On July 10, 2019, the Centers for Medicare and Medicaid Services (CMS) released a proposed rule, entitled Specialty Care Models to Improve Quality of Care and Reduce Expenditures, which proposes to implement a Radiation Oncology Model (RO Model) and the End-Stage Renal Disease (ESRD) Treatment Choices Model (ETC Model). This proposed rule offers a 60-day comment period ending the first week of September.
The RO Model is proposed to be mandatory for providers who provide RO services in randomly selected Core-Based Statistical Areas. It is designed to qualify as an Advanced Alternative Payment Model (APM) under the Quality Payment Program (QPP).
The RO Model would require participants to annually certify their intent to use of Certified Electronic Health Record Technology (CEHRT), include quality measure performance as a factor when determining payments and require RO participants to bear more than a nominal amount of financial risk.
Participants who do not meet the QP threshold would not qualify for the APM incentive payment and, instead, would be assigned to a MIPS APM. This five-year model is projected to begin on either January 1, 2020, or April 1, 2020, and end December 31, 2024.
Unique to this model is a proposal that would have CMS and the Centers for Medicare and Medicaid Innovation (CMMI) impose prospective, site-neutral, episode-based payments for 17 different cancer types (84 percent of all RO episodes) to physician group practices (PGPs), hospital outpatient departments (HOPD) and freestanding radiation therapy centers. This would mean participants would be prospectively paid the same adjusted national base payment rates calculated for each episode instead of traditional Medicare fee-for-service payments for the professional and technical components of a 90-day episode of care, regardless of the care setting.
Participants would bill for new RO Model-specific HCPCS codes and modifier to indicate an episode has begun (which will result in half of payment) and would bill the same codes and modifier to indicate episode has ended (and then paid the second half of the payment).
RO participants would practice in the model as a professional, technical or dual participant. Beneficiaries would still be able to receive care from any provider or supplier of their choice.
CMS proposes to apply a discount factor of four percent on the professional component (PC) and five percent for the technical component (TC), which would be allocated as the Agency’s reserved savings.
The payment amount would also be prospectively adjusted for withholds for incomplete episodes (two percent for PC and TC), quality (two percent for PC) and beneficiary experience (one percent for TC starting in 2022). No minimum (or maximum) financial stop loss provisions would be available to RO participants, meaning RO participants would be at 100 percent risk for all expenditures in excess of the expected amount of expenditures, which are the episode payments.
Beneficiaries would still be responsible for the same cost-sharing requirement as traditional payment systems (i.e., typically 20 percent of the Medicare-approved amount for service), but because CMS would be applying a discount to each of these components, beneficiary cost-sharing may be, on average, lower relative to what would be typically paid under traditional Medicare fee-for-service reimbursement.
CMS and CMMI’s goal of the proposed mandatory RO model and its 17 episodes is to enhance the quality of care while reducing Medicare program spending through enhanced financial accountability for RO Model participants. They also want to test whether episode payments lead to shorter courses of radiotherapy (i.e. fewer fractions), more efficient care delivery and higher value care for Medicare beneficiaries.
The American College of Radiology will review this proposed rule in detail in the coming weeks to prepare comments in coordination with its MACRA Committee and the Radiation Oncology Commission. Go to the CMS.gov webpage devoted to the Radiation Oncology Model to learn more about the proposal.