Blog Post

Your top questions on the Radiation Oncology Model, answered

July 23, 2021

    Editor's note: This blog was originally published on September 30, 2020

    On July 19th, 2021, CMS released its Calendar Year (CY) 2022 Hospital Outpatient Prospective Payment System (OPPS) and Ambulatory Surgical Center (ASC) Payment System Proposed rule, which includes proposed updates to the upcoming Radiation Oncology Model (RO Model). Keep reading for answers to the most frequently asked questions we've received about the model based on the latest information from CMS.

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    Note: Since the answers below are based on the latest information from CMS, some of the model details may be finalized while others may still be proposed. Proposed model details are subject to change in CMS's CY 2022 OPPS/ASC final rule.

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

    What revisions did CMS make to the RO Model in the CY 2022 OPPS/ASC proposed rule?

    CMS proposed keeping the RO Model start date on January 1, 2022.

    The model performance period will be five years, beginning on Jan. 1, 2022 and ending on Dec. 31, 2026; each performance year (PY) will be a full calendar year. CMS also proposed the following revisions to several other aspects of the RO Model in the CY 2022 OPPS/ASC proposed rule:

    1. Participants in the Community Transformation track of the Community Health Access and Rural Transformation (CHART) Model or the Pennsylvania Rural Health Model (PARHM) will be excluded from participation. HOPDs that are eligible for but not participating in PARHM will not be excluded from the RO Model.
    2. The "low volume opt-out" criteria were updated to include any physician group practice, freestanding radiation therapy center, or HOPD that furnishes fewer than 20 episodes in all of the selected CBSAs in the calendar year that is two years prior to the start of the PY (instead of in the most recent year with claims data available).
    3. The baseline period used to calculate the national base rates, historical experience adjustments, and case mix adjustments will be the three calendar year period beginning on January 1 before the start of each performance period; for PY1, the baseline period will be January 1, 2017 through December 31, 2019.
    4. Along with using a participant's current TIN or CCN to calculate case mix and historical experience adjustments, CMS will also use a participant's "legacy TIN" or "legacy CCN," defined as a TIN or CCN that has previously been used to bill Medicare for included radiation therapy services.
    5. Liver cancer will be removed from the model along with a slight revision to the cancer inclusion criteria to improve clarity and consistency.
    6. Brachytherapy will be removed from the list of included modalities.
    7. The discount factor will be lowered from 3.75% to 3.5% for the professional component and from 4.75% to 4.5% for the technical component (contingent upon the finalized removal of liver cancer and brachytherapy from the model).
    8. Quality measure requirements will begin in PY1 (instead of being delayed to PY2); RO Model participants' first annual submission of quality measures data will be in March 2022 (instead of March 2023) to submit PY1 data (instead of PY2 data).
    9. Three quality measures (Plan of Care for Pain, Screening for Depression and Follow-Up Plan, and Advance Care Plan) will be pay-for-performance for PY1-5 (instead of PY2-5); the fourth quality measure (Treatment Summary Communication—Radiation Oncology) will be pay-for-reporting for PY1-2 (instead of PY2-3) and pay-for-performance for PY3-5 (instead of PY4-5)
    10. CAHPS Cancer Care Survey for Radiation will be administered starting in April 2022 (instead of October 2021).
    11. Data collection period for clinical data elements will begin in PY1 (instead of PY2), with the first submission of clinical data elements for Jan. 1, 2022 through June 30, 2022 due in July 2022.
    12. CMS will remove the 2% sequestration amount and instead will apply sequestration "in accordance with applicable law."
    13. In cases where a beneficiary switches from Medicare fee-for-service to Medicare Advantage during an episode before treatment is complete, their episode will be considered incomplete and CMS will pay the traditional Medicare rate.
    14. CMS expects the RO Model to meet the criteria to be both an Advanced Alternative Payment Model and a MIPS APM starting in PY1.
    15. Beginning in PY1, the individual practitioner list will be used to identify the relevant eligible clinicians for purposes of making Qualifying APM Participant (QP) determinations and for certain aspects of MIPS under the Quality Payment Program. Along with professional and dual participants, technical participants that are freestanding radiation therapy centers will also be provided an individual practitioner list. Participants who begin participating in the model after the start of a given PY must certify their individual practitioner list by the last QP determination snapshot date of that PY.
    16. The requirement that RO Model participants must use CEHRT in a manner sufficient to meet the applicable requirements of the Advanced APM criteria will now begin in PY1 (instead of PY2) and last through PY5.
    17. CMS will adopt an extreme and uncontrollable circumstances policy that allows it to adjust model performance periods, reporting requirements, and/or payment methodology when necessary. As part of this policy, it will consider removing 2020 data from baseline period or trend factor calculations, depending on results from its analysis of how the Covid-19 pandemic impacted claims submissions for radiation therapy services during 2020.

    What are CMS's 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 with 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 with 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, CMS emphasized the lack of uptake in hypofractionation despite growing evidence supporting its use.

    When will this model start?

    The RO Model is set to begin on Jan. 1, 2022 and continue for five years through Dec. 31, 2026. This start date is in accordance with the Consolidated Appropriations Act, 2021 which prohibits implementation of the model prior to that date.

    Will my organization have to participate?

    Participation in the RO Model is mandatory for all radiation therapy providers and suppliers within randomly selected Core-Based Statistical Areas (CBSAs) (listed here). The model is intended to include 30% of eligible radiation oncology episodes in the U.S.

    Given the model mechanics (explained in more detail below), there will be three types of participants:

    1. Professional participants: Physician groups billing under PFS that furnish just the professional component (physician-dependent services) at a freestanding center or HOPD;
    2. Technical participants: HOPD or freestanding centers that furnish only the technical component (equipment, overhead, etc.) of radiation therapy; and
    3. 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, PARHM, the Community Transformation track of the CHART Model, and PPS-exempt cancer hospitals. HOPDs that are eligible for but not participating in PARHM are not excluded from the RO Model.

    Additionally, physician group practices, freestanding radiation therapy centers, or HOPDs that would otherwise be required to participate in the RO Model will be allowed to opt out of the RO Model on an annual basis if they furnish fewer than 20 episodes across all selected CBSAs in the calendar year that is two years prior to the start of the PY.

    How will CMS set the prices for an episode of care?

    Here's a summary of the eight steps that CMS will use in its pricing methodology:

    1. Create national base rates for the professional and technical components for each cancer type. Since 15 cancers are included (liver cancer was removed in CMS's most recent proposal), CMS will create 30 base rates using historical average cost for an episode of care based on fee-for-service claims from 2017 to 2019.

      Here are the national base rates by cancer type CMS shared in the  CY 2022 OPPS/ASC proposed rule (in 2019 dollars):

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    2. Apply a trend factor to the base rates to reflect current trends in payment and treatment pattern changes.
    3. Apply geographic adjustments.
    4. 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.
    5. Apply a discount factor. The discount is the set percentage by which CMS will reduce an episode payment amount after the trend, geographic, and historic adjustments. The discount will be 3.5% for the professional component and 4.5% for the technical component.
    6. 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 1% 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 1%, a portion of it, or owe money to CMS.
      • The quality withhold will hold 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 during PY3 for the technical component and will be based on scores from the Cancer CAHPS for Radiation Therapy.
    7. Apply beneficiary coinsurance. Beneficiaries will still have 20% coinsurance, but they will have fewer and higher payments because of the nature of the bundle. CMS encourages providers to help set up payment plans for these patients, especially those without secondary insurance. CMS also notes that beneficiary coinsurance for the participant-specific technical payment amount cannot exceed the inpatient deductible limit under OPPS.
    8. Apply a sequestration adjustment in accordance with applicable law.

    Will this model include total costs of care during the 90-day episode?

    No. This makes this model different 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. Participants can submit an end of episode (EOE) claim requesting the second installment of the episode payment at the completion of the planned course of treatment (but no earlier than 28 days after the initial treatment planning service was furnished), instead of waiting until the end of the 90-day episode period as proposed (although the duration of the episode remains 90 days).

    That said, 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 for CMS to monitor utilization under the model.

    What is the aggregate quality score (AQS)?

    Starting in PY1, the AQS will be used to calculate the quality reconciliation payment for professional and dual participants. The AQS is based on the five pay-for-reporting and pay-for-performance quality measures in the table below and submission of clinical data elements.

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    CMS will administer the CAHPS Cancer Care Survey for Radiation starting in the fourth month of the model performance period at the earliest. 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.

    For the clinical data elements component, professional and dual participants will be required to submit clinical data biannually describing cancer stage, disease characteristics, treatment intent, and specific treatment plan information for RO Model beneficiaries with five types of cancer: prostate, breast, lung, bone metastases, and brain metastases. More details about clinical data elements can be found in CMS's new RO Model Quality Measure and Clinical Data Element Collection and Submission Guide and other resources can be found in the "Technical Documents" section of CMS's RO Model webpage. Data collection will start in PY1 and will be shared with EHR vendors and specialty societies to help build reporting standards into current platforms.

    What clinical data elements will participants be required to submit?

    The clinical data elements that professional and dual participants will be required to submit are included in the table below:

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    For RO beneficiaries with multiple primary cancers, participants must report the clinical data elements for the cancer type they bill for the episode.

    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 with 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?

    Yes. CMS expects the RO Model to qualify as an Advanced APM and a MIPS APM because it requires RO Model participants to annually certify their intent to use Certified Electronic Health Record Technology (CEHRT), includes quality measure performance as a factor when determining payments, and bears more than a nominal amount of financial risk. In addition, the RO Model requires participants to discuss goals of care and RO Model cost-sharing responsibilities with each RO beneficiary; adhere to nationally recognized, evidence-based clinical treatment guidelines when appropriate; assess each RO beneficiary's tumor, note, and metastasis cancer stage; and send a treatment summary to each RO beneficiary's referring physician within three months of the end of the treatment, which are all qualification requirements for Advanced and MIPS APMs.

    CMS explains that professional and dual RO Model participants who are APM Entities and eligible clinicians seeking Qualifying APM Participant status in an Advanced APM must comply with all RO Model requirements to be eligible for Advanced APM incentive payments. These participants will be considered to be participating in "Track One" of the RO Model. Track One RO Model participants who do not meet the Qualifying APM Participant threshold do not qualify for the Advanced APM incentive payment and may be required to report to MIPS and will be considered participants in a MIPS APM. Professional and dual participants who fail to meet any of the model requirements at the start of a PY will be moved into "Track Two" of the model for that PY and cannot participate in an Advanced APM or MIPS APM for the RO Model. Technical participants will also fall into Track Two of the RO Model and will not be considered to be participating in an Advanced APM or MIPS APM under the model.

    What does this mean for practices enrolled in the OCM or other CMS payment programs?

    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 finalized the following provisions for addressing overlap between the OCM and the RO Model provisions in two potential 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 will waive specific payment adjustments that depend on whether care is delivered in a freestanding or HOPD setting. For example, it will waive the MIPS payment adjustment factor for the technical component of RO Model payments (not the professional component) and the 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. If a beneficiary switches from Medicare fee-for-service to Medicare Advantage during an episode before treatment is complete, their episode will be considered incomplete and CMS will pay the traditional Medicare rate.

    Is CMS really including proton beam therapy?

    Yes, CMS finalized including proton specifically because of the debate around its value. CMS cited 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 will be excluded if patients are enrolled in a federally funded, multi-organizational, randomized control clinical trial.

    In addition to proton therapy, the following radiation modalities will also be included in the RO Model: 3-dimensional conformal radiotherapy (3DCRT), intensity-modulated radiotherapy (IMRT), stereotactic radiosurgery (SRS), stereotactic body radiotherapy (SBRT), and image-guided radiation therapy (IGRT).

    Which radiation therapy modalities are excluded from the model?

    CMS excluded intraoperative radiotherapy (IORT) from the model in the 2021 OPPS/ASC final rule because the evidence base for IORT is limited only to certain cancer types and because it is primarily delivered in HOPDs during surgery, meaning it is not site neutral. The decision to exclude IORT was upheld in the CY 2022 OPPS/ASC proposed rule, though CMS did reconsider the exclusion based on comments from stakeholders.

    In the CY 2022 OPPS/ASC proposed rule, CMS also excluded brachytherapy from the model to ensure that providers wouldn't be incentivized to forego brachytherapy in situations when a combination of both brachytherapy and EBRT is clinically indicated.

    What were the major milestones in implementing the RO Model?

    CMS first published its proposal for the Radiation Oncology Model in July 2019. It finalized the model in September 2020 with the intended start date of January 1, 2021. In the CY 2021 OPPS/ASC final rule published in December 2020, CMS announced its intent to delay the model start date to July 1, 2021 in response to feedback from stakeholders and the ongoing Covid-19 pandemic.

    On December 27, 2020, Congress enacted the Consolidated Appropriations Act, 2021, which prohibited implementation of the RO Model prior to January 1, 2022. CMS proposed additional modifications to the model design in the CY 2022 OPPS/ASC proposed rule, which was published in July 2021 and proposes starting the model on January 1, 2022. CMS is expected to release the CY 2022 OPPS/ASC final rule with finalized details for the RO Model in November 2021.

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