The American Society for Radiation Oncology (ASTRO) has long advocated for an alternative payment model (APM) that recognizes the high-value care that radiation oncology provides to patients with cancer, and the society will continue to do so despite the indefinite delay of Medicare’s Radiation Oncology (RO) Model announced in August.
Annual Medicare expenditures for radiation oncology services, both in the hospital outpatient setting and in the freestanding setting, equate to just over $4 billion, which is significantly less than the more than the $6 billion that CMS spends on just the top 3 cancer drugs.1 Despite its high value in comparison to other oncology services, radiation oncology has experienced significant payment reductions in the Medicare Physician Fee Schedule resulting in a 27% cut between 2010 and 2019, when adjusted for utilization and inflation.2
This rate instability in recent years has resulted in practice consolidation, creating access to care issues that have an outsized impact on populations that experience health care disparities. CMS’ continued efforts to shift more resources from specialty care to primary care mean that radiation oncology is likely to face additional cuts in coming years, necessitating a new payment model that ensures payment stability and safeguards patient access to state-of-the-art care.
ASTRO is committed to improving quality and reducing costs as part of a value-based payment model for radiation oncology, and this transition also presents a unique policy-based opportunity to improve outcomes for underserved populations. As designed, the RO Model does not provide sufficient resources to help minority, rural and other underserved populations overcome barriers to accessing and completing cancer treatment. In fact, the model’s severe discount factors, waiver of the Advanced APM bonus on technical payments and onerous reporting requirements would exacerbate health disparities by causing disproportionate burden for practices who serve these populations. Future rulemaking can address these shortcomings; however, with a more reasonable payment methodology and the inclusion of wraparound services that help patients complete the cancer care this model was designed to support.
Jeopardizing Access to Care for Underserved Populations
Resource investment and interventions are necessary to address barriers facing patients from medical underserved populations to ensure that they have adequate access to treatment; otherwise, disparities in care will persist.
A Mayo Clinic analysis of the RO Model indicated that practices caring for patients from socioeconomically disadvantaged populations would face significant revenue reductions under the model, resulting in access to care issues for the communities they serve.3 According to the analysis, the RO Model base reimbursement rates for late-stage cancers were surprisingly lower than historical rates. Under the RO Model, this change would have resulted in a dramatic reduction in reimbursement for practices that treat patients with advanced cancers, which are disproportionately more prevalent among racial/ethnic minority and rural populations.
Decades of research have demonstrated that patients from racial/ethnic minority and rural populations are more likely than White patients to present with advanced-stage cancers, due largely to limited access to preventive services. For example, Black patients (12.3%) and Hispanic patients (10.5%) present with clinically advanced–stage prostate cancer more frequently than White patients (6.3%).4 Additionally, Black women are more likely than White women to receive a breast cancer diagnosis at an advanced stage of disease.5
Patients with late-stage cancers often receive palliative radiation therapy, which reduces pain and improves quality of life for patients with metastatic cancer. Despite this benefit, Black patients are 20% and 28% less likely to receive palliative radiation therapy for prostate and colorectal cancer, respectively, when compared with White patients.6
The RO Model in its current form would potentially exacerbate these health inequities for several reasons; for example, its 90-day bundle only recognizes/reimburses for 1 disease site, while patients with advanced cancers often have multiple sites of metastasis.7
Additionally, while cancer incidence and mortality rates in the US are declining, rural-urban differences in access and outcomes persist. Rural health care providers and their patients face many challenges in the delivery of care, such as limited availability of physicians and treatments, transportation barriers and financial issues. A recent study found that a substantial portion of the US population still suffers from poor geographic access to radiation therapy, with nearly 2% of the population (6 million people, 1 million of whom are aged 65 or older) living more than 50 miles from a radiation therapy facility.8 The authors recommend policies and technologies that aid geographically isolated populations to ensure no patient gets left behind, yet the RO Model would have done the opposite.
Another recent analysis demonstrates that there would have been a significant disparity between urban and rural RO Model participants’ capacity to deliver high-value treatments such as stereotactic radiation and brachytherapy.9 According to the study, rural practices under the model would be less likely to have technology that supports shorter, more cost-effective radiation treatment regimens for patients. Additionally, a report last year from the Government Accountability Office stated that providers in rural, shortage, or medically underserved areas face financial, technology, and other challenges in transitioning to APMs. These include barriers related to capital to finance the upfront costs of the transition, purchasing electronic health record technology and acquiring the data analysis necessary to comply with the reporting requirements.10 Cuts, in lieu of investments, are likely to further disadvantage rural clinics and their patients.
Finally, radiation oncologists that provide care in rural communities or to underserved populations serve patients who are more likely to be covered by Medicare or Medicaid programs, rather than privately funded employer-based health plans. Due to this payer mix, this group of physicians typically has more limited financial resources than their peers in other areas. This financial reality makes it difficult to invest in the resources necessary to participate in value-based payment programs.
Addressing Disparities Through Health Equity Achievement in Radiation Therapy (HEART)
ASTRO recommended numerous reforms to the RO Model including the establishment of a Health Equity Achievement in Radiation Therapy (HEART) scoring methodology based on social determinants of health that would trigger a payment for wraparound services to address healthcare disparities.
HEART payments could support services that are not currently billable, such as:
Symptom management clinics or triage units established in oncology settings have proven to be successful at reducing costs and ensuring patients have access to resources that improve their quality of life during their treatment. These units are typically run by nurse care managers that meet with patients during regular clinic visits to assess symptoms associated with radiation therapy and provide guidance regarding self-management, as well as treatment follow up. A University of North Carolina Chapel Hill study demonstrated significant savings associated with the implementation of a symptom management program leading to reduced unnecessary emergency department visits and inpatient admissions.11 Programs such as this are currently not reimbursable—and therefore difficult for smaller practices to establish—yet they have a substantial impact on the patient’s quality of life and the cost of care.
A similar initiative pursued by Cone Health, a regional multihospital health system in Greensboro, North Carolina, created a transportation hub to remove barriers to treatment by identifying patients at risk for not pursuing or completing treatment through the establishment of a real-time registry managed by care navigators.12 Implementing the program flattened the gap in treatment completion rates for early-stage breast and lung cancer between Black and White patients, and it improved completion rates for all patients. After the intervention, treatment was completed by 88.4% of Black patients and 89.5% of White patients, up from 79.8% and 87.3% before the wraparound services were implemented. Survival rates also rose for both Black and white patients, and the historical gap in survival between the groups was eliminated. A HEART payment could support initiatives such as these to ensure that patients from underserved populations can achieve improved health outcomes.
Transportation barriers are particularly salient for radiation oncology, given that radiation therapy treatments often require daily clinic visits lasting several weeks and interruptions can negatively impact the ability to control disease progression.13 A recent study indicated that regions with the least access to radiation therapy are disproportionately rural and have older populations that are more likely to be uninsured, placing these patients at higher risk for not securing adequate care.8
Data associated with episodes that include a HEART payment could be collected and used to determine the effectiveness of HEART interventions. By learning more about what drives disparities and which interventions are most effective at closing gaps, radiation oncology teams and patients can actively work together to reduce health disparities. Additionally, meaningful quality measures can be established to measure treatment interruptions, completion of the radiation therapy episode of care and duration of treatments.
Despite the evidence supporting these reasonable modifications to improve the RO Model, CMS ignored concerns from radiation oncology stakeholders about the model’s impact on health disparities. ASTRO continues to believe that radiation oncology represents a unique opportunity to address health disparities and establish stable payment for high-value radiation oncology services. We will continue to work toward achieving these goals.
Anne Hubbard, MBA, is director of Health Policy, American Society for Radiation Oncology (ASTRO).
1. Cubanski J, Sroczynski N, Neuman T. Medicare Part B drugs: Cost implications for beneficiaries in traditional Medicare and Medicare
2. Advantage. Kaiser Family Foundation. March 15, 2022. Accessed September 16, 2022. https://www.kff.org/medicare/issue-brief/medicare-part-b-drugs-cost-implications-for-beneficiaries-in-traditional-medicare-and-medicare-advantage/
3. Hogan J, Roy A, Karraker P, et al. Decreases in radiation oncology reimbursement over time: analysis by billing code. Int J Radiat Oncol Biol Phys. 2022;114(1):47-56. doi:10.1016/j.ijrobp.2022.05.018
4. Waddle MR, Stross WC, Vallow LA, et al. Impact of patient stage and disease characteristics on the proposed Radiation Oncology Alternative Payment Model (RO-APM). Int J Radiation Oncol Biol Phys. 2020;106(5):905-911. doi:10.1016/j.ijrobp.2019.12.012
5. Hoffman RM, Gilliland FD, Eley JW, et al. Racial and ethnic differences in advanced-stage prostate cancer: the Prostate Cancer Outcomes Study. J Natl Cancer Inst. 2001;93(5):388-395. doi:10.1093/jnci/93.5.388
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7. Murphy JD, Nelson LM, Chang DT, Mell LK, Le QT. Patterns of care in palliative radiotherapy: a population-based study. J Oncol Pract. 2013;9(5):e220-e227. doi:10.1200/JOP.2012.000835
8. Erfani P, Figueroa JF, Lam MB. Reforms to the Radiation Oncology Model: prioritizing health equity. Int J Radiat Oncol Biol Phys. 2021;110(2):328-330. doi:10.1016/j.ijrobp.2021.01.029
9. Maroongroge S, Wallington DG, Taylor PA, et al. Geographic access to radiation therapy facilities in the United States. Int J Radiat Oncol Biol Phys. 2022;112(3):600-610. doi:10.1016/j.ijrobp.2021.10.144
10. Mantz CA, Thaker NG, Pendyala P, et al. Disproportionate negative impact of the Radiation Oncology Alternative Payment Model on rural providers: a cost identification analysis of Medicare claims. JCO Oncol Pract. 2021;17(12):e1977-e1983. doi:10.1200/OP.21.00330
11. Government Accountability Office. Information on the transition to Alternative Payment Models by providers in rural, health professional shortage, or underserved areas. GAO Publication No. 22-104618. 2021. Washington, D.C.: U.S. Government Printing Office. https://www.gao.gov/products/gao-22-104618
12. Chera BS, Yechoor A, Stravers L, et al. Reducing emergency room visits and unplanned admissions in patients with head and neck cancer. Int J Radiat Oncol Biol Phys. 2016;96(2):e334-e335. doi:10.1016/j.ijrobp.2016.06.1468
13. Stern J. Tackling racial disparities in cancer care by creating new ways for institutions to operate. The Washington Post. October 25, 2021. Accessed September 16, 2022. https://www.washingtonpost.com/health/racism-cancer-health-care-disparity/2021/10/22/a2da80f0-3039-11ec-93e2-dba2c2c11851_story.html