overview of the Specialty Care Strategy.
- Guest panelist feedback on the Specialty Care Strategy.