Preparing for dramatic changes in the way health care is delivered and paid for, the American Society for Radiation Oncology is undertaking a comprehensive payment reform action plan.
“The vision is to embrace the value proposition in health care,” said Michael L. Steinberg, MD, Chairman of the Board of Directors, referring to the widespread agreement that the current payment system rewards physicians for the volume of services they provide, regardless of the quality or cost.
Payers and policymakers are experimenting with a wide array of payment approaches to reward physicians and other caregivers who differentiate themselves on quality and cost measures—and punish those who do not.
In an effort to be proactive in influencing new payment systems, ASTRO has developed a three-prong strategy that seeks to improve the current fee-for-service system as it pertains to radiation oncology; help radiation oncologists improve the quality of care they deliver; and recommend new payment methods that reward physician practices for the quality and cost of care.
First Step: Fee for Service
Despite many payment reform initiatives, the current fee-for-service system will be in place for many years and its pay rates will influence the new payment methods that emerge. For that reason, the first component of ASTRO's action plan is to seek changes to the radiation therapy codes in Medicare's physician fee schedule.
Radiation oncologists were jolted last summer when the Centers for Medicare & Medicaid Services proposed significant cuts for its 2013 fee schedule—including reducing reimbursement rates for intensity-modulated radiation therapy (IMRT) by 40 percent and for stereotactic body radiation therapy by 28 percent.
CMS later backed off a bit; the final 2013 fee schedule reflected a seven percent pay cut for radiation oncology services and an overall nine percent cut to radiation therapy centers. When CMS issued its final rule, it said it wanted the American Medical Association's Specialty Society Relative Value Scale Update Committee (RUC) to re-evaluate more than 20 radiation therapy Current Procedural Terminology (CPT) codes.
The RUC makes recommendations to CMS about the relative value of services performed by various medical specialties. Some of the radiation therapy codes were first put in place many years ago and need to be updated to reflect changes in technology, equipment prices, and changes in practice, Steinberg said. “We know, CMS knows, the RUC knows, everybody knows, so we want to address that.”
To that end, ASTRO proposed revisions to the codes for IMRT, image-guided radiation therapy, and other treatment delivery codes that, among other things, packages together services typically billed at the same time. If approved by the RUC and ultimately by CMS, the new codes would become effective Jan. 1, 2015, at the earliest.
Meanwhile, ASTRO is launching a series of quality-improvement initiatives that will help radiation oncology practices assess, improve, and document the quality of care they provide.
- Practice accreditation program: Standards in five domains—process of care, radiation oncology team, safety, quality management/assurance, and patient-centered care—have been proposed. Steinberg said the goal is to create a program that recognizes practices that have the highest standards of care and differentiates them from their less quality-oriented peers.
“Rather than just be an organizational exercise, we want the accreditation process to be a real-time and ongoing quality-check process that's really useful to the practitioner.” Public comments on the proposed standards were accepted through the middle of April, and the expectation is that the program will launch early next year, said Emily Wilson, ASTRO's Vice President of Advocacy and Clinical Affairs.
- National Radiation Oncology Registry (NROR): ASTRO is working with the Radiation Oncology Institute to develop an electronic registry that captures real-time information on radiation treatments and health outcomes. The database would allow physicians, patients, payers, and policymakers to compare competing treatment options to help make decisions. A pilot study for prostate cancer treatments was launched early this year. After beta testing with dummy data, the registry will begin collecting actual data from six practices this summer and expand to 30 total sites later in the year. Wilson said the registry will be released after evaluation of the initial 30 sites is complete.
- Practice improvement initiative: ASTRO's Performance Assessment for the Advancement of Radiation Oncology Treatment (PAAROT) program has “been put on steroids,” with the goal of increasing its use among radiation oncology practices, Steinberg says. Physician practices that submit quality indicators to the program can identify treatment variations and gaps in care, helping the practices see where improvement is needed.
- Choosing Wisely: ASTRO has joined the Choosing Wisely campaign, which seeks to reduce the inappropriate use of tests and procedures. The campaign, initiated last year by the ABIM Foundation, currently includes 26 medical specialties that have each identified five common tests or procedures of questionable value and encouraged physicians and patients to discuss the pros and cons before proceeding with them. ASTRO's list of five cautionary radiation oncology tests or procedures is expected to be announced by the Choosing Wisely campaign this fall.
New Payment Systems
The third thrust of ASTRO's action plan is an effort to develop alternatives to the fee-for-service model used for most radiation oncology payments today. Steinberg says ASTRO's leadership believes that cancer care will eventually be paid for in a global payment system in which medical oncologists, radiation oncologists, surgeons, palliative care specialists. and others divide a single payment for a patient's care.
“Not only do we believe that's the direction things are going, but the reality is we have to figure out how to be part of that,” he said. “How does a tertiary specialty participate in a global payment system?”
ASTRO's payment reform task force, led by Brian D. Kavanagh, MD, MPH, Vice Chair of ASTRO's Health Policy Council, is monitoring a variety of payment reform initiatives that may be pertinent to radiation oncology.
Among these: a shared-savings contract that Advanced Medical Specialties, which has 16 cancer treatment facilities in south Florida, started last year (OT, 1/10/13); and a proactive palliative care and palliative radiation model developed by Paul Read, MD, at the University of Virginia, which received funding from the CMS Innovation Center in 2012, its first year for funding health care innovation projects.
The task force is also engaging outside consultants to learn about payment reform concepts in other medical specialties and emerging ideas of how to leave fee-for-service behind.
“We're hoping to identify opportunities to realign incentives in a way that encourages efficiencies and cost savings while maintaining the highest quality of care, which is always the top priority,” Kavanagh said. “Ideally, we will reach a point in the next year or two where we will be able to propose some good ideas to federal or private payers.”
What It Means for Oncologists
Payment reform has the potential to spur oncologists to change the way they practice.
“Historically, providers have not been actively incentivized to think about giving the best care possible at the least cost,” said Justin E. Bekelman, MD, a radiation oncologist at Penn Medicine. “For physicians like myself who see patients, there are plenty of opportunities in our practices to begin to think about that. And there are plenty of opportunities to think, in our relationships with our colleagues and referring providers, how to better coordinate care to improve the quality of care.”
He predicts that those changes could lead to better patient care and greater professional satisfaction. “I would be extremely excited about the possibility that with payment reform, we can once again focus on our patients,” he said. “Let's focus on delivering the best care possible, and be paid to do just that.”