To the Editor:
Drs Howard and Torres provided a synopsis of the alternative payment model for radiation oncology proposed by the Centers for Medicare & Medicaid Services (CMS).1 Four points deserve further consideration.
First, the scope and mandatory participation are radical departures from previous alternative payment models that have largely been voluntary with limited participation. Of radiation oncology episodes for traditional fee-for-service Medicare patients, 40% will be included in the Radiation Oncology Model. Thus, 60% of the specialty essentially will be assigned to a control group and 40% to an experimental group. From 2013–2015, this would have included more than 250,000 episodes of care.2 The model should be piloted via an evidence-based approach to assess its function and consequences before a widespread mandate is adopted.
Second, as noted by the authors, the complex payment methodology is fraught with challenges. Although a full discussion is beyond this letter’s scope, major issues include the 4%−5% discounts (larger than the 1.5%−4% discounts in prior alternative payment models) and limited application of the 5% incentive payment to only 10%−20% of reimbursements. Furthermore, final practice-specific payment is heavily weighted by historical costs (90%), which are calculated from error-prone claims data, making the final payment not truly site-neutral. The Radiation Oncology Model also undervalues care underrepresented within the Medicare dataset (e.g. those requiring multiple radiation modalities), leaving practices treating higher-risk patients at financial risk.
Third, the authors observed that CMS believes that the use of more expensive treatments have increased without adequate evidence basis. Innovative therapies over 3 decades have improved the therapeutic window for radiation oncology patients3; intensity-modulated radiation is a centerpiece of that innovation.4 There is concern that the structure of the Radiation Oncology Model threatens to stifle innovative cancer care. The American Society of Radiation Oncology has suggested that the model cover new technology at fee-for-service rates for a limited time and adopt a rate review mechanism for new service lines and upgrades.5
Fourth, alternative payment models provide an opportunity to mitigate the growing administrative requirements of modern cancer care typified by fee-for-service. However, the Radiation Oncology Model falls short of this goal by mandating unfunded collection and reporting of quality measures and clinical data for all patients (not limited to Medicare patients) that will stress administrative resources.5
Footnotes
Conflict of Interest Disclosures: None reported.
Contributor Information
Trevor J. Royce, Department of Radiation Oncology, University of North Carolina at Chapel Hill.
Nikhil G. Thaker, Division of Radiation Oncology, Arizona Oncology, Tucson.
Ankit Agarwal, Department of Radiation Oncology, University of North Carolina at Chapel Hill.
References
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- [5].Thevenot L ASTRO-RO Model Final Comment Letter: Medicare Program; Specialty Care Models to Improve Quality of Care and Reduce Expenditures. 2019. https://www.astro.org/ASTRO/media/ASTRO/Daily%20Practice/PDFs/ASTRO-ROModelFinalCommentLetter.pdf. Last accessed January 8, 2020.