Skip to main content

Update on the CMS Radiation Oncology Model

Background: 

After months of anticipation, CMS is planning to go forward with the mandatory Radiation Oncology Model. This bundled payment model, which was first announced in a proposed rule on July 10, 2019, with an anticipated start in January or April 2020, is notable for being one of the first mandatory models the industry has seen from CMS in years.

While the model has been delayed, in part due to the complications presented by the COVID-19 public health emergency, CMS finally broke its silence on the future of the model in September with the publication of the RO model final rule. A revised start date was announced in the OPPS final rule in December: the RO model is anticipated to begin on July 1, 2021 and will run through 2025.

Key facts:

RO participants include freestanding radiation therapy centers, hospital outpatient departments and physician group practices with radiation oncologists that furnish radiation therapy services. The model is mandatory for selected participants. These were chosen by random selection of Core-based Statistical Areas. Any entities that deliver radiation therapy within the selected CBSAs’ Zip Codes are included in the mandate. According to CMS, the model covers 30% of all eligible RO model episodes in the country.

Radiation therapy episodes are defined as 90-day episodes of care covering radiation therapy services only. This makes sense, as most courses of radiation therapy complete in under 90 days. Unlike previous CMS bundled payment programs, RO is not a total cost of care model. The model includes episodes for 16 cancer types, which primarily target solid tumors.

The RO payment model differs greatly from other Medicare bundled payment programs. Prospective payments will be made to providers who furnish the professional component of the episode (i.e., treatment planning) and providers who furnish the technical component of the episode (i.e., delivery of radiation therapy). The first half of the payment will be paid after the episode begins and the second half will be paid after the episode has ended.

While payment rates will be specific to the component of the episode and the cancer type, they will not vary by site of service. A variety of risk adjustments will also be applied in the creation of each RO participant’s payment rate to account for case mix and historical experience.

CMS will withhold a percentage of the episode payment amount up front, which will be later allocated during reconciliation based on metrics such as quality measure performance and patient experience.

What’s unique about this model?

RO takes several methodological features of prior Innovation Center models and introduces a few new concepts to create a unique evolution of alternative payment models. It marks a striking departure from other bundled payment programs — especially in the way it makes prospectively set payments for the bundle of services. Rather than continuing fee-for-service payments in the interim and settling up to a target price in the reconciliation, RO replaces existing fee-for-service payment structures for radiation therapy episodes. In this way, the RO payment mechanism bears a resemblance to capitated payment arrangements.

What is still unknown?

RO participants are still looking to CMS to release more information in the coming months, including new Healthcare Common Procedure Coding System codes to indicate the start and end of the episode by cancer type. CMS will host a much-anticipated billing guidelines webinar in January.

CMS plans to collect clinical data elements from RO participants beginning in January 2022. These CDEs would include important clinical information about the beneficiary’s disease that is absent from claims data, like cancer stage, treatment intent and dosage of radiation delivered. As practices currently in the Oncology Care Model can attest, this clinical data collection can be burdensome. CMS accepted comments on the currently proposed set of CDEs through mid-October, but industry stakeholders and RO participants are still waiting to hear how this will be finalized for the upcoming model.

There are still plenty of other unknowns clouding RO’s future: COVID-19 continues to surge throughout the country, the public health emergency declaration is likely to be extended again and a new administration takes office in January. All of these things may still impact the revised July 1 start date and the future of the RO model.

It’s going to be interesting to see how RO launches and develops. Levels of enthusiasm for mandatory bundled programs have fluctuated through changes in leadership at HHS over the past five years. It also marks one more alternative payment model focused on specialty care. RO could become the first testing ground for the next evolution of alternative payment models. Specialty care providers should keep a close watch on this program. To learn more about RO and other APMs be sure to contact us and request a free consultation.


Comments

Popular posts from this blog

Alternative payment models: Strategies for success

In this edition of DataGen Insights, we look at how alternative payment model participants can ensure their processes and workflows are optimally set up for success. To help, DataGen listed the top three strategies all providers participating in APMs can employ and created a handy checklist to enable maximum returns and reduce financial risk. Please explore our website to learn more about our  products and services .  Download DataGen Insights today .  We hope you enjoy!

Why it's critical for Primary Care First participants to control and understand leakage

Patients' primary care visits outside of their attributed primary care office, also called “leaked” patient visits, can have unintended consequences for Primary Care First participants. Beginning July 2022, PCF Cohort 1 will face a reduction in population-based payments based on their leakage rate. The payment adjustment will be based on their 2021 claims data and will roll forward quarterly. To calculate your leakage rate, divide the number of qualifying visits and services your attributed beneficiaries have made to care centers outside of your practice (for example, visits to urgent care centers) by the total number of qualifying visits and services your attributed beneficiaries have made. Calculating primary care leakage with claims data alone comes with some unintended challenges. Unfortunately, some circumstances can unfairly and negatively impact a practice’s leakage rate: Nuances classifying care delivered by provider team members: It’s difficult to distinguish

Start the year off right: DataGen answers your Primary Care First questions

The Primary Care First Model , an alternative payment model offering an innovative payment structure for the delivery of advanced primary care, welcomed the involvement of Cohort 2 participants on Jan. 1 . This cohort, which was open to all primary care practices that met the eligibility criteria, will participate from 2022 to 2026. Participants in PCF Cohorts 1 and 2 can expect the following benefits: an opportunity to increase revenue with performance-based payments that reward participants for reducing acute hospital utilization; the ability to assess and improve performance through actionable, timely data; less administrative burden so providers can spend more time focusing on patient needs; and potential to become a Qualifying APM Participant , which includes eligibility for a 5% incentive payment and eliminates Merit-based Incentive Payment System reporting requirements. To ensure that new and prior participants succeed in this model, DataGen has compiled and answered some of t