Providers are urging the Biden administration to make a drastic overhaul of a radiation oncology payment model if the agency decides to bring back the oft-delayed experiment.
Comments were due Tuesday on a Centers for Medicare & Medicaid Services (CMS) proposed rule that indefinitely delays the model, which already had its start date delayed to 2023 by Congress. Providers who have long fought the Trump-era model are worried that it could come back and call for major changes if that happens.
The model was created to reimburse oncology practices and outpatient hospital sites for total episodes of care. The mandatory model would also make site-neutral payments for specific radiation therapies. But the model has generated major industry and congressional pushback since its announcement. Various provider groups charged that the model masqueraded as a pay cut to oncology practices and hospitals.
“We believe that an overemphasis on demonstrating savings under the model has sacrificed achievable goals of quality improvement and payment stability,” said the American Society for Radiation Oncology (ASTRO) in its comments on the proposed rule.
Providers decried not just the mandatory nature of the model but also its payment methodology.
The model installed what ASTRO called a “site-neutral” test that created a national base rate for services despite where the service is furnished. The goal was to remove incentives among providers to promote one site for radiation services over another.
But providers charged that CMS relied on data from the Outpatient Prospective Payment System that details Medicare payment rates.
“Because this methodology will largely tend to reduce reimbursement rates for participants, facilities and providers that are required to participate in the mandatory [radiation oncology] model are disadvantaged relative to their peers,” said health system Ascension in comments on the model.
Ascension was also concerned about the need for a manual and specialized billing process for the model, creating more dedicated resources.
The model was originally supposed to start this year, but Congress passed a provision to delay it until the start of 2023.
CMS said in the proposed rule that the delays from Congress and the need to continue to devote funding to starting the model played a part in the decision for the indefinite delay.
It remains unclear whether CMS plans to ever start the model. The Center for Medicare and Medicaid Innovation is also taking a hard look at existing payment models to ensure they don’t overlap and can fully address health equity.
But providers are still worried about the model potentially coming back and asked for a series of reforms if CMS does so.
“Our experience in standing up value-based care models in both Medicare and commercial plans has taught us that there is typically significant investment required in software and staff training,” wrote the US Oncology Network, a collection of more than 900 physicians. “A voluntary model could be phased in and iterative to allow the most sophisticated practices to test the model before expanding it to practices that may have less resources.”
The network added in comments that there needs to be better communication between CMS and model participants.
“A primary shortcoming of the … model was the lack of communication between CMS and participating practices,” the network said. “Even though the model was set to start within weeks, CMS had yet to provide claims data, detailed billing guidance or critical pieces of the model’s financial methodology to participants.”
The American Medical Association (AMA) said CMS also needs to rethink its performance monitoring plan that requires practices to submit clinical data elements.
“At a time when physicians and other health professionals are facing tremendous levels of burnout following more than two years on the front lines of a global pandemic, CMS should work with the radiation oncology community to help them recover, not add to their already high data collection and reporting costs,” the AMA wrote.