Radiation Oncology Model

UPDATE: (10/21/2020)CMS has received feedback from a number of stakeholders about the challenges of preparing to implement the RO Model by January 1, 2021. Based on this feedback, CMS intends to delay the RO Model start date to July 1, 2021. We are pursuing rulemaking to make this change.

The Radiation Oncology (RO) Model aims to improve the quality of care for cancer patients receiving radiotherapy (RT) and move toward a simplified and predictable payment system.  The RO Model tests whether bundled, prospective, site neutral, modality agnostic, episode-based payments to physician group practices (PGPs), hospital outpatient departments (HOPD), and freestanding radiation therapy centers for radiotherapy (RT) episodes of care reduces Medicare expenditures while preserving or enhancing the quality of care for Medicare beneficiaries.  The RO Model has a five-year Model performance period that begins on January 1, 2021 and runs through December 31, 2025.  

Background

Since 2014, CMS has explored potential ways to test an episode-based payment model for RT services.  In December 2015, Congress passed the Patient Access and Medicare Protection Act, which required the Secretary of Health and Human Services to submit to Congress a report on “the development of an episodic alternative payment model” for RT services.  The report was published in November 2017. The report (PDF) identified three key reasons why RT is ready for payment and service delivery reform: the lack of site neutrality for payments; incentives that encourage volume of services over the value of services; and coding and payment challenges. 

Model Design

The RO Model is a mandatory model that tests whether changing the way RT services are currently paid – via fee-for-service payments – to prospective, site neutral, modality agnostic, episode-based payments incentivizes physicians to deliver higher-value RT care. The design of the RO Model includes several key programmatic elements:

  1. Alternative Payment:
    1. Episode Payments: CMS makes prospective, episode-based (i.e., bundled) payments, based on a patient's cancer diagnosis, that cover RT services furnished in a 90-day episode for the 16 cancer types meeting the included cancer type criteria described in the final rule;
    2. Site-neutrality: The Model uses site-neutral payment by establishing a common, adjusted national base payment amount for the episode, regardless of the setting where it is furnished;
    3. Professional and Technical Payment Components: Episode payments are split into professional and technical components to allow the current claims systems for PFS and OPPS to be used to adjudicate RO Model claims and for consistency with existing business relationships.
       
  2. Linking Payment to Quality: The Model links payment to quality using reporting and performance on quality measures, clinical data reporting, and patient experience as factors when determining payment to RO participants. The Model meets the requirements to qualify as an Advanced APM and a MIPS APM under QPP.
     
  3. RO Participants in a Mandatory Model: The RO Model is a mandatory model that requires participation from RT providers and suppliers that furnish RT services within randomly selected CBSAs to participate.

RO Model Participants

A RO participant can be any of the following entities: 1) a physician group practice (PGP); 2) a freestanding radiation therapy center; or 3) a Hospital Outpatient Department (HOPD).  RO Model participants can participate in the Model as Professional participants, Technical participants, or Dual participants.  Some participants, like PGPs, can be both Professional participants and Dual participants.  

  • A Professional participant is a Medicare-enrolled PGP, identified by a single Taxpayer Identification Number (TIN) that furnishes only the PC of RT services at either a freestanding radiation therapy center or a HOPD.
  • A Technical participant is an HOPD or freestanding radiation therapy center, identified by a single CMS Certification Number (CCN) or TIN, which furnishes only the TC of RT services. 
  • A Dual participant furnishes both the PC and TC of an episode for RT services through a freestanding radiation therapy center, identified by a single TIN.

RO Model Episode Pricing

RO participant-specific payment amounts are determined based on proposed national base rates, trend factors, and adjustments for each participant’s case-mix, historical experience, and geographic location.  CMS further adjusts payment amounts by applying a discount factor.  The discount factor, or the set percentage by which CMS reduces an episode payment amount, reserves savings for Medicare and reduces beneficiary cost-sharing.  The discount factor for the PC is 3.75 percent, and the discount factor for the TC is 4.75 percent.  The payment amount is also adjusted for withholds for incorrect payments (1 percent for PC and TC), quality (2 percent for PC), and patient experience (1 percent for TC starting in 2023).  RO participants can earn back all or some of the incorrect withhold based on the amount of incorrect payments during the previous PY.  RO participants have an opportunity to earn back a portion of the quality and patient experience withholds based on clinical data reporting, quality measure reporting and performance, and the beneficiary-reported Consumer Assessment of Healthcare Providers and Systems (CAHPS®) Cancer Care Radiation Therapy Survey.  The standard beneficiary coinsurance and sequestration policies remain in effect. 

Participant Payment

Episode payments are paid prospectively in the RO Model, meaning that half of the episode payment amount is paid when the RO episode is initiated, and the second half is paid when the episode ends.  Episode payments in the RO Model are split into a professional component (PC) payment, which is meant to represent payment for the included RT services that may only be furnished by a physician; and the technical component (TC) payment, which is meant to represent payment for the included RT services that are not furnished by a physician, including the provision of equipment, supplies, personnel, and costs related to RT servicesThis division reflects the fact that RT professional and technical services are sometimes furnished by separate providers or suppliers. 

Advanced APM and MIPS APM

The RO Model is an Advanced APM and a MIPS APM under QPP.  To meet those requirements, the RO Model (1) requires RO participants to annually certify their intent to the use of Certified Electronic Health Record Technology (CEHRT), (2) includes quality measure performance as a factor when determining payments, and (3) requires RO participants bear more than a nominal amount of financial risk.  RO participants who are APM Entities and eligible clinicians seeking Qualifying APM Participant (QP) status in an Advanced APM must comply with all RO Model requirements in order to be eligible for Advanced APM incentive payments.  RO participants who do not meet the QP threshold do not qualify for the Advanced APM incentive payment and instead are in a MIPS APM.

Quality Measures

The RO Model includes four quality measures, starting in PY1. The Consumer Assessment of Healthcare Providers and Systems (CAHPS®) Cancer Care Radiation Therapy Survey will be administered starting in 2021 to determine patient experience measures used in PY3-5.  These measures allow the RO Model to apply a pay-for-performance methodology that incorporates performance measurement with a focus on clinical care and beneficiary experience with the aim of capturing a reduction in expenditures and preserving or enhancing quality of care for beneficiaries. To do this, the Model withholds 2 percent of the PC and 1 percent of the TC payments for each episode.  RO participants have the ability to earn back a portion of the quality and patient experience withholds based on clinical data reporting, quality measure reporting and performance, and the beneficiary reported CAHPS® Cancer Care Radiation Therapy Survey.  Patient experience measures based on the CAHPS® Cancer Care Survey for Radiation Therapy will be proposed through future rulemaking.  RO Participants are also required to submit clinical data elements for five cancer types (bone, brain, breast, lung, prostate) biannually.  The clinical data requirements will be provided to RO participants prior to the start of PY1.  See the RO Clinical Data Elements Informal Request for Information below.

The four quality measures are:

  • Oncology: Medical and Radiation - Plan of Care for Pain -NQF #0383; CMS Quality ID #144
  • Treatment Summary Communication – Radiation Oncology
  • Preventive Care and Screening: Screening for Depression and Follow-Up Plan -NQF #0418; CMS Quality ID #134
  • Advance Care Plan -NQF #0326; CMS Quality ID #047

Beneficiaries

CMS recognizes the importance of beneficiaries’ awareness that their RT providers and suppliers are participating in the RO Model. Therefore, all RO participants must provide a RO Model Beneficiary Notification Letter to RO beneficiaries who are included in the RO Model

Beneficiaries are still responsible for cost-sharing as under the traditional payment systems (e.g., typically 20 percent of the Medicare-approved amount for services), but because CMS is applying a discount to each of these components, beneficiary cost-sharing may be, on average, lower relative to what is typically paid under traditional Medicare FFS. As with all Innovation Center models, we monitor the RO Model to guard against any unintended consequences that might negatively impact beneficiaries.

Beneficiaries retain their freedom to choose any provider or supplier and, if they feel their care has been compromised, they should call 1-800-MEDICARE or contact their Quality Improvement Organization (QIO).

Timeline

  • 01/01/2021: RO participants begin Performance Year 1 (PY1)
  • 12/31/2025: Final performance year (PY5) ends

Events

Additional Information

Regulations and Notices

CMS Enterprise Data Management Portal (EIDM)

The CMS Enterprise Data Portal (EIDM) is the entry point for several CMS systems. Please refer to this link for instructions on how to register in the CMS EIDM if you have not already done so.

Radiation Oncology Administrative Portal (ROAP)

The ROAP is an online platform that is used to track RO participant information through the participant profile page and to allow users to access and review organizational data; update participant information and contacts; download and submit Data Request and Attestation (DRA) forms; access participant specific data, including Historical Experience and Case Mix adjustments and Performance Reports; attest to CEHRT, revise the Individual Practitioner List, and attest to participating with a Patient Safety Organization.

It is important that you access the ROAP to add/update points of contact and confirm the information in the participant list; as well as to indicate if you will choose the low-volume opt-out option, if you are eligible.

To register for ROAP, you will need your Model ID, Taxpayer Identification Number (TIN) or CMS Certification Number (CCN), first name, last name, and email address of the designated primary contact in the appropriate fields. For more information, please visit the ROAP login page.

To receive your Model ID, please call the Helpdesk at 1-844-711-2664, option 5.  Be ready to provide your TIN or CCN number to receive your Model ID (Note that you may provide your CCN by email but you may never provide your TIN by email).  You will also need to supply the first and last name of a primary contact and their email.

View the ROAP User Manual here.

The RO Model Secure Data Portal

The RO Model Secure Data Portal is the platform via which RO participants have the opportunity to request different types of files from CMS, including: beneficiary line-level claims data, episode-level data, participant-level data, as well as submit quality measures and clinical data. 

To request claims data, RO participants use a Data Request and Attestation (DRA) form, if appropriate for that RO participant’s situation, which is available on ROAP.  Throughout the model performance period, RO participants may request to continue to receive these data until the final reconciliation and final true-up processes have been completed if they continue to use such data for care coordination and quality improvement purposes.  At the conclusion of these processes, the RO participant would be required to maintain or destroy all data in its possession in accordance with the DRA and applicable law.

Further information regarding access to the RO Model Secure Data Portal will be posted here when available.

RO Connect

The RO Model Connect Site is a collaborative resource site for the RO Model. RO participants and the RO Model team use this site for sharing documents, participating in online discussions, and receiving updates about RO Model activities, among other features. The RO Model Connect Site library contains technical and operational resource documents important for program implementation, as well as audio-visual recordings, and transcripts of RO Model learning events.

Further information regarding access to RO Connect will be posted here when available.

For questions regarding the RO Model, please reach out to the RO Model Helpdesk by phone: 1-844-711-2664, option 5; or email: RadiationTherapy@cms.hhs.gov.

Last updated on:
10/21/2020