September 13, 2021

RO Corner: Radiation Oncology Alternative Payment Model — 2021 Updates

By Aaron Bush, MD

The radiation oncology economic landscape is currently facing a pivotal crossroad. Recent proposed rule changes regarding the Medicare Physician Fee Schedule (MPFS) and radiation oncology alternative payment model (RO-APM) are expected to introduce unprecedented Medicare reimbursement cuts over the course of 2022 and beyond. Numerous practices are already reeling from decreased volumes secondary to the COVID-19 pandemic; therefore, the timing of these cuts are both disappointing and alarming.

The RO-APM was first announced in July 2019 with the intent of transitioning Medicare Part B reimbursement from a fee-for-service model to a 90-day, episodic, bundled payment system. Base payment rates will be calculated from the historical average of fee-for-service claims per cancer type using Hospital Outpatient Prospective Payment System (HOPPS) data. Included cancer types are: anal, bladder, breast, cervical, CNS, colorectal, head & neck, lung, lymphoma, pancreatic, prostate, upper GI, uterine, bone metastases and brain metastases.

Base payment rates will be site neutral and modality agnostic. Currently the following will all receive equal reimbursement: 2D, 3DCRT, IMRT, SRS, SBRT and proton therapy. Numerous adjustment factors and withholds will then be applied to the base rate with the intention of reducing Medicare costs and improving treatment quality. The RO-APM will be a mandatory model, which will include 30% of all eligible radiotherapy episodes determined by core-based statistical area.

A “final” RO-APM ruling was released in September 2020, which received significant backlash from the radiation oncology community given the lack of payment methodology transparency, ignored rule change requests and overall poor incentives to participate. Since that time, the ACR has continued to actively work with CMS and Congress to further optimize the RO-APM in an effort to benefit both cancer patients and radiation oncologists alike.

On July 19, 2021, a revised final ruling of the RO-APM was proposed with the current comment period set to close on Sept. 17 , 2021. Highlighted changes include reduction of discount factors by 0.25%, exclusion of liver cancer and brachytherapy, incorporation of quality metrics during performance year 1, a two-pronged approach to advanced APM status, and the implementation of an extreme and uncontrollable circumstance policy.

While these adjustments are a small step in the right direction, significant concerns related to downstream effects of the model still remain. For example, budget cuts are set to disproportionally harm rural practices and could significantly limit access to care for patient populations that are already disadvantaged. Please refer to this editorial by current CARROS President Join Y. Luh, MD, FACR, for more information.

Clearly, much more work is required to improve the RO-APM. Unfortunately, the stakes are quite high for both the field of radiation oncology and the patients whom we treat. Further discussions with

CMS representatives and members of Congress will be crucial over the upcoming months before the implementation of the APM in January 2022.
For a more detailed review of RO-APM and MPFS updates, please refer to the ACR-ARRO educational webinar.