Whether in or out of the RO Model, 2021 Could be a Struggle for Radiation Oncology

By Anne Hubbard, Director, Health Policy, and Bryan Hull, Assistant Director, Health Policy

Proposed Medicare payment policies set to start January 1, represent significant financial challenges for radiation oncology practices as they enter the new year, regardless of whether or not your practice is participating in the Radiation Oncology Alternative Payment Model (RO Model). Despite many practices experiencing revenue declines of 20-30% in 2020, the Centers for Medicare and Medicaid Services (CMS) is pushing ahead with massive cuts for radiation oncology and other specialties.

In August 2020, CMS issued the 2021 Medicare Physician Fee Schedule (MPFS) proposed rule effective January 1, 2021. The MPFS proposed rule includes significant cuts that will be implemented broadly across the field of medicine. Subsequently, on September 18, 2020, the Center for Medicare and Medicaid Innovation (CMMI) issued a final rule establishing a Radiation Oncology Alternative Payment Model (RO Model), effective January 1, 2021. The RO Model also includes significant payment cuts due to the payment methodology that involves discounts and withholds.

ASTRO is fighting hard to reverse these pending cuts, which are unwarranted and will potentially lead to serious access to care issues across the country. We have engaged ASTRO’s congressional champions and have contacted the highest levels of leadership within the Department of Health and Human Services to intervene. That said, ASTRO members must be aware of just how dire the consequences are for the field. Below is an overview of what practices can expect in 2021. Be forewarned, the outlook is grim.

Medicare Fee-for-Service Payments

Under fee-for-service payments, which will continue to apply to the professional component payments of those practices not participating in the RO Model, providers are paid according to patient care delivered based on the provisions of the MPFS. The Impact Table below (Table 90 of the 2021 MPFS proposed rule) shows the estimated impact on total allowed charges for radiation oncology based on the relative value unit (RVU) changes contained within the proposed rule.

The expected impact on radiation oncology is a combined reduction of 6% on payment rates for 2021. These reductions are specifically related to modifications of the Evaluation and Management (E/M) codes that create a shift in payments across all specialties resulting in a reduction to the Conversion Factor (CF) of more than 10% to comply with the statutorily mandated budget neutrality requirement.

Table 90: CY 2021 PFS Estimated Impact on Total Allowed Charges by Specialty

Specialty Allowed Charges (mil) Impact of Work RVU Changes Impact of PE RVU Changes Impact of MP RVU Changes Combined Impact
Radiation Oncology and Radiation Therapy Centers $1,803 -3% -3% 0% -6%
Total $96,557 0% 0% 0% 0%

Upon closer analysis, the budget neutrality adjustment results in even greater variation across radiation oncology services. For instance, CPT code 77014, Computed tomography guidance for placement of radiation therapy fields, is expected to see an 11% reduction in payment under fee-for-service billing in 2021. In addition, CPT code 77301, IMRT plan, including dose-volume histograms for target and critical structure partial tolerance specifications, is expected to see a 7% ($129.76) reimbursement cut for 2021. Of note, CMS proposed RVU increases for several key radiation oncology codes; however, the budget neutrality adjustment largely offset those increases. The table below demonstrates the impact of the CF reduction on key radiation oncology services.

CPT Code CPT Descriptor 2020 National Rate 2021 Estimated National Rate 2021 Impact
77014 CT scan for therapy guide $46.20 $40.97 -11%
77300 Radiation therapy dose plan $33.56 $30.00 -11%
77301 Radiotherapy dose plan IMRT $432.72 $387.12 -11%
77334 Radiation treatment aid(s) $62.80 $55.49 -12%
77014 CT scan for therapy guide $124.51 $117.75 -5%
77263 Radiation therapy planning $174.31 $156.14 -10%
77290 Set radiation therapy field $508.15 $472.93 -7%
77300 Radiation therapy dose plan $67.85 $62.58 -8%
77301 Radiotherapy dose plan IMRT $1,949.22 $1,819.46 -7%
77336 Radiation physics consult $81.20 $78.71 -3%
77338 Design MLC device for IMRT $497.32 $448.09 -10%
77373 SBRT delivery $1,230.67 $1,110.39 -10%
77427 Radiation tx management x5 $196.33 $175.82 -10%
G6002 Stereoscopic x-ray guidance $76.51 $72.26 -6%
G6012 Radiation treatment delivery $262.74 $251.31 -4%
G6013 Radiation treatment delivery $263.10 $251.95 -4%
G6015 Radiation tx delivery IMRT $369.92 $365.83 -1%

ASTRO is engaged in a comprehensive advocacy campaign to mitigate or postpone the expected cuts for 2021. In collaboration with a broad coalition of physician and non-physician health care provider organizations, ASTRO has urged Congress in a letter to waive the budget neutrality requirement for 2021 in any forthcoming health-related legislative package to provide relief from the reimbursement cuts associated with the MPFS updates. ASTRO’s congressional allies have also been contacted and are aware of the significant impact these cuts have on the profession. In addition to congressional action, ASTRO provided CMS with substantial comments in response to the 2021 MPFS proposed rule addressing how the budget neutrality adjustment poses a significant threat to the profession, which is already suffering significant losses as a result of the COVID-19 public health emergency (PHE). ASTRO urged CMS to use its authority under the PHE to waive the budget neutrality requirement for at least another year, allowing practices time to recuperate from significant losses already suffered in 2020.

RO Model Payment Rates for 2021

For those practices required to participate in the RO Model, it’s bad news as well. ASTRO has documented and is advocating for significant changes to the RO Model payment methodology, which layers a series of deep cuts on participants. But one aspect of the RO Model payment methodology, a “Trend Factor,” is influenced by the MPFS and Hospital Outpatient Prospective Payment System (HOPPS) and deserves greater scrutiny in light of the PFS cuts discussed above.

The Trend Factor serves as an annual update to the payment methodology by reflecting utilization and payment changes outside the Model, i.e., the MPFS and HOPPS. For 2021, the Trend Factor will use 2018 utilization data and 2021 MPFS and HOPPS data to establish an update to the RO Model payment methodology. Due to the anticipated reduction in the 2021 MPFS rates, the Trend Factor is likely to put additional undue financial strain on radiation oncology practices participating in the Model.

Practices participating in the RO Model are already subject to discount factors of 3.75% off the Professional component payment and 4.75% off the Technical component rates, as well as payment withholds for quality measures performance and incorrect payments. These reductions will be compounded by a low or potentially negative Trend Factor. This “double whammy” rate reduction is a disservice to practices that are compelled to participate in the Model, which is particularly disappointing given that the purpose of the RO Model was to establish rate stability over time. By establishing a Trend Factor that fluctuates based on the whims of the MFPS and HOPPS, CMS has effectively eroded the stability that practices thought they might be able to secure under the RO Model.

ASTRO has raised concerns regarding the RO Model’s aggressive implementation timeline and cuts with our congressional champions, as well as those at the highest levels of the Department of Health and Human Services (HHS). We are urgently seeking a delay in the RO Model’s implementation date of January 1, 2021, so that practices have more time to prepare for implementation. This will also allow for additional time to address the flaws in the payment methodology, which, as they currently stand, equate to a series of cuts on radiation oncology services.

As we enter the last quarter of 2020, a year that has been fraught with tragedy, we are bracing ourselves for further struggles in 2021, with serious potential for more financial instability.  Whether your practice is in or out of the RO Model, Congress needs to hear your voice about the direct impact of these flawed policies. Go to https://www.astro.org/Advocacy/Become-an-Advocate and join the fight for the future of radiation oncology.

Posted: October 19, 2020 | with 1 comments
Filed under: Health policy

A persistent revenue loss or most practices is due to treatment restrictions imposed by insurance companies through Evicore and other intermediaries. In addition to Evicore's new Hypofractionation mandate for breast and prostate cancers, which ASTRO has opposed, they also limit treatments and 3-D or IMRT for many cancers. For the growing number of Medicare Advantage patients,The Evicore Guidelines preface states that "the coverage policies of CMS take precedance over eviCore's guidelines". I believe equal treatment for Medicare Advantage vs Medicare patients is a CMS mandate.
Unfortunately the insurance carriers in our area do not honor this and make coverage determinations based on Evicore approvals and not the Medicare carrier policies.
Do we have any legal or other recourse to fight this policy that can result in considerable revenue loss and compromise patient care? Has ASTRO tried to intervene?.
10/22/2020 10:32:23 AM

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