With the start of CMS's mandatory Radiation Oncology Model (RO Model) less than three months away, participating cancer programs are gearing up for implementation. In August, the Oncology Roundtable held another virtual networking forum to facilitate an open discussion about preparation successes and challenges among Model participants. Keep reading to learn five key questions raised by the 17 cancer program leaders who joined the forum and the solutions proposed by their peers.

Decision guide: Radiation Oncology Model readiness assessment

Read through the entire page or jump to the most relevant section below:

Meeting model requirements

• How should we document quality measures and clinical data elements (CDEs)?
• What would be the impact of not complying with quality reporting requirements?
• How do you ensure optimal project management for alternative payment models like the RO Model?

Adjusting clinical care delivery

• Should we wait to change clinical workflows until we get more clarification from CMS on quality measures and CDEs?
• Should we change clinical care delivery for all radiation oncology patients or just RO Model beneficiaries?

Meeting model requirements

How should we document quality measures and clinical data elements (CDEs)?

Resource library: Oncology value-based payment

Cancer programs varied in whether they plan to use their radiation oncology-specific EHR (e.g., Elekta's MOSAIQ, Varian's ARIA) or their general health system EHR (e.g., Epic, Cerner) as the main source of care documentation for the RO Model. Participants are considering a variety of factors in making this decision, such as:

• Current location of most radiation oncology documentation
• Current level of integration between EHRs, and resources and time required to achieve necessary integration
• EHR compliance with Certified EHR Technology (CEHRT) requirements, and resources required to meet CEHRT requirements
• Reporting capabilities and available IT support for each EHR
• Impact on clinical workflows and collaboration

Cancer programs planning to use their radiation oncology-specific EHR already do most of their documentation in this platform and don't have the organizational capacity to integrate it with the general health system EHR by the start of the RO Model. For these organizations, this option is a way to minimize disruptions to clinical workflows. However, many of these platforms don't meet CMS's CEHRT requirements, so cancer programs going this route are working closely with vendors to implement various upgrades needed to comply.

In an ideal world, our attendees agreed that using the general health system EHR is a worthwhile long-term investment to improve data sharing and communication across departments, as well as coordinating patient support, such as depression screening and advance care planning. Many participants also shared that using their general health system EHR would make reporting data easier in the RO Model, since these platforms have better reporting capabilities and dedicated IT support at their organizations. The programs planning to take this approach either have access to the resources needed to support integration or may be further along in the integration process compared to others.

Your top questions on the Radiation Oncology Model, answered

What would be the impact of not complying with quality reporting requirements?

Given the significant investment needed to meet RO Model quality reporting requirements, one cancer program leader asked if anyone was considering simply not complying with them. The consensus among most participants was that this likely wasn't a financially beneficial option. Non-compliance would not only mean automatically forgoing recoupment of CMS's 2% quality withhold, which depends on reporting of and performance on quality measures, but also losing eligibility for the 5% Advanced APM incentive payment. However, participants weren't sure how exactly this would translate to dollars, and one organization planned to use analytics to more definitively quantify the size of this financial loss compared to investment costs.

One participant also pointed out that cancer programs may have an opportunity to shape the quality reporting requirements by attempting to comply with them and sharing challenges they encounter with CMS. For the Oncology Care Model (OCM), CMS loosened some of the reporting requirements based on lessons learned from cancer programs' experiences attempting to comply.

While we understand the significant resource investment required for quality reporting, we do believe it’s a worthy aim for RO Model participants. It provides an opportunity to gain insight into total costs and quality of care, which has historically been challenging for cancer programs. Being able to track your performance and benchmark yourself against other organizations will be critical for improving cancer patient care and clinical outcomes in the long run.

How do you ensure optimal project management for alternative payment models like the RO Model?

Given the complexity of the RO Model, cancer program leaders agreed on the importance of having someone who is responsible for project management to monitor compliance and performance. Due to limited capacity and funding to hire additional staff, some participants are adding this responsibility to their oncology clinical teams’ or clinical managers’ plates. But one participant recommended that that cancer programs have at least a partial FTE dedicated to project management for the RO Model given the considerable amount of work they discovered this entails based on their experience with the OCM. For the OCM, their organization created a director-level position for quality and care transformation and filled an existing analyst position that hadn't been consistently filled in the past.

Another participant shared their experience using the "train-the-trainer" approach in a radiation oncology bundled payment model with a private payer. This approach focuses on training a small number of internal "experts" on the Model, who then train additional staff across the organization on documenting and monitoring compliance with Model requirements. With this approach, it's important to ensure each trainee has access to the CMS RO Model portals necessary to complete their assigned tasks.

To reduce the staffing burden, other cancer program leaders are embracing digital technology by partnering with EHR vendors to build dashboards that will streamline managing Model beneficiaries and requirements. One organization hopes to build a dashboard that will at least pull patients for whom they need to report CDEs.

Adjusting clinical care delivery

Should we wait to change clinical workflows until we get more clarification from CMS on quality measures and CDEs?

How 17 cancer programs are preparing for Medicare's new Radiation Oncology Model

As we heard from multiple attendees, the Quality Measure and Clinical Data Elements Guide published by CMS can be difficult to interpret, making it challenging to move forward in adjusting clinical workflows to meet requirements.

However, one leader recommended peers start implementing changes to clinical workflows (e.g., standardizing advance care plan discussion) now based on their best interpretation of the requirements to prepare their clinical team as soon as possible, rather than wait for clarification from CMS. This organization has begun meeting regularly with their clinical team to improve performance on metrics they're not currently meeting requirements for, but they plan to continue adapting their implementation strategy as CMS issues additional guidance on quality measures and CDEs in the coming months.

Check CMS's RO Model webpage for upcoming webinars, and other resources, for RO Model participants that may provide more clarity on these requirements:

• RO Model Clinical and Quality Measures Reporting Requirements Webinar (November 2021)
• RO Model QPP, APM, and MIPS Webinar (December 2021)

Should we change clinical care delivery for all radiation oncology patients or just RO Model beneficiaries?

This is a longstanding question for organizations where only a subset of their patient population is enrolled in a value-based payment model: How do you justify treating RO Model beneficiaries differently than other radiation patients? One participant said that they felt they owed it to all their patients to revisit their clinical protocols and created a workstream focused on how to redesign care delivery in a way that is both cost-effective for the cancer program and patient-centric.

However, another cancer program leader whose organization implemented OCM care delivery changes for all their patients advised others to proceed with caution if they're considering this for the RO Model. This approach ultimately hurt their program's OCM performance by stretching the resources needed to address OCM components even thinner.

But it's important to consider the differences between the OCM and RO Model when applying lessons between models. For example, the eligible patient population is more clearly defined for the RO Model compared to the OCM, which may make it easier to take a targeted approach to implementing RO Model care delivery changes. On the other hand, the RO Model is less prescriptive than the OCM about the care delivery changes required from participants, which may make it more financially feasible to implement them for all radiation patients.

Several other cancer program leaders suggested organizations consider their payer mix when deciding how far to extend RO Model care delivery changes. Organizations with a significant proportion of fee-for-service contracts stand to lose revenue (that could offset some of the investment costs to meet RO Model requirements for a subset of beneficiaries) by implementing the RO Model care delivery changes intended to reduce costs (e.g., hypofractionation).

Finally, another cancer program leader shared that they advised their clinical team to hold off on widespread care redesign at least until they know what those changes will actually look and feel like, unless they've already been wanting to make certain changes.