番茄社区

WASHINGTON -- The Biden administration's Center for Medicare & Medicaid Innovation (CMMI) is currently full steam ahead with its mandatory radiation oncology model for Medicare payment, and physician groups are not happy about it.

"We are totally, adamantly against mandatory models," Ted Okon, MBA, executive director of the Community Oncology Alliance (COA), said in a phone call, quickly adding that this does not mean his group doesn't support experimenting with Medicare payment reform. "We at COA are so invested in oncology payment reform that no one can accuse us of wanting to hold back the days of fee-for-service and not push payment reform. Go to our ; you will see a map of the United States with 35 different models and practices that are participating."

However, "mandatory models, by definition, violate the spirit of CMMI, which we totally support as a great concept," he continued. Instead of instituting a mandatory model, CMMI should be hewing to its original concept as outlined in the Affordable Care Act and "piloting [voluntary] phase one models, then turning them into broader phase two models, which should be done in collaboration with stakeholders ... Mandatory models are like castor oil -- they're shoved down your throat."

Three Reasons for Reform

The radiation oncology model started as a result of the Patient Access and Medicare Protection Act passed by Congress in December 2015, as the Centers for Medicare & Medicaid Services (CMS) about the model. The act required the Secretary of Health and Human Services to submit to Congress a report on "the development of an episodic alternative payment model" for radiation therapy services, CMS noted. The and listed three reasons why radiation therapy needed payment reform:

• No site neutrality. Under the Medicare fee-for-service system, Medicare pays a lower rate for radiation therapy (RT) provided at a freestanding community radiation therapy center than for the same therapy provided at a hospital outpatient department. "This difference in payment rates may incentivize Medicare providers and suppliers to deliver radiation therapy services in one setting over another, even though the actual treatment and care received by Medicare beneficiaries for a given modality is the same in both settings," the fact sheet said.
• Incentivizing volume over value. Incentives in the current fee-for-service system encourage clinicians to provide more services, rather than to just provide those with the most clinical value. "These incentives are not always aligned with what is clinically appropriate for the beneficiary," CMS noted. "For example, for some cancer types, stages, and beneficiary characteristics, a shorter course of RT treatment with more radiation per fraction may be clinically appropriate."
• Coding and payment issues. The agency "determined that there are difficulties in coding and setting payment rates appropriately for radiation therapy services," the fact sheet stated. "These difficulties have led to pricing changes for these services under the physician fee schedules (e.g., payment reductions) and coding complexity across both [the Physician Fee Schedule and the Hospital Outpatient Prospective Payment System]."

Under the radiation oncology payment model, Medicare will "make prospective, modality agnostic, episode-based payments in a site-neutral manner for 16 different cancer types," according to CMS, which also said the model "is expected to improve the beneficiary experience by rewarding high-quality, patient-centered care and incentivizes high-value radiation therapy that results in better patient outcomes."

Implementation Delayed

The model was originally supposed to start Jan. 1, 2021 but has been delayed until January 2022; it will require mandatory participation from clinicians practicing in certain U.S. Postal Service zip codes. RT providers within the selected zip codes perform services representing about 30% of all eligible fee-for-service radiotherapy episodes nationally, CMS said; a list of the affected zip codes is .

The payments will be made in two parts: one when the therapy begins and the other when the therapy ends; the amount will include reimbursement for RT services furnished during a 90-day care episode. Payments will include both a professional component for services provided by a physician, and a technical component for services provided by non-physician personnel, as well as supplies and equipment.

Payment rates for each participant will be determined by a number of factors including a national base rate, the participant's case mix, and the participant's geographic location. In addition, CMS is applying a "discount factor" -- or payment reduction -- of 3.75% for the professional component and 4.75% for the technical component to "reserve savings for Medicare and reduce beneficiary cost-sharing."

There will also be "withholds" for incorrect payments (1% for both the professional and technical components), quality (2% for the professional component), and patient experience (1% for the technical component starting in 2023). Model participants can earn back all or some of the withholds under various scenarios involving their clinical data reporting and quality measure reporting and performance, as well as patient surveys.

Disappointment Over Discount Factor

Radiation oncologists expressed disappointment with various parts of the model, including the discount factor. "These discounts are problematic for a couple of reasons," said Constantine "Connie" Mantz, MD, a radiation oncologist in Cape Coral, Florida and chair of health policy for the American Society for Radiation Oncology (ASTRO). For one thing, the Medicare and CHIP Access Reauthorization Act of 2015 (MACRA) requires that physicians joining in advanced alternative payment models such as this one put a minimum of 3% of their income at risk, not 3.75% or 4.75%, Mantz said in a phone call.

Another issue is that "unlike other fields of medicine where costs are flexible, they are not flexible in radiation therapy; they are extremely inflexible," Mantz continued. "We make commitments in purchasing expensive equipment to install in our facilities and departments, and those costs are fixed over the life of the equipment. If payments change drastically, we don't have a way to accommodate to those shifts through our operating expenses."

This is in contrast to medical oncology, "where a lot of the expense ... is in the inventory of drugs, and medical oncologists can decide that if reimbursement changes drastically, they could simply exchange one set of drugs for another, so that they can meet their costs and still treat patients," he added. "We can't do that in radiation therapy, so we have very little flexibility in our costs. Any discounts, particularly those that are in excess of what is absolutely required, create conditions of financial jeopardy for these operations. And so for those reasons, we really would like Medicare to consider rolling back the discount factors to 3% as MACRA requires."

Will the Biden administration listen to the oncology community's concerns? Mantz has some hope that it will. "The current administration has expressly stated that it intends to have all agencies of government address inequity in services for disadvantaged groups, and in medicine, those patient groups are rural patients and minority groups, for which there is already data to demonstrate that under current fee-for-service, there are gaps in providing high-quality, high-value services to these patients," he said. "So we feel that we can appeal to that stated goal of the current administration and ask that some of these deep discounts can be at least partially redressed, so that providers can continue to improve their technical service offerings, and provide the level of care necessary to begin to close these gaps that are already observed among certain patient groups."

番茄社区 emailed CMS to ask for comment on this story, in particular on concerns raised in a written last year by ASTRO, including that the model oversampled rural oncology practices, that it had no positive payment incentives, and that there was -- when the summary was written -- no hardship waiver for smaller practices. Regarding the possible rural oversampling, "the selection methodology is based on Core-Based Statistical Areas (CBSAs) only, which are large geographic areas with an urban core," the spokesperson said in an email. "Of the Zip codes included in the CBSAs randomly selected for participation in the RO Model, less than 6% are deemed rural by the most recent rural-urban commuting area classification, and of these Zip codes less than half include radiation therapy providers and suppliers."

Regarding the lack of positive incentives, the spokesperson noted that "model participants can potentially earn a positive payment adjustment through the Quality Payment Program, as the model is considered an Advanced Alternative Payment Model (APM) and a Merit-Based Incentive Payment System (MIPS) APM. Eligible clinicians who are Professional participants and Dual participants may potentially become Qualifying APM Participants (QPs) who earn a 5% APM Incentive Payment and are excluded from the MIPS reporting requirements and payment adjustments."

As for the hardship waiver, the spokesperson said that the model now "includes a low-volume exception for practices that fall below certain episode thresholds. In response to stakeholder feedback, and in light of the current public health emergency and several recent natural disasters, CMS is also proposing to adopt an 'extreme and uncontrollable circumstances' policy. This policy would provide flexibility to reduce administrative burden of model participation, including reporting requirements, and/or adjust the payment methodology as necessary."

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