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CMS Proposes Simplified Payment Plan for Cancer Radiotherapy Services

Samson, Kurt

doi: 10.1097/01.COT.0000586236.17574.40
radiation oncology

radiation oncology

The Centers for Medicare and Medicaid Services (CMS) is seeking input on a new plan to adopt a uniform system for reimbursing cancer radiotherapy (RT) services in an effort to provide a simplified and more predictable payment system that it hopes will help patients and providers alike.

According to a July 10 announcement from the CMS, the Radiation Oncology Model, if approved, will move toward a simplified and more predictable payment system by making site-neutral, episode-based payments to physician group practices, hospital outpatient departments, and freestanding radiation centers.

The 5-year model, according to CMS, will apply to 17 cancer types constituting 84 percent of all radiotherapy services and qualify as an advanced alternative payment model (APM) and a merit-based incentive payment system APM under the CMS Quality Payment Program.

CMS said the model is projected to begin either Jan. 1, 2020, or April 1, 2020, and conclude on Dec. 31, 2024. It will require participation from radiotherapy providers and suppliers that “furnish” radiation therapy services within randomly selected core-based statistical areas.

“The proposed payment model is a step forward in allowing the nation's 4,500 radiation oncologists to participate in the transition to value-based care that improves outcomes for cancer patients,” said Paul Harari, MD, Chair of the board of directors of the American Society for Radiation Oncology (ASTRO).

The agency said that, under the proposed payment system, a therapy center would be reimbursed at the non-facility rate under the Medicare Physician Fee Schedule. This includes payment for both professional and technical aspects of services. In an outpatient department of a hospital, services will be paid under the hospital Outpatient Prospective Payment System and professional services will be reimbursed under Medicare's Physician Fee Schedule.

“These payment systems determine payment rates for the same services in different ways, which creates site-of-service payment differentials,” the agency said in announcing the proposed plan. “This difference in payment rate may incentivize Medicare providers and suppliers to deliver RT 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.”

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The new reimbursement model is a move toward prospective, episode-based payments in a “site-neutral manner” for 17 different cancer types and would allow for testing of site-neutral models as well as patient-centered, physician-focused models that provide an opportunity for physicians to participate in an APM under the Quality Payment Program, according to the CMS. It is also expected to reward high-quality, patient-centered care and provide incentives for better patient outcomes.

Under the plan, beneficiaries would still receive care from any provider or supplier they choose, and model participants treating beneficiaries with one of the included cancer types would receive prospective, episode-based payment amounts for treatment furnished during a 90-day episode of care instead of regular Medicare FFS payments.

Model episode payments would be split into a professional component payment, which is meant to represent payment for the included RT services that may only be furnished by a physician, and the technical component 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.

Significantly, participant-specific payments would be determined using proposed national base rates, trend factors, and adjustments for each participant's case-mix, historical experience, and geographic location.

CMS would further apply a discount to reserve savings for the agency and reduce cost-sharing for beneficiaries. For professional services, this discount would be 4 percent, and 5 percent for technical services. In addition, reimbursement would be prospectively adjusted by 2 percent for incomplete episodes and by 1 percent for beneficiary experience, beginning in 2022. However, participants could earn back a portion of the quality and patient experience withholds based on clinical data reporting, quality measure reporting and performance, and a standardized beneficiary-reported assessment survey of both professional and technical services.

Also, under the proposal, Medicare and Medicaid beneficiaries will still have to adhere to the same traditional cost-sharing requirements, typically 20 percent.

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Moving Ahead

Harari called the proposal “a step forward in allowing the nation's 4,500 radiation oncologists to participate in the transition to value-based care that improves outcomes for cancer patients.

“We believe that once implemented with modifications, the model will incentivize higher quality, more convenient radiation treatments for patients and support their journey toward a cure,” he said.

The organization is and will continue to be providing comments on different specific aspects of the proposed plan, Harari added, and will look for opportunities to ensure the model is consistent with initiatives to reduce physician burden and paperwork.

“ASTRO has worked for many years to craft a viable payment model that would stabilize payments, drive adherence to nationally recognized clinical guidelines, and improve patient care. We appreciate the administration's focus and commitment to ensuring radiation oncologists' ability to participate in an advanced payment model.”

The proposed rule (CMS 5527-P), developed by the Center for Medicare and Medicaid Innovation, can be downloaded at

Kurt Samson is a contributing writer.

Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.
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