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 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.