JCO Oncology Practice Special Series Focuses on The Radiation Oncology Alternative Payment Model and Potential Impact on Practices

Jan 14, 2022

By Geraldine Carroll, ASCO Publishing

A new payment model in radiation oncology takes effect in January 2022 and will make significant strides towards transitioning Medicare reimbursement models into an episode-based payment system for certain cancers. 
The Radiation Oncology Alternative Payment Model (RO-APM) is an alternative payment model developed by the Centers for Medicare and Medicaid Services (CMS). It will be implemented in selected centers initially and mandatory at all centers in the coming years. JCO Oncology Practice published a timely Special Series that examines the potential impact of the RO-APM on the oncology community and addresses concerns over access to care and quality metrics. 
The RO-APM is part of a broader initiative by the CMS Innovation Center (CMMI) to transform Medicare reimbursement from a fee-for-service to an episode-based payment system for 16 cancer types and incorporates quality metrics. Under this model, Medicare will pay providers a pre-determined, site-neutral, bundled rate for most radiation therapy services provided within a 90-day episode of care, rather than paying for each service individually. The goal of RO-APM is to incentivize providers to deliver radiation therapy services more efficiently while maintaining or improving the quality of care for patients.1
Radiation oncologist Chirag Shah, MD, served as guest editor of the series of 12 articles, which represent a broad range of stakeholders.
“We wanted to explore how the RO-APM is going to impact different groups, for example rural practices versus urban practices versus academic practices; how it is going to impact practices that do a lot of procedures and use special technologies; and how is it going to potentially exacerbate differences that already exist in the reimbursement climate that we operate in,” Dr. Shah said.

RO-APM’s Impact on Small and Rural Practices 

Small and rural practices that serve patients who are impacted by disparities due to geography and socioeconomic status will likely face significant challenges with the implementation of RO-APM. 
“The most important takeaway is that radiation practices are not all the same, so I think rural practices face unique challenges as compared to larger centers, and their patient populations may also face challenges in terms of ability to access certain types of care,” Dr. Shah said. “How [rural practices] have to handle finances and reimbursement is likely to be very different than large centers. I think it’s important to realize that, while CMS wanted to standardize reimbursement, since we don’t have standardized practices and standardized geographies, it may not be appropriate to standardize reimbursement in some cases.” 
Dr. Shah emphasized that RO-APM should account for these complexities and differences to allow providers to give patients the best care possible while not harming practices even in challenging situations. 
Join Y. Luh, MD, raises similar concerns in the article “Radiation Oncology Alternative Payment Model’s Impact on Small and Rural Practices,” about how the RO-APM may disproportionately affect smaller practices (JCO Oncol Pract. 2021:OP2100286). Dr. Luh noted that small and rural practices have “fewer opportunities to distribute higher fixed costs, greater baseline cost variation for historical episodes because of fewer episodes, and a payor mix that may include a larger proportion of Medicare or dual-eligible beneficiaries.” Additionally, Dr. Luh noted that smaller practices will likely face more financial pressure as they incur the cost of new quality metric reporting requirements, which are costly to abstract and report with limited administrative support. 

CMS and the History of Reimbursement in Radiation Oncology

Previous endeavors by CMMI in value-based reimbursement show that the willingness of CMS to listen, learn, and be flexible with providers will be paramount to the success of the RO-APM, according to Dr. Shah. 
The experience of CMMI in value-based reimbursement is captured in several articles in the series and serves as counterpoint to criticism of the new payment model. In the article “Innovation in Payment for Radiotherapy: The Radiation Oncology Model,” Kehoe et al. explore CMS methodology and the history of reimbursement in radiation oncology (JCO Oncol Pract. 2021:OP2100559). 
“I think it’s important that if you’re going to look at the model, it’s good to know what the architect of the model was thinking when they built it,” Dr. Shah said. 
In the article “Radiation Oncology’s Place in Payment Reform: At the Table, Not on It,” Hubbard et al. illustrate the efforts of the American Society for Radiation Oncology (ASTRO) to advocate for a meaningful alternative payment model for radiation oncology and for changes that CMMI can make to improve the RO model (JCO Oncol Pract. 2021:OP2100294). 

Establishing Meaningful Quality Metrics 

How the RO-APM will improve the quality of care while reducing costs is a major concern among radiation oncologists. “I think that’s the biggest question—in some ways this model has the premise of improving quality, but no one knows what those metrics are yet and whether they are validated,” Dr. Shah said. “If you look at other models, they are really designed for validated metrics, proven from either prospective studies or large studies that really show the utility of a metric.” 
Dr. Shah cited quality metrics that exist in clinical trials for safety of dose to organs for different disease sites as an example of validated metrics. “We don’t know if that is going to be part of the quality metrics [of RO-APM],” Dr. Shah said. Practices are being asked to submit data, he noted, but it is not clear how that data will be incorporated into the model or which segments of data will be relevant to the quality metrics. 
Dr. Shah said a key question that is top of mind for many in the field is whether centers will drastically reduce the number of treatments for a given disease to reduce their costs and maintain their profit margins if reimbursement is fixed and centers have fixed costs. “We don’t know if that’s going to be the case or not, but it seems like that would be the opposite of trying to ensure quality,” he said.
Implementing quality metrics that are meaningful and account for the potential challenges that could impact patient safety and quality will be key, he said, as the field adapts to the RO-APM. 
  1. Centers for Medicare and Medicaid Services. CMS Announces Innovative Payment Model to Improve Care, Lower Costs for Cancer Patients. Sep 18, 2020. Available at: https://www.cms.gov/newsroom/press-releases/cms-announces-innovative-payment-model-improve-care-lower-costs-cancer-patients. Accessed Nov 9, 2021.
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