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Breaking: CMS releases proposal for radiation therapy APM. Get our 4 key takeaways.

July 11, 2019

    Yesterday, CMS and Center for Medicare and Medicaid Innovation (CMMI) published a long-awaited proposal for a radiation oncology alternative payment model. The aim is to test whether transitioning to prospective, episode-based, site-neutral payments will reduce Medicare spending while preserving or improving care quality.

    Access our resources on CMMI's Oncology Care Model—all in one place

    Over the next week or two, we'll be poring through the 400-plus page rule and sharing our takeaways, but in the meantime, here's what you should know about the basics of the model—and how you should start preparing.

    Four things to know about the model

    1. The proposed model will be mandatory. This model would require participation from radiation therapy providers, including physician group practices, hospital outpatient departments, and freestanding centers, within randomly-selected Core Based Statistical Areas. When HHS Secretary Alex Azar first mentioned the model last winter, physician groups, especially ASTRO, were opposed to a mandatory model, expressing concerns that it could negatively affect patient access to care. (Note that certain participants are excluded, such as providers in Maryland and Vermont, as well as PPS-exempt cancer hospitals.) As proposed, the model would qualify as an Advanced Alternative APM and a MIPS APM. 

    2. Beneficiaries with one of 17 different cancer types are included. They must be enrolled in Medicare Part B, and patients enrolled in clinical trials where Medicare pays routine costs would also be included. The model proposes to exclude patients in Medicare managed care, including Medicare Advantage.
    3. Participants will receive prospective payments for a 90-day episode of care. Payment will be broken into professional and technical components. The amounts will be based on national payment rates, trend factors, and adjustments for case mix, historical performance, and geographic location. CMS will apply a discount factor of 4% to the professional component payment and 5% to the technical component. The components of radiation therapy care to be included in the episode-based payment are: treatment planning, technical preparation (e.g., planning, dosimetry), delivery services, and treatment management (e.g., changes to dose delivery, follow-up care).

      Modalities included are: 3D-CRT, IMRT, SRS, SBRT, proton, IORT, IGRT, and brachytherapy (non-surgical).

      Services excluded are: E&M visits and low-volume radiation services, such as brachytherapy surgical procedures, neutron beam therapy, and radiopharmaceuticals.

    4. Participants could earn reconciliation payments based on Aggregate Quality Scores. There are four quality measures proposed:
      • Oncology: Medical and Radiation - Plan of Care for Pain -NQF41 #0383; CMS Quality ID #144
      • Preventive Care and Screening: Screening for Depression and Follow-Up Plan -NQF #0418; CMS Quality ID #134
      • Advance Care Plan -NQF #0326; CMS Quality ID #134
      • Treatment Summary Communication – Radiation Oncology

    In addition, participants can earn back withheld technical component payments based on their performance on the patient-reported CAHPS Cancer Care Survey for Radiation Therapy.

    The proposed rule hasn't been officially published on the Federal Register yet, but, once it is, stakeholders will have 60 days to submit comments. CMS projects that this pilot would kick off on either January 1, 2020, or April 1, 2020, and run for five years.

    What will be keys to success?

    Whether or not your radiation therapy program will be required to participate, you need to start strategizing on how to reduce costs and improve quality. We've seen best-in-class radiation providers take the following four steps:

    1. Ensure adherence to evidence-based care: Encourage the development of more clinical evidence and rapidly incorporate new information on cost and patient outcomes into treatment protocols. After implementing clinical pathways, one cancer program increased its use of hypofractionation for breast patients from 8% to 77% in just three years.

    2. Facilitate shared decision making: Engage patients in treatment decisions that factor in costs to the patient, outcomes, and their goals for care. For instance, Jefferson Health's decision counseling program helps low-risk prostate cancer patients select the treatment that aligns with their goals. In a pilot, 83% of participants chose active surveillance. Find tools and additional best practices in our Shared Decision Making Resources Compendium for Cancer Programs.

    3. Find ways to improve safety: Seek new opportunities to improve safety and compliance with processes and protocols. Northwell Health developed its Smarter Radiation Oncology™ program consisting of evidence-based pathways, daily peer review to ensure consensus on directives and contours, and rescheduling requirements designed to ensure every step occurs sequentially. Over a 22-month period, their peer review corrected issues in 25% of cases, saving time in the long run by reducing the number of treatment plans that require modification later on.

    4. Rethink your investment strategy: Invest in technologies that promote higher-value care. In the past, capital equipment's ROI was primarily determined by its impact on cash flow and capacity. These are still important, but episode-based payments mean you need to consider nontraditional returns and total costs of care, such as modalities that reduce toxicities and, therefore, costs of symptom management and ED visits.


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