By Geraldine Jacobson, MD, MBA, MPH, FASTRO, ASTRO Chair; Connie Mantz, MD, FASTRO, Health Policy Council Chair; and Catheryn Yashar, MD, FASTRO, Health Policy Council Vice-chair

On June 23, ASTRO’s Board of Directors approved pursuing legislation to create a new Radiation Oncology Case Rate (ROCR) payment program under traditional Medicare, which would:

• Change radiation oncology payment from per fraction to per patient.
• Reverse decade-long declines in Medicare payments.
• Usher in a new era of stable payments, higher quality care, and reduced disparities.

ROCR represents a bold initiative to reverse disastrous Medicare payment trends. ASTRO believes ROCR is our best chance to secure long-term rate stability and continue to deliver cutting-edge care to patients close to home. ASTRO is seeking feedback on ROCR with the goal of securing broad support from the radiation oncology community before advancing this legislative proposal in Congress.

Background:

Medicare spends less on all radiation oncology treatments than it spends on just three top cancer drugs; yet radiation oncologists treat more than twice the number of beneficiaries. Despite its high value, radiation oncology has faced more payment cuts than nearly all other specialties through a combination of direct cuts and policy proposals that shift resources from specialty care to primary care. More cuts are likely to come.

The Facts:

• Medicare has cut RadOnc payments by more than 20% over the last 10 years.
• Practice costs are rising, as equipment and staff are getting more expensive.
• More Medicare beneficiaries are receiving radiation therapy.
• The current payment system penalizes the use of shorter treatment regimens.
• The CMS RO Model failed due to excessive payment cuts and administrative burden.

Without stable payments, access to care and quality will suffer and the field will struggle.

Radiation therapy is primed to make great gains for cancer patients, but the current Medicare payment system is prohibiting the investments necessary to achieve those goals. ASTRO refuses to let the status quo of cuts and failure of the RO Model stand in the way of radiation oncologists who are committed to providing greater value to their patients. The specialty needs to look forward and act now.

ASTRO has invested significant time and resources in developing this new Medicare payment system for radiation oncology. Developed by ASTRO’s Health Policy Council physician leaders from various practice settings and with the help of expert consultants, the ASTRO Board approved ROCR as a proposal in June after numerous versions were evaluated and analyzed.

Several practices, including private practices (freestanding and hospital based) and academic centers, modeled ROCR using the tool linked below and determined ROCR was favorable in comparison to expected Medicare fee-for-service payments.

Why ROCR?

Because it:

• Addresses the instability of the current payment systems;
• Aligns financial incentives with clinical guidelines;
• Ensures use of quality assurance and improvement standards;
• Reduces disparities by helping underserved patients initiate, access and complete treatments;
• Uses a more simplified approach than the CMS RO Model;
• Unifies payment that levels the playing field across care delivery settings;
• Updates payments annually based on medical inflation trends.

ROCR has precedent in past payment reforms for capital intensive health care services, such as End Stage Renal Disease, which is paid on a prospective basis.

ROCR Ins and Outs

• All radiation oncology practices participating in Medicare.
• Professional and technical services paid under Medicare physician fee schedule and hospital outpatient prospective payment system for 15 common cancer types.
• External beam modalities and associated services.
  • Conventional, IMRT, SRS, SBRT

• Services delivered in inpatient hospitals, ASCs, PPS-exempt cancer hospitals.
• Medicare Advantage and commercial insurance payments.
• New Technology and Services (without Cat 1 CPT codes).
  • i.e., Adaptive RT
• Services without national Medicare prices.
  • Proton therapy, surface guidance
• Lower volume services.
  • Protons, brachytherapy, radiopharmaceuticals

Excluded technology and services potentially eligible for inclusion in future years.

How does ROCR work?

1. Payment rates and RVUs are derived from “M code” case rates published by Medicare in 2022 for technical and professional payments for 15 cancer types.
   1. ASTRO’s consultants validated the accuracy of these unified payment rates.
   2. Half of the payment will be paid at the start of the radiation treatment.
   3. Final payment will be made at the end of the course of treatment.
2. Applies annual inflationary payment updates.
   1. Professional payments updated by the Medicare Economic Index.
   2. Technical payments updated by the Hospital Inpatient Prospective Payment System market basket update.
3. Applies a savings adjustment, which is phased in over five years. 
   1. Savings adjustment would reduce Medicare radiation oncology spending by slightly more than $200 million over five years, which is about 1% of total Medicare spending on radiation oncology each year or about $17,500 per practice, per year.
   2. Savings are needed for Congress to even consider ROCR.
   3. Savings are primarily derived from technical payments.
      1. ASTRO estimates ROCR’s level of savings to be less than what is likely to happen if current payment and hypofractionation trends continue.
4. Provides a Health Equity Achievement in Radiation Therapy (HEART) payment of $500 per patient to technical payments to cover transportation services for underserved patients.
   1. Triggered by using a standardized screening question and billing code.
5. Provides a technical payment incentive to earn/maintain practice accreditation, which is well accepted by radiation oncology clinics for assessing and improving quality of care.
   1. First three years, accredited practices receive a .5% positive payment adjustment.
   2. After three years, practices would receive a -1.0% adjustment for lack of accreditation.
6. Applies geographic adjustments and the federally mandated cut of 2%, per current law.

What’s next?

Practices are encouraged to use the modeling tool to compare payments under ROCR to trended fee-for-service payments. Tell us how your practice would perform under ROCR.

• Keep in mind that the tool does not account for additional expected Medicare payment cuts under the fee schedule and the continued impact of increasing hypofractionation on technical revenues.

Review the full ROCR report, technical analysis and modeling tool. We want to hear from you — please send us your feedback via email to Health Policy.

Read the draft letter to Congress and if you agree with ROCR, indicate your practice or organizational support by filling out this form.

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.