Since July 2019, we've been waiting to see how CMS would proceed with the proposed Radiation Oncology Model (RO Model). Well, the wait is over. CMS released the final rule for the RO Model earlier this month, and it's set to start on January 1, 2021. Keep reading for the answers to the most frequently asked questions we've received.
Check out our resources on CMMI's Oncology Care Model
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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 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, the proposal emphasized the lack of uptake in hypofractionation despite growing evidence supporting its use, which CMS reiterated in the final rule.
Will my organization have to participate?
CMS finalized that participation in the RO Model will be mandatory for all radiation therapy providers and suppliers within randomly selected Core-Based Statistical Areas (CBSAs) (listed here) as proposed. Compared with the proposed rule, CMS is reducing the scale of the RO Model from 40% of eligible episodes to 30% of eligible episodes. The final RO Model also includes a "low volume opt-out" for any physician group practice, freestanding radiation therapy center, or HOPD that furnishes fewer than 20 episodes in one or more of the selected CBSAs in the most recent year with claims data available.
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; and
- 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.
Has your organization been selected to participate in the RO Model? Email email@example.com if you'd be interested in joining a networking forum for program leaders to share how they're preparing, ask questions of one another, and brainstorm solutions together. This session is not intended to provide an in-depth review of methodology and will be best suited for leaders with strategic oversight of the cancer program.
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.
Additionally, physician group practices, freestanding radiation therapy centers, or HOPDs which would otherwise be required to participate in the RO Model will now 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 most recent calendar year with available claims data.
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:
- Create national base rates for the professional and technical components for each cancer type. Since 16 cancers are included, CMS will create 32 base rates using historical average cost for an episode of care based on fee-for-service claims from 2016 to 2018.
Here are the national base rates by cancer type CMS shared in the final rule (in 2018 dollars):
- Apply a trend factor to the base rates to reflect current trends in payment and treatment pattern changes.
- Apply geographic adjustments.
- 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, geographic, and historic adjustments. The discount will be 3.75% for the professional component and 4.75% 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 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 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 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.
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 performance year (PY) 1, the AQS will 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 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. CMS has yet to determine the specific clinical data elements that will be collected, but it noted it will determine these "prior to PY1" of the RO Model and communicate them on the RO Model website. Data collection will start in PY1 and will be shared 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 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 (APM)?
Yes. The RO Model qualifies as an Advanced Alternative Payment Model (APM) and a MIPS APM under the Quality Payment Program because it requires RO 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.
CMS explains that 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. RO 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.
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 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.
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), image-guided radiation therapy (IGRT), and brachytherapy (intraoperative radiotherapy was removed from proposed list).
Has your organization been selected to participate in the RO Model? Email firstname.lastname@example.org if you’d be interested in joining a networking forum for program leaders to share how they’re preparing, ask questions of one another, and brainstorm solutions together. This session is not intended to provide an in-depth review of methodology and will be best suited for leaders with strategic oversight of the cancer program.
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