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:

1. Drive accountable care.
2. Advance health equity.
3. Support innovation.
4. Address affordability.
5. Partner to achieve system transformation.

CMS also introduced a strategy to improve access to high-quality integrated specialty care focused on four key areas:

1. Enhance transparency in clinician performance.
2. Continue deployment of episode payment models that align with ACOs and primary care, including mandatory models.
3. Support specialists to further embed primary-care focused models.
4. 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.

By Howard Sandler, MD, MS, FASTRO, and Constantine Mantz, MD, FASTRO

ASTRO members are frustrated by the scourge of restrictive and burdensome prior authorization requirements that frequently result in care delays or outright denials of coverage, and ASTRO is dedicating significant advocacy resources, across the Health Policy and Government Relations Councils, to this issue.  In member surveys, radiation oncologists consistently rank prior authorization as the top challenge facing practices, and ASTRO has conducted and publicized numerous studies demonstrating the negative impact of prior authorization on patients and practices.

The Health Policy Council’s Payer Relations Committee (PRC) engages with Radiation Oncology Benefit Managers (ROBM) and payers to educate them on appropriate coverage and directly advocate on behalf of members that are experiencing delays or denials for standards of care that are reasonable and appropriate. In addition to regular communications with ROBMs and payers, ASTRO issues Model Policies for each radiation therapy modality of treatment that are designed to educate payers on appropriate coverage based on clinical evidence. ASTRO also provides ROBMs and payers with a copy of the ASTRO Radiation Oncology Coding Resource and access to webinars that detail appropriate coverage policies. Despite these efforts, ASTRO members continue to face restrictive coverage policies, some of which are described below.

eviCore, a ROBM that contracts with many payers, has determined that conventional fractionation schemes for breast and prostate cancer are no longer medically necessary. They will only approve hypofractionation, which is a shorter course of treatment, for these two disease sites. This restrictive policy ignores the fact that some patients have certain clinical characteristics that are more suitable for longer course treatments. ASTRO has pushed back on this policy, as it is merely designed to save money.  Additionally, it does not take into consideration the clinical characteristics of the patient, nor does it recognize the important role of shared decision making between a doctor and their patient. Despite our efforts, eviCore refuses to reconsider this policy.

Another issue ASTRO frequently hears about is complaints regarding eviCore’s peer-to-peer reviews. These coverage determination reviews have increased dramatically during the COVID-19 PHE, consuming significant amounts of physician time and causing a high level of frustration. ASTRO members frequently report that peer reviews often involve a physician that is not a radiation oncologist, resulting in inappropriate denials and delayed care. In order to help address the issue, ASTRO has devoted a section of its website to house sample ROBM appeal form letters that radiation oncology practices have successfully used to appeal denials. This allows practices across the radiation oncology community to share letters with other radiation oncologists to help save time and administrative burden associated with growing denials and delays in care.

Private payers are also utilizing prior authorization as part of their coverage review process. ASTRO has written numerous letters to payers about inappropriate prior authorization denials and restrictive medical policies. ASTRO sent a comment letter to eviCore on their oligometastases policy, after several members reported receiving denials that did not align with current guidelines.

UnitedHealthcare (UHC) recently announced the establishment of a prior authorization electronic portal for approval of all the following services: IMRT, PBT, SBRT and IGRT; “Special and Associated radiation therapy services;” and fractionated breast, prostate and lung cancers, and bone metastasis. This list encompasses a significant portion of the services delivered by radiation oncologists. ASTRO’s Payer Relations Committee, Health Policy Committee and Clinical Affairs and Quality Council met with UHC to emphasize the negative impact this policy would have on radiation oncologists and their patients. UHC made modest modifications; however, members still report delays in patient care and other administrative burdens despite the electronic format.

ASTRO supports professionally developed and vetted clinical practice guidelines, appropriateness of care criteria, and consensus-based model policies developed in a transparent manner with peer review and input as a foundation for clinical decision making. We oppose restrictive practice guidelines that oversimplify the process of individual patient management and abrogate the professional judgments that are often only possible within the private boundaries of a direct patient-doctor relationship.

With prior authorization out of control, one of ASTRO’s top advocacy priorities is to push Congress and Medicare to intervene. ASTRO has sent numerous letters to the Centers for Medicare and Medicaid Services describing how restrictive prior authorization practices are keeping patients from the care they need and the care they have paid for in premiums. Congress is getting closer to passing ASTRO-backed legislation to enact significant prior authorization reforms. Passage of the Improving Seniors Timely Access to Care Act may possibly occur later this year, as now more than 330 representatives and senators have cosponsored the bill. The bill was a priority focus during ASTRO Advocacy Day, as radiation oncologists pressed their members of Congress during more than 100 meetings in May to advance the legislation.

ASTRO is committed to reining in excessive prior authorization, and we encourage members to voice their concerns directly to members of Congress via ASTRO’s grassroots system and social media. If you are experiencing difficulties with eviCore or payers, please contact Emilio Beatley, ASTRO Health Policy Analyst, so we can provide resources and engage on your behalf.

By Jan Dragotta, Radiation Oncology Services Director, Princeton Radiation Oncology, Astera Cancer Care

ASTRO’s annual Coding and Coverage Seminar is an excellent opportunity for those involved in the field of radiation oncology to gain more insight into CPT^® coding guidance, billing practices and the evolving challenges medical professionals face in the radiation oncology field today. As an attendee of the Coding and Coverage Seminar, I was surrounded by professional coders and billers, practice administrators and radiation oncologists who experience these same challenges every day. The ASTRO virtual Coding and Coverage Seminar allows for engagement and discussion among participants, which is invaluable, particularly as practices find themselves spread thin and unable to travel due to COVID-19. Attendees have direct access to ASTRO faculty and staff, and I was impressed with the ease with which questions were answered and dialogues transitioned to group discussions throughout the program and after.

As someone who has attended the Coding and Coverage Seminar, I can speak to how highly interactive and informative the sessions are. The ASTRO faculty involved in the seminar included subject matter experts who write ASTRO’s Coding Resource, which serves as a textbook for the seminar and benchmark for best practice. It is a wonderful opportunity to engage in conversations and interact on coding issues, with a heavy emphasis on the clinical process of care. Case studies are presented on intensity-modulated radiation therapy, brachytherapy, proton beam therapy and stereotactic radiosurgery/stereotactic body radiation therapy for a variety of disease sites. These studies are a great tool for discussion and help attendees learn how to apply their newfound coding knowledge and provide specific coding guidance related to each scenario.

The seminar is a wonderful way to not only understand how to correctly use the CPT codes for radiation oncology, but to also understand some background information on the process of code development and valuation. Specific coding changes that are set to occur in the new year are discussed, and attendees can ask questions and gain clarity on this complex subject, helping practices avoid coding and billing errors. Faculty of the Coding and Coverage Seminar genuinely enjoy the opportunity to engage with attendees and help them navigate some of the more complex nuances of radiation oncology coding.

Additional topics covered during the seminar include sessions on the RO Model and Merit-based Incentive Payment System (MIPS), payer policy changes and other hot topics impacting the field of radiation oncology.  It’s a day well worth spending with ASTRO! I would encourage anyone with a responsibility for coding and those who want to learn more in order to grow within their profession to register for the upcoming December 11 event. An added bonus is that the electronic and hard copy versions of the ASTRO Radiation Oncology Coding Resource is included with your registration, an invaluable reference both during and after the program.