ASTRO Releases New Radiation Oncology Payment Reform Legislative Proposal

On June 23, ASTRO’s Board of Directors approved pursuing legislation to create a new Radiation Oncology Case Rate (ROCR) payment program under traditional Medicare, which would:

• Change radiation oncology payment from per fraction to per patient.
• Reverse decade-long declines in Medicare payments.
• Usher in a new era of stable payments, higher quality care, and reduced disparities.

ROCR represents a bold initiative to reverse disastrous Medicare payment trends. ASTRO believes ROCR is our best chance to secure long-term rate stability and continue to deliver cutting-edge care to patients close to home. ASTRO is seeking feedback on ROCR with the goal of securing broad support from the radiation oncology community before advancing this legislative proposal in Congress.

Background:

Medicare spends less on all radiation oncology treatments than it spends on just three top cancer drugs; yet radiation oncologists treat more than twice the number of beneficiaries. Despite its high value, radiation oncology has faced more payment cuts than nearly all other specialties through a combination of direct cuts and policy proposals that shift resources from specialty care to primary care. More cuts are likely to come.

The Facts:

• Medicare has cut RadOnc payments by more than 20% over the last 10 years.
• Practice costs are rising, as equipment and staff are getting more expensive.
• More Medicare beneficiaries are receiving radiation therapy.
• The current payment system penalizes the use of shorter treatment regimens.
• The CMS RO Model failed due to excessive payment cuts and administrative burden.

Without stable payments, access to care and quality will suffer and the field will struggle.

Radiation therapy is primed to make great gains for cancer patients, but the current Medicare payment system is prohibiting the investments necessary to achieve those goals. ASTRO refuses to let the status quo of cuts and failure of the RO Model stand in the way of radiation oncologists who are committed to providing greater value to their patients. The specialty needs to look forward and act now.

ASTRO has invested significant time and resources in developing this new Medicare payment system for radiation oncology. Developed by ASTRO’s Health Policy Council physician leaders from various practice settings and with the help of expert consultants, the ASTRO Board approved ROCR as a proposal in June after numerous versions were evaluated and analyzed.

Several practices, including private practices (freestanding and hospital based) and academic centers, modeled ROCR using the tool linked below and determined ROCR was favorable in comparison to expected Medicare fee-for-service payments.

Why ROCR?

Because it:

• Addresses the instability of the current payment systems;
• Aligns financial incentives with clinical guidelines;
• Ensures use of quality assurance and improvement standards;
• Reduces disparities by helping underserved patients initiate, access and complete treatments;
• Uses a more simplified approach than the CMS RO Model;
• Unifies payment that levels the playing field across care delivery settings;
• Updates payments annually based on medical inflation trends.

ROCR has precedent in past payment reforms for capital intensive health care services, such as End Stage Renal Disease, which is paid on a prospective basis.

ROCR Ins and Outs

• All radiation oncology practices participating in Medicare.
• Professional and technical services paid under Medicare physician fee schedule and hospital outpatient prospective payment system for 15 common cancer types.
• External beam modalities and associated services.
  • Conventional, IMRT, SRS, SBRT

• Services delivered in inpatient hospitals, ASCs, PPS-exempt cancer hospitals.
• Medicare Advantage and commercial insurance payments.
• New Technology and Services (without Cat 1 CPT codes).
  • i.e., Adaptive RT
• Services without national Medicare prices.
  • Proton therapy, surface guidance
• Lower volume services.
  • Protons, brachytherapy, radiopharmaceuticals

Excluded technology and services potentially eligible for inclusion in future years.

How does ROCR work?

1. Payment rates and RVUs are derived from “M code” case rates published by Medicare in 2022 for technical and professional payments for 15 cancer types.
   1. ASTRO’s consultants validated the accuracy of these unified payment rates.
   2. Half of the payment will be paid at the start of the radiation treatment.
   3. Final payment will be made at the end of the course of treatment.
2. Applies annual inflationary payment updates.
   1. Professional payments updated by the Medicare Economic Index.
   2. Technical payments updated by the Hospital Inpatient Prospective Payment System market basket update.
3. Applies a savings adjustment, which is phased in over five years. 
   1. Savings adjustment would reduce Medicare radiation oncology spending by slightly more than $200 million over five years, which is about 1% of total Medicare spending on radiation oncology each year or about $17,500 per practice, per year.
   2. Savings are needed for Congress to even consider ROCR.
   3. Savings are primarily derived from technical payments.
      1. ASTRO estimates ROCR’s level of savings to be less than what is likely to happen if current payment and hypofractionation trends continue.
4. Provides a Health Equity Achievement in Radiation Therapy (HEART) payment of $500 per patient to technical payments to cover transportation services for underserved patients.
   1. Triggered by using a standardized screening question and billing code.
5. Provides a technical payment incentive to earn/maintain practice accreditation, which is well accepted by radiation oncology clinics for assessing and improving quality of care.
   1. First three years, accredited practices receive a .5% positive payment adjustment.
   2. After three years, practices would receive a -1.0% adjustment for lack of accreditation.
6. Applies geographic adjustments and the federally mandated cut of 2%, per current law.

What’s next?

Practices are encouraged to use the modeling tool to compare payments under ROCR to trended fee-for-service payments. Tell us how your practice would perform under ROCR.

• Keep in mind that the tool does not account for additional expected Medicare payment cuts under the fee schedule and the continued impact of increasing hypofractionation on technical revenues.

Review the full ROCR report, technical analysis and modeling tool. We want to hear from you — please send us your feedback via email to Health Policy.

Read the draft letter to Congress and if you agree with ROCR, indicate your practice or organizational support by filling out this form.