By William Hartsell, MD, FASTRO, Chair, ASTRO Health Policy Council and Howard Sandler, MD, MS, FASTRO, Chair, ASTRO Government Relations Council
On April 28, 2021, President Joe Biden declared in his State of the Union address a commitment to “end cancer as we know it,” a goal ASTRO strongly supports. Sadly, three months later, the Centers for Medicare and Medicaid Services (CMS) unveiled two policy proposals that threaten to end radiation oncology as we know it. ASTRO was prepared for the possibility of Medicare payment cuts and is rolling out a comprehensive advocacy strategy to combat these flawed policies.
Medicare is planning a draconian double whammy for radiation oncology payments starting in 2022, with significant payment cuts totaling $300 million under the Medicare Physician Fee Schedule ($140 million) and Radiation Oncology Model ($160 million). ASTRO believes these cuts contradict the president’s anti-cancer goals as well as initiatives to advance health equity. Instead, these excessive cuts will jeopardize cancer patients’ ability to receive state-of-the-art care close to home. ASTRO is disturbed that practices treating rural and underserved populations will be hit hardest, limiting their ability to provide critical services to their patients and possibly forcing patients to travel long distances for treatment.
The facts are grim. If the Physician Fee Schedule cuts are finalized, payments to radiation oncology will have plummeted by 25% since 2012. The cuts proposed for 2022 for radiation oncology are among the highest of any medical specialty, with some key services dropping by as much as 22%. This follows on radiation oncology revenues dropping by 8% in 2020, according to an American Medical Association analysis, as clinics now try to recover while treating patients with more advanced disease that require more complex and costly treatments.
Meanwhile, the Radiation Oncology Model (RO Model) discount factor payment cuts are out of step with other alternative payment models and will put practices that are required to participate in jeopardy. Combined, the constant, year-after-year threats to clinics’ financial viability and out of control administrative burden will further contribute to burnout among physician staff.
ASTRO is sounding the alarm on the impact these cuts will have on cancer patient care. ASTRO’s Health Policy Council and Government Relations Council leadership, in concert with the ASTRO Board of Directors, is focused on dramatically scaling back the cuts stemming from both the fee schedule and RO Model and has developed an advocacy plan of action. The multipronged advocacy strategy will be in high gear through the end of the year and likely beyond. It’s important that members know some of the key features of that strategy so they can actively participate in stopping the cuts.
ASTRO is directly engaging President Biden and White House officials, with the goal of applying significant pressure on CMS to reverse course. In July, ASTRO sent a strong letter to President Biden and his senior staff and is following up with high-level meetings on the collective threats of the RO Model and fee schedule cuts. ASTRO already has secured numerous media reports highlighting for Biden Administration leadership the severity and impact of the payment cuts, and more public relations outreach is in the works.
ASTRO’s health policy team is engaged in extensive policy and data analysis to identify changes that must be made to the RO Model and fee schedule to protect access to radiation therapy. We’re working closely with partners in the House of Medicine on official comment letters to influence CMS.
To further influence the regulatory process, ASTRO’s government relations team is reaching out to congressional champions to contact CMS and demand changes that finally correct the RO Model and hold radiation oncology harmless from fee schedule payment shifts unrelated to radiation oncology. ASTRO has been working with legislators in the event congressional oversight is needed, and this initiative jumpstarted during Advocacy Day in late July when 100 ASTRO members met with 160 congressional offices on the proposed cuts.
ASTRO members should be on the lookout for action alerts in the coming weeks that will encourage radiation oncology team members to directly engage in grassroots efforts to urge members of Congress to support the specialty against the cuts. But there’s no need to wait, as senators and representatives are in their home states and districts for August recess and looking to meet with their constituents ― you!
ASTRO advocacy volunteers and staff will spend the next several months aggressively executing this strategy, recognizing it will be a great challenge to force CMS to change course. Therefore, ASTRO is preparing for the potential that legislative relief will be necessary before the end of the year.
For every aspect of the advocacy strategy, ASTRO is working closely with a committed group of radiation oncology stakeholders representing health professionals, patients, hospitals, office-based clinics, device manufacturers and more. We appreciate the hard work and support of our members and partners, as a unified and devoted team is essential for success against this dire threat.
Posted: August 17, 2021
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By Casey Chollet, MD, Government Relations Committee Chair
2020. By any standard, it was a year to remember...and forget. The COVID-19 pandemic took hold over almost everyone’s energy and focus, sidelining so many routine things we previously took for granted. While the public health emergency rightly became the primary focus of our medical community, the radiation oncology field continued to face direct challenges and looming burdens on the congressional horizon. Be it the threat of a flawed RO Model, payment cuts in the 2021 Medicare Physician Fee Schedule (MPFS) or the progressive burdens of prior authorization, the ASTRO Advocacy team continued to fight for relief throughout the year.
Ultimately, 2020 closed with many victories for our community. The RO Model was delayed until at least January 2022, saving participants approximately $45 million in 2021. Payment cuts in the 2021 MPFS were significantly reduced, protecting radiation oncology from another $100 million in losses in 2021. And prior authorization reform legislation received the support of more than 280 bipartisan co-sponsors in the House, as well as a companion bill introduced in the Senate. On top of these radiation oncology victories, COVID-19 support was secured in the form of continued funding for the Provider Relief Fund that helped offset revenue declines triggered by the reduction of in-person care visits and cancer screenings.
These victories were possible only because of close collaboration between ASTRO Advocacy and our members, and strengthening this collaboration is critical to making 2021 even more successful for radiation oncology. Whether it be through participating in Advocacy Day or email advocacy campaigns, increased engagement by our membership is critical to success.
For instance, ASTRO staff lobbyists and Najeeb Mohideen, MD, FASTRO, teamed up to keep Rep. Raja Krishnamoorthi (D-IL), Dr. Mohideen’s congressman, informed about RO Model concerns. In response, Rep. Krishnamoorthi joined his colleagues in writing the HHS Secretary at the time, Alex Azar, about the need for reforms.
In 2020, ASTRO members sent over 3,200 messages to their representatives and senators advocating for our specialty: that’s almost nine messages a day! Rising to the challenge of the COVID era, 69 members participated in a virtual Advocacy Day on the Hill, attending over 90 meetings. But despite these impressive efforts, our specialty must do more to achieve our long-term policy goals. If we were able to make such a big impact in 2020 with a relatively small level of member participation, just think of the positive changes we can bring about by making our unified voice that much louder. Meaningful prior authorization reform, a viable value-based payment opportunity and sustained investment into cancer research are all possible, but they rely on your action.
Engaging your representatives and senators on these issues is easier than ever, and I encourage you to take advantage of every opportunity to support our policy goals. Write letters, send emails and engage leaders on social media. And if COVID-19 trends continue to improve in your community, please consider inviting them to visit your treatment facilities.
So, keep an eye out for those action alerts and ASTROgram stories, and be sure to check astro.org/advocate regularly. Every effort you make is another step toward improvements for our patients and our community.
Posted: April 20, 2021
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By Colin Whitney, ASTRO Government Relations Specialist
2020 has been a year of unavoidable changes and challenges. ASTRO’s annual Advocacy Day was no exception, as the original April event dates were canceled in early March. But with the release of the RO Model, steep cuts in the 2021 Medicare Physician Fee Schedule (MPFS) and increased prior authorization delays, ASTRO’s Advocacy team knew that the event was now more critical than ever.
Following ASTRO’s successful virtual Annual Meeting, the team decided to move forward with a new, virtual Advocacy Day experience on November 19-20. Virtual Advocacy Day 2020 ultimately consisted of more than 50 ASTRO members and 14 ASTRO staff meeting with 94 congressional offices. In the meetings, ASTRO members were able to share the key issues facing the radiation oncology community going into 2021 and inform Congress on action they can take to protect patients and providers. To gauge the success of this new look for Advocacy Day, we posed some questions to our participants:
Q: What were your key takeaways from this year’s Advocacy Day?
Casey Chollet, MD, chair of ASTRO’s Government Relations Committee, Tennessee Oncology, PLLC, Nashville: I have been attending ASTRO Advocacy Day since 2009 and really appreciate the extraordinary effort ASTRO staff put into making our first virtual Advocacy event a success. One of my big takeaways was that the virtual format allowed for more dedicated discussion time with the congressional staff members. It was a pleasant surprise to have a full 30 minutes to really go into the details of the critical issues facing our specialty and the accompanying congressional asks; plus, there were none of the usual interruptions that come with being in D.C. Given the unique circumstances created by the COVID-19 public health emergency, this was a welcome change from the sometimes rushed in-person meetings.
Krisha Howell, MD, Fox Chase Cancer Center, Philadelphia: My key takeaways were that ASTRO continues to work with our government officials of both parties to further the issues important to our field. It is evident from this event that the ASTRO staff has made alliances and is working hard throughout the calendar year on these concerns.
Q: Why is it important to advocate for the profession?
Anish Butala, MD, resident, University of Pennsylvania, Philadelphia: As physicians, we are not only leaders of our health care teams but are also responsible for promoting the interests of our patients and society. We are privileged to care for cancer patients, which arms us with unique insights surrounding the impact of broad legislative measures on health care policy and daily clinical practice. As such, when negatively impactful legislation is identified, it is our duty to reach out to our congressional leaders to inform them of the issues at hand and advocate for meaningful change. Doing so may not only improve the administrative and financial burdens facing our field but ultimately influence the care received by each of our patients.
Q: What advice would you give to someone who wants to get engaged in advocacy?
Dr. Butala: It can be challenging to know where to begin within this complex landscape. With this in mind, initial steps might include reaching out to a peer or colleague who has engaged in prior advocacy work to obtain their guidance. Participating in the annual Advocacy Day is an additional avenue to broaden your exposure to public policy and expand your professional network. Finally, becoming involved with ASTRO Subcommittees is another important way to gain valuable experience and advocate on our profession’s behalf.
Thomas Eichler, MD, FASTRO, chair of ASTRO, VCU Health Massey Cancer Center, Richmond, Virginia: Advocacy for our patients and our specialty can take many forms, ranging from the face-to-face interactions that occur during Advocacy Day, to sending letters and contacting your state congressional delegation via ASTRO’s Advocacy Action Center. Writing to your senators and representative is a critical and meaningful way to make your voice heard in Washington. The ASTRO Advocacy team is continually updating the center to include new campaigns focused on actions that Congress can take to address the issues of greatest urgency for our community. Participating in these advocacy campaigns takes less than a minute and lets Congress know exactly how they can help to solve the pressing challenges we face.
Social media provides another easy route to jumpstart or amplify your advocacy efforts. Retweeting #ASTROAdvocacy posts and posting directly to your representative and senators is not only easy but is an effective means of keeping our issues on their radar screen.
Thank you to all our members who participated in Advocacy Day! Learn more about the key issues addressed during the congressional visits at www.astro.org/advocacy.
Posted: January 5, 2021
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By Dave Adler, Vice President, Advocacy
The coronavirus is challenging the nation’s health care infrastructure in unprecedented ways, and radiation oncology clinics are adapting to this rapidly changing environment in response to the crisis. Similarly, ASTRO’s advocacy must adjust course on key priorities, including tackling new initiatives to support the membership’s response to this crisis and a shift to ensure a smooth transition to value-based payments, particularly at this challenging time.
On March 10, the long-awaited Center for Medicare and Medicaid Innovation’s (CMMI) Radiation Oncology Model (RO Model) moved to its final stage of review at the Trump administration’s Office of Management and Budget (OMB). This final review could last a few weeks or even months before the agency publicly releases the details of this all-important regulation for implementing the model. Even during these final days of government review, ASTRO continues to advocate strongly for necessary reforms to what CMMI proposed last summer, including major changes to the scope of the model and the payment methodology.
ASTRO has expressed concern to CMMI about the potential that one-third of all oncology practices would be required to implement the model on July 1, which CMMI has said is its goal, leaving only a few months for practices to review the final rule details and make practice changes to implement the model. ASTRO also has shared concerns about the aggressive implementation timeline with radiation oncology champions on Capitol Hill, particularly since the model has taken so long to be released.
In recent days, as the coronavirus crisis has spiked and nearly every aspect of the health care system and our daily lives have been impacted, causing ASTRO’s concern with the planned implementation timeline to be exacerbated. We are hearing from both freestanding centers and hospital-based clinics that the combined burden of addressing the coronavirus and implementing the likely mandatory RO Model would be overwhelming.
Data from China indicates that cancer patients are at greater risk of contracting the COVID-19 virus and have poorer outcomes once infected. Radiation oncology practices are making drastic coronavirus-related preparations and changes, such as postponing follow-up visits and non-urgent treatments. Practices report that non-essential staff — such as coding and billing staff that would play a major role in RO model implementation — are now working from home, while some hospitals are retraining clinical staff to help handle the expected surge in coronavirus patients.
Given this highly disruptive, but hopefully short-term emergency, ASTRO is reaching out to CMMI and Congress to discuss a delay in implementation. While ASTRO wants the RO Model, with our recommended reforms, implemented sooner rather than later, this situation necessitates delay to allow radiation oncology clinics, their patients and the broader health system to combat the crisis facing our country.
ASTRO also has heard from members that are seeking best practices for how to deal with the coronavirus, and ASTRO advocacy is working to help. ASTRO has been in contact with senior Centers for Disease Control and Prevention (CDC) officials, and we’ve requested that the agency provide coronavirus-specific recommended best practices and considerations for cancer patients. We hope to have more information from the CDC soon.
Unfortunately, due to travel restrictions placed on our members and the importance of reducing the risk of coronavirus transmission, ASTRO has cancelled Advocacy Day 2020. While this premier advocacy meeting is called off until 2021, the spirit of advocacy must continue. It’s important for the radiation oncology community to continue to push Congress and the administration for policies that support high-quality cancer care. To that end, ASTRO will be providing members with opportunities to communicate issues virtually, including direct conversations with Congress on existing priorities and new issues brought to the forefront.
Stay tuned as we roll these changes out in the coming weeks in a manner that supports your essential mission of serving your patients and communities during this challenging time. Please comment below or via the ROhub on how the coronavirus is impacting your practice and patients and how ASTRO can support radiation oncology at this time.
Posted: March 13, 2020
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By Constantine Mantz, MD, ASTRO Health Policy Council Vice-chair
In the last two weeks, I’ve joined fellow ASTRO advocacy leaders in critical meetings with senior officials at the Centers for Medicare and Medicaid Services (CMS) on a variety of pressing payment issues facing the specialty.
The Radiation Oncology Model (RO Model), of course, continues to be the focus of ASTRO’s attention, as we continue pressing the Trump administration on necessary reforms. However, with the RO Model final rule going through the last stages of administration clearance, federal rules restrict agency staff from discussing the model. ASTRO continues to expect the model to be released in 2020. Contrary to rumors, there is no delay and practices should be preparing.
The key issues on our agenda for these meetings were those keeping me, ASTRO leaders and the membership up at night: How can recent payment stability be maintained? How can new medical oncology-focused payment models ensure appropriate radiation therapy utilization?
Given that the Agency is pursuing formal rulemaking on all of these issues, the ASTRO team did not expect to hear any final answers to these key questions from the high-level staff at the CMS’ Hospital and Ambulatory Payment Group (HAPG), which oversees physician fee schedule and hospital outpatient payments, nor the senior team at the Center for Medicare and Medicaid Innovation (CMMI), which is responsible for oncology alternative payment models, including the RO Model and the next iteration of the Oncology Care Model (OCM), known as Oncology Care First. Instead, these meetings provided an opportunity for ASTRO to press our case face-to-face with decision makers, enhancing our numerous letters with real-world illustrations of how Medicare payment policy impacts clinical and business decisions on the ground in radiation oncology.
On February 4, the ASTRO team met in Baltimore with CMS HAPG senior staff to urge the agency to again extend the G codes and payment rates for treatment delivery, IMRT and image guidance delivered in freestanding centers under the physician fee schedule until the end of 2021. ASTRO initiated and extended this payment freeze through legislation, and successfully advocated for CMS to continue the freeze through its regulatory authority in 2020. As the radiation oncology community transitions to the RO Model, which has numerous components that are linked with the physician fee schedule, we argued that continued payment stability in the fee schedule is essential to ensure successful adoption of value-based radiation oncology payments.
In addition, ASTRO again discussed the need for the agency to increase reimbursement for hospital-based brachytherapy payments, most notably for cervical cancer, where there is a gap in covering the costs of the standard of care due to CMS’ approach to packaging payments. ASTRO appreciated the HAPG attention to our issues, and we look forward to seeing the direction CMS takes when the Agency releases proposed payment rules for hospitals and freestanding centers this summer.
On February 18, our team returned to Baltimore to meet with CMMI to discuss concerns that radiation therapy utilization may be shrinking inappropriately under the OCM. We focused on ASTRO’s longstanding concerns about the perverse incentives to reduce radiation therapy utilization under the OCM. Our goal was to convince CMMI to avoid replicating the problem in the next iteration of the model, and we left with a better understanding of the Agency’s goals and agreement to explore some potential fixes that ensure radiation oncologists are better positioned under the model to be equal partners in multidisciplinary cancer care with other cancer specialists.
Each time I travel to CMS offices, I’m struck by the candid and constructive discussions we have with policymakers as we work to solve the complex radiation oncology health policy problems to the benefit of our patients. While we may not always agree with the Agency, ASTRO has established itself as a credible voice with key officials, and the data and ideas we provide are treated with respect.
When the RO Model final rule and other Medicare payment rules are released in coming months, ASTRO will be ready with a strong response that protects cancer patients’ access to radiation therapy.
Posted: February 25, 2020
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