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ASTRO Calls for Voluntary Start, Scaling Back Excessive Cuts in CMS' Proposed Radiation Oncology Model
Paul Harari, MD, FASTRO
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ASTRO Calls for Voluntary Start, Scaling Back Excessive Cuts in CMS' Proposed Radiation Oncology Model

Paul Harari, MD, FASTRO
In a commentary adapted from the organization's official response to CMS' proposal, the author highlights potential challenges that proposed alternative payment model presents for members of the American Society for Radiation Oncology (ASTRO).
In July 2019, CMS proposed the Radiation Oncology (RO) Model,1 an important step forward in allowing the nation’s 4500 radiation oncologists to join in the transition to value-based healthcare, as envisioned by the 2015 Medicare Access and CHIP Reauthorization Act (MACRA).2

The American Society for Radiation Oncology (ASTRO)—the leading medical society for members of the RO care team—submitted comments to CMS in September 2019 to express its appreciation with the agency’s decision to move forward with an alternative payment model (APM) for the specialty.However, ASTRO leaders have shared multiple concerns about the proposal, such as the model’s mandatory nature and its excessive payment cuts to practices. Below is a review the
strengths and shortcomings of the proposed RO Model, as well as suggested policy solutions to ensure the model can achieve its intended goals of improving patient outcomes while generating savings for Medicare.

Compared with the current fee-for-service structure that incentivizes volume over value in Medicare reimbursement, an APM for RO could realign incentives to encourage the use of guideline-concordant and efficient patient care. A successful RO Model also could create stable and predictable payment rates that avoid jeopardizing patient access to life-saving treatments, and support medical innovation while reducing administrative burden.

Our organization appreciates that CMS recognizes the effort that radiation oncologists have put into the development of an APM for their specialty, as evidenced by the fact that several elements of the proposed CMS RO Model align with the Radiation Oncology Alternative Payment Model concept paper that ASTRO submitted to CMS in April 2017.4 The positive aspects of the CMS model include the prospective payment; the episode trigger mechanism, timeline and clean period; establishment of distinct professional component and technical component payments; the inclusion of all modalities of treatment; and key quality measure elements.

We are concerned, however, that the proposed CMS RO Model falls short of meeting 3 key goals that ASTRO identified in comments submitted to CMS3 as necessary for successful, longstanding payment reform. From our perspective, an APM for RO should:

• Reward radiation oncologists for participation and performance in quality initiatives that improve the value of healthcare for patients;
• Ensure fair, predictable payment for the radiation oncologist in both hospital and freestanding cancer clinics to protect patients’ access to care in all settings; and 
• Incentivize the appropriate use of cancer treatments that result in the highest quality of care and the best patient outcomes.3

An ASTRO analysis estimates that the RO Model would cut payments to participants by approximately $320 million during the 5-year period—an excessive amount that would undermine this unique opportunity.3 Cuts of this magnitude could strain RO practices that have little choice but to take part in the model, which could put access to safe and effective radiation treatments at risk. For the RO Model to be successful, ASTRO recommends specific, significant changes that will incentivize
the use of high-quality, efficient radiation therapy treatments that drive value-based reform and generate savings for Medicare. A summary of the key issues and recommended ASTRO policy solutions to address them follow:

MANDATORY PARTICIPATION that extends to 40% of RO episodes is excessive for an untested model.
ASTRO recommends that CMS should begin with voluntary participation before moving to a mandatory model, while allowing opt-outs for low-volume practices and
hardship exceptions.

NATIONAL CASE RATES. Calculations for the national case rates contain flaws that would result in significant and unfair payment penalties. ASTRO leaders are concerned that the methodology fails to appropriately account for a range of complex clinical scenarios and average treatment costs for many clinics.
ASTRO recommends that CMS include some costs from the Medicare Physician Fee Schedule, properly attribute palliative care cases, and ensure adequate payments for patients receiving standard-of-care multimodality treatments, such as combination therapy for gynecological cancer.

DISCOUNT FACTOR AND EFFICIENCY ADJUSTMENT.  Proposed adjustments could result in significant funding cuts to all participants and unfairly harm practices that are already efficient.
ASTRO recommends that CMS adjust the efficiency factor to avoid penalizing efficient practices and scale back the discount factors, which put patient access at risk by causing significant financial issues for such a capital expenditure–intensive specialty.

• APM INCENTIVE PAYMENT. CMS’ selective waiver of the 5% APM incentive payment on freestanding center technical payments does not align with either the spirit or the letter of MACRA, which calls for giving providers incentives to take on risk by participating in APMs.
ASTRO recommends removing this waiver.

• INNOVATION. Advances in RO have increased cure rates and reduced adverse effects from treatment. Yet, the RO Model does not adequately account for future innovation in the delivery of RO. Practices should be able to continue to invest in technology and other changes that provide clinical benefit for patients.
ASTRO recommends that CMS pay for new technology at fee-for-service rates and adopt a rate review mechanism for new service lines and upgrades.

• BURDEN. The proposed RO Model would heap additional administrative tasks and costly requirements on already burdened RO practices that are required to participate in the model.
ASTRO recommends that CMS delay many of these requirements and rely instead on recommendations from the RO community to ensure that only information that is most meaningful and least burdensome is collected.

ASTRO believes the RO Model, with significant modifications, could represent a meaningful and viable first step toward enabling the field of RO to participate in the evolving world of healthcare payment reform, as initiated by MACRA. The proposed model has serious flaws, but none of these issues are insurmountable. Radiation oncologists are committed to working with CMS to modify the model in such a way that it meets the stated goals.
Author Information

Paul Harari, MD, FASTRO, is a member of the American Society for Radiation Oncology Board of Directors. He is professor and chairman, Department of Human Oncology, University of Wisconsin School of Medicine and Public Health.
 
References

1. Radiation Oncology Model. CMS website. innovation.cms.gov/initiatives/radiation-oncology-model/. Updated August 7, 2019. Accessed September 27, 2019.
2. MACRA. CMS website. cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Value-Based-Programs/MACRA-MIPSand-
APMs/MACRA-MIPS-and-APMs.html. Updated June 14, 2019. Accessed September 27, 2019.
3. Thevenot LI. ASTRO comment letter on RO model proposed rule. American Society for Radiation Oncology website. astro.org/ASTRO/media/ASTRO/Daily%20Practice/PDFs/ASTRO-ROModelFinalCommentLetter.pdf. Published September 16, 2019. Accessed September 27, 2019.
4. Radiation Oncology Alternative Payment Model. American Society for Radiation Oncology website. astro.org/uploadedFiles/_MAIN_SITE/Daily_
Practice/Medicare_Payment_Initiatives/Alternative_Payment_Model_Program/Content_Pieces/ROAPM_Description.pdf. Published April 27, 2017. Accessed  September 27, 2019.
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