The Centers for Medicare & Medicaid Services (CMS) and the Center for Medicare and Medicaid Innovation (Innovation Center) are proposing a Radiation Oncology (RO) Model. The aim of this model would be to test whether prospective episode-based payments to physician group practices (PGPs), hospital outpatient departments (HOPD), and freestanding radiation therapy centers for radiotherapy (RT) episodes of care would reduce Medicare expenditures while preserving or enhancing the quality of care for Medicare beneficiaries. This patient-centric and provider-focused model would improve the quality of care cancer patients receive and improve patient experience by rewarding high-quality patient-centered care that results in better outcomes through a prospective, episode-based payment methodology. The RO Model would qualify as an Advanced Alternative Payment Model (Advanced APM) and a Merit-based Incentive Payment System APM (MIPS APM) under the CMS Quality Payment Program (QPP).
Since 2014, CMS has been exploring 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 (PDF) was published in November 2017. The report identified three key reasons why radiation therapy 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.
The proposed RO Model would test whether changing the current fee-for-service payments for RT services to prospective, episode-based payments incentivizes physicians to deliver higher-value RT care. The design of the RO Model includes several key programmatic elements:
- CMS would make prospective, episode-based (i.e., bundled) payments, based on a patient's cancer diagnosis, that would cover radiotherapy services furnished in a 90-day episode for the 17 cancer types meeting the included cancer type criteria;
- Required participation in selected Core Based Statistical Areas (CBSAs) would be used to test the Model;
- The Model would transition to site-neutral payment by establishing a common, adjusted national base payment amount for the episode, regardless of where it is furnished;
- Episode payments would be split into two components - professional and technical - to allow for use of current claims systems for PFS and OPPS to be used to adjudicate RO Model claims and be consistent with existing business relationships; and,
- The Model would link payment to quality using reporting and performance on quality measures, clinical data reporting, and patient experience as factors when determining payment to participants. The Model would meet the requirements to qualify as an Advanced Alternative Payment Model (APM) and a MIPS APM under QPP.
The proposed RO Model would require participation from RT providers and suppliers that furnish RT services within randomly selected CBSAs to participate. The Model participants treating beneficiaries with one of the 17 included cancer types (which make up 84% of all RT episodes) would receive prospective, episode-based payment amounts for RT services furnished during a 90-day episode of care, instead of regular Medicare FFS payments throughout the model performance period.
Episode payments in the RO Model would be 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 services. This division reflects the fact that RT professional and technical services are sometimes furnished by separate providers or suppliers.
An RO participant would be a physician group practice (PGP), freestanding radiation therapy center, or HOPD. An RO participant would participate in the Model as a Professional participant, Technical participant, or Dual participant.
- 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 a 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.
Pricing and Payment
The RO Model would take significant steps towards making prospective episode-based payments in a site-neutral manner for 17 different cancer types. The RO Model would test the cost-saving potential of prospective episode payments for certain RT services furnished during a 90-day episode, and also test whether episode payments lead to shorter courses of RT (that is, fewer doses, also known as fractions), more efficient care delivery, and higher value care for Medicare beneficiaries.
Participant-specific payment amounts would be determined based on proposed national base rates, trend factors, and adjustments for each participant’s case-mix, historical experience, and geographic location. CMS would further adjust payment amounts by applying a discount factor. The discount factor, or the set percentage by which CMS reduces an episode payment amount, would reserve savings for Medicare and reduce beneficiary cost-sharing. The discount factor for the PC would be 4%, and the discount factor for the TC would be 5%. The payment amount would also be adjusted for withholds for incomplete episodes (2% for PC and TC), quality (2% for PC), and beneficiary experience (1% for TC starting in 2022). RO participants would 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 Consumer Assessment of Healthcare Providers and Systems (CAHPS®) Cancer Care Radiation Therapy Survey. The standard beneficiary coinsurance amount and sequestration would remain in effect.
The RO Model would be an Advanced APM and a MIPS APM under QPP. The RO Model would require RO participants to annually certify their intent to use of Certified Electronic Health Record Technology (CEHRT), include quality measure performance as a factor when determining payments, and bear more than a nominal amount of financial risk. RO Model 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. Participants who do not meet the QP threshold would not qualify for the Advanced APM incentive payment and instead would be in a MIPS APM.
CMS recognizes the importance of beneficiaries being aware that their RT providers and suppliers are participating in the RO Model. Therefore, all professional RO participants must provide a RO Model Beneficiary Notification Letter to Medicare beneficiaries receiving treatment from them.
Beneficiaries would still be responsible for the same cost-sharing as under the traditional payment systems (e.g., typically 20% of the Medicare-approved amount for services), but because CMS would be applying a discount to each of these components, beneficiary cost-sharing may be, on average, lower relative to what typically would be paid under traditional Medicare FFS. As with all Innovation Center models, we would monitor RO Model to guard against any unintended consequences that might negatively impact beneficiaries.
The proposed Radiation Oncology Model is included in the Medicare Program; Specialty Care Models to Improve Quality of Care and Reduce Expenditures Notice of Proposed Rule Making. The public comment period for the Notice of Proposed Rule Making closed on September 16, 2019.
The Specialty Care Models to Improve Quality of Care and Reduce Expenditures Notice of Proposed Rule Making proposed that the Radiation Oncology Model would begin on January 1, 2020. As this date has already passed and we have not yet issued a final rule, the Radiation Oncology Model, if finalized, would not begin on this date. If finalized, we would provide information on the effective date of the Radiation Oncology Model in the final rule.
The Fall 2019 Unified Agenda lists the Specialty Care Models to Improve Quality of Care And Reduce Expenditures Final Rule (CMS-5527-F) as a long-term action with a final action date of July, 2022 and includes the following procedural language:
- “We schedule all Medicare final regulations for publication within the three-year standardized time limit in the current Unified Agenda. We do not intend to delay publishing a Medicare final regulation for three (3) years if we are able to publish it sooner.”
By statute, there is a three (3) year window from the time a Notice of Proposed Rulemaking (NPRM) is published to when a Final Rule must be published, or a new NPRM would need to be issued. This procedural language is not specific to the Radiation Oncology Model or potential finalization of the Model, and the date listed in the Unified Agenda does not indicate the date on which a final rule for the Radiation Oncology Model, if finalized, would be published. Every regulation goes through a clearance process for which the timing varies.
- RO Episode File (2015-2017) (XLS)
- HCPCS_CD Chemotherapy Codes File (CSV)
- NDC Chemotherapy Codes File (CSV)
- Major Procedures File (CSV)
- RT Expenditures by Time (PDF)
- Data Dictionary (PDF)