Read through the entire page or jump to the most relevant section below:
- What are CMS' goals with this model?
- Will my organization have to participate?
- Who's excluded from the model?
- How will CMS set the prices for an episode of care?
- Will this model include total costs of care during the 90-day episode?
- How will participants get paid?
- What is the aggregate quality score (AQS)?
- How would CMS calculate the AQS?
- How would the AQS impact payment?
- Would this model count as an advanced APM?
- What does this mean for practices enrolled in the OCM?
- Will Medicare Advantage patients be enrolled?
- Is CMS really including proton beam therapy?
What are CMS' goals with this model?
First off, cost control. Medicare Part B spending on radiation therapy increased 216% from 2000 to 2010. Second, CMS doesn't shy away from using "site neutrality" in its reasoning for this model. Interestingly, however, in its analysis of FY 2017 claims, CMS found that Medicare paid 11% more for radiation therapy episodes delivered in freestanding settings compared to hospital outpatient departments (HOPDs), even though Medicare payments are lower per-unit in freestanding settings. The findings indicate that these settings tend to use more expensive therapies, such as intensity-modulated radiation therapy (IMRT), and less hypofractionation (in which radiation therapy is given in higher doses over a shorter period of time) compared to HOPDs.
In addition to unequal payments, there is also inconsistent coding under the Physician Fee Schedule (PFS) and Outpatient Prospective Payment System (OPPS) for radiation services. Lastly, CMS calls out the need to align payments to quality and value, which isn't surprising. In particular, the proposal emphasizes the lack of uptake in hypofractionation despite growing evidence supporting its use.
Will my organization have to participate?
Well, we don't know exactly who will be required to participate yet. But CMS is proposing to make the model mandatory for all radiation therapy service providers, including HOPDs, physician group practices, and freestanding centers, in randomly-selected Core-Based Statistical Areas (CBSAs). CMS aims to have 40% of applicable radiation therapy episodes included in the model, and it would be unlikely for this level of participation to happen if it isn't mandatory. In fact, the voluntary Bundled Payments for Care Improvement (BCPI) Model 4 got only 23 participants, 78% of whom withdrew from the model.
Given the model mechanics (explained in more detail below), there will be three types of participants:
- Professional participants: Physician groups billing under PFS that furnish just the professional component (physician-dependent services) at a freestanding center or HOPD;
- Technical participants: HOPD or freestanding centers that furnish only the technical component (equipment, overhead, etc.) of radiation therapy;
- Dual participants: When the physicians performing radiation also own the location where it is delivered, meaning they furnish both the technical and professional components.
This structure means that one qualifying episode could be delivered by one dual participant or by one professional and one technical participant.
Who's excluded from the model?
The model will exclude providers in Maryland, Vermont, U.S. territories, ambulatory surgical centers, critical access hospitals, the Pennsylvania rural health model, and PPS-exempt cancer hospitals.
How will CMS set the prices for an episode of care?
In the proposal, CMS provides a lot of detail on the pricing methodology. Here's my "CliffsNotes" of the eight steps CMS will undertake:
- Create national base rates for the professional and technical components for each cancer type. Since 17 cancers are included, CMS will create 34 base rates using historical average cost for an episode of care based on fee-for-service claims from 2015 to 2017.
- Apply a trend factor to the base rates to reflect current trends in payment and treatment pattern changes.
- Adjust the base rates for each participant's historical experience and case mix history. Each participant will receive one professional component and/or one technical component case mix adjustment. This adjustment will be based on a set of characteristics strongly correlated to costs, such as tumor site, age, sex, major procedures, chemotherapy, and death. (Note on this last point: This means that if a beneficiary dies or is enrolled in hospice during the episode, providers will still receive full payment whether or not treatment is completed.) Historical experience adjustment will be based on Winsorized payment amounts, then weighted with an efficiency factor that reflects if a provider has historically been more or less costly than the national base rates.
- Apply a discount factor. The discount is the set percentage by which CMS will reduce an episode payment amount after the trend and historic adjustments. The discount will be 4% for the professional component and 5% for the technical component.
- Apply an incorrect payment withhold, as well as a quality withhold and/or patient experience withhold.
- The incorrect payment withhold reserves money for reconciling duplicate or incomplete episodes—it will be 2% of the total episode payment for the professional and technical components. There will be an annual reconciliation process to determine if participants receive back the full 2%, a portion of it, or owe money to CMS.
- The quality withhold holds back 2% of payment that participants can earn back based on their performance on and reporting of quality measures (aggregate quality score explained in more detail below).This applies only to the professional component.
- A 1% patient experience withhold will kick in in performance year 3 for the technical component and will be based on scores from the Cancer CAHPS for Radiation Therapy.
- Apply geographic adjustments.
- Apply beneficiary coinsurance. Beneficiaries will still have 20% coinsurance, but because of the nature of the bundle, there will be fewer and higher payments. So CMS encourages providers to help set up payment plans for these patients, especially those without secondary insurance.
- Apply 2% sequestration adjustment.
Here are the national base rates by cancer type CMS shared in its proposal (in 2017 dollars):
Will this model include total costs of care during the 90-day episode?
No. This makes this model different and, in my opinion, more reasonable than the Oncology Care Model (OCM), in which providers are held accountable for total costs of care. In the Radiation Oncology Model, only specified radiation therapy services provided during the 90-day episode would be included.
How will participants get paid?
There will be two installments for all participants, one at the beginning and another at the end of an episode. To do this, CMS will issue new model-specific HCPCS codes and modifiers to signal the start and end points. However, participants will still need to submit encounter data (no-pay) claims for all radiation services included in the bundle. Even though they will not be separately reimbursed for this, it is critical CMS to monitor utilization under the model.
What is the aggregate quality score (AQS)?
Starting in performance year (PY) 1, the AQS would be used to calculate the quality reconciliation payment for professional and dual participants. In addition, professional and dual participants will be required to submit clinical data. While those data elements aren't finalized yet, the proposal mentions that this could be required for specific tumor types, such as breast, lung, prostate, brain metastases, and bone metastases, and could include cancer stage, disease involvement, treatment intent, and specific treatment plan information. The plan is to share this information with EHR vendors and specialty societies to help build reporting standards into current platforms.
By PY3, patient experience scores will be added to the AQS for dual and professional participants. For technical participants, patient experience scores will be added in as well and applied to the 1% patient experience withhold outlined above.
As you can see in the table below, the measures are a mix of pay-for-reporting and pay-for-performance:
How would CMS calculate the AQS?
The equation for the AQS is: AQS = quality measures (0-50 points based on weighted measure scores and reporting) + clinical data (50 points when data is submitted for at least 95% of applicable beneficiaries)
For the pay-for-performance measures, participants' performance will be compared to MIPS benchmarks. For the pay-for-reporting measures, the plan is to gather those benchmarks and then shift them to pay-for-performance. All quality measures will be weighted equally, awarded up to 10 points, and then recalibrated to a denominator of 50 points.
How would the AQS impact payment?
AQS would be taken as a percentage against the 2% quality withhold amount. So, if a participant receives an AQS of 88.3, the participant will receive 1.77% of the reconciliation payment amount. If a total episode payment after all of the discounts and adjustments was $2,465.68, the quality reconciliation payment would be $43.64 ($2,465.68 x 0.0177).
Would this model count as an advanced alternative payment model (APM)?
Yes. There will be an individual practitioner list so CMS can make Qualifying APM Participant (QP) determinations for APM incentive payments and to identify any MIPS-eligible clinicians for the MIPS APM.
To qualify as an advanced APM, a model must meet the following:
- Use certified EHR technology:
- Include quality measure performance as a factor when determining payment; and
- Bear financial risk for monetary losses.
CMS believes this proposal would meet the requirements. One point of contention could be that an advanced APM needs to include an outcomes-based measure, but CMS feels there is not currently any outcome measure that is available or applicable to this model.
What does this mean for practices enrolled in the OCM?
Practices in selected CBSAs that are also enrolled in OCM will still be required to participate. While the radiation oncology episode is limited to just radiation-related services, OCM looks at total costs of care so changes in radiation oncology costs could impact an OCM participant's performance. To account for this, CMS proposes the following scenarios:
- Entire radiation oncology model episode (90 days) occurs within a six-month OCM episode: The associated radiation payments would be included in the OCM episode. But to account for the radiation oncology model impact, the radiation oncology model's discount and withhold amounts (explained above) will be added to the total cost of the OCM episode during the reconciliation process. This is meant to avoid double counting of savings and double payments of the withhold amounts between the two models.
- Radiation oncology model overlaps partially with an OCM episode: The radiation oncology services and payments would be attributed to the OCM on a prorated basis based on the days of overlap.
CMS also stated that it intends to continue reviewing overlap with OCM and that CMMI will notify OCM participants of any further impact or information.
When it comes to other payment programs, CMS does propose waiving specific payment adjustments that depend on whether or not care is delivered in a freestanding or HOPD setting. For example, it will waive the MIPS payment adjustment factor and Outpatient Quality Reporting Program payment adjustment for all radiation services included in the bundle. This will ensure that payment comparisons across HOPDs, freestanding centers, and physician group practices are not impacted due to performance in those specific programs. For the APM incentive program, CMS will waive the inclusion of technical fees and only include professional fees.
Will Medicare Advantage patients be enrolled?
Nope, just patients in Medicare fee-for-service. Patients must receive radiation services in a five-digit zip code linked to a selected CBSA, have a qualifying ICD-10 diagnosis code, and be enrolled in Medicare Part B. Patients in clinical trials for which CMS pays routine costs will also be enrolled in the model.
Is CMS really including proton beam therapy?
Yes, CMS proposes including proton specifically because of the debate around its value. In the proposal, CMS refers to ICER's report finding that proton offers superior net health benefit for ocular tumors, incremental net health benefit for adult brain and spinal tumors and pediatric tumors, and comparable net health benefit for prostate, lung, and liver cancers. One of the main goals of this model is to incentivize providers to choose the highest-value modality, and including proton in the model is critical to accomplish that.
Of note, proton may be excluded if patients are enrolled in a federally-funded, multi-organizational, randomized control clinical trial.
Comments on the proposal are being accepted at the Federal Register until 5 p.m. EST September 16, 2019.
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