The CMS Radiation Oncology APM

 

The CMS Radiation Oncology APM and the opportunity for payers

The Centers for Medicare & Medicaid Services (CMS) Radiation Oncology Alternative Payment Model (APM) will likely pave the way for commercial health plans to improve the affordability of radiation treatment for their members.

In fact, despite the program’s six month delay, plans may be able to use the model’s momentum imminently: in October 2020, the CMS announced that the reimbursement model begins on July 1, 2021.

What is the CMS Radiation Oncology APM?

Bundled payments to advance value-based care

Proposed by CMS and the Center for Medicare & Medicaid Innovation, or CMMI, in July 2019, the CMS Radiation Oncology APM advances a prospective, episode-based payment methodology to accomplish two objectives: first, address coding and payment challenges, and second, promote value over volume of services while preserving or enhancing the quality of care for Medicare beneficiaries.

The model uses bundled payments to reimburse providers in select areas for a 90-day episode of radiotherapy for 16 types of cancer. Initial research estimates that the program will impact 30% of all radiation episodes nationally.

The program is site neutral: the model applies to all physician group practices, hospitals, and freestanding centers within the designated area.

Additionally, it is modality agnostic: the reimbursement is the same whether or not the provider prescribes proton beam therapy or a more conventional, less-expensive form of radiation therapy.

Ongoing calls for change to the radiation oncology bundled payments program

Since the announcement of the CMS Radiation Oncology APM two years ago, many providers have urged CMS to modify the bundled payment program because of two concerns: payment reductions and participation requirements.

In comments submitted to the CMS in September 2019 and again in October 2020, the American Society for Radiation Oncology (ASTRO) described the reduction as being “excessive.” The COVID-19 pandemic has only exacerbated providers’ financial concerns.

ASTRO has also contested the agency’s mandatory participation.

In a September 2019 letter to the CMS, Theodore L. DeWeese, MD, FASTRO, chair of the ASTRO Board of Directors, wrote:

“[M]andatory participation representing 30% of all radiation oncology episodes…goes too far for an untested model and runs counter to our recommendation that CMS launch the model as voluntary, then transition to a mandatory model that includes opt-outs for low-volume practices and hardship exemptions.”

An opening for health plans to partner with providers

Despite providers’ concerns about the specifics of the current CMS model, ASTRO has recognized the potential of a bundled payment model like CMS’s.

In a 2017 concept paper, ASTRO stated, “The Radiation Oncology Alternative Payment Model provides the field of radiation oncology with a meaningful and viable opportunity to participate in the evolving world of health care payment reform as initiated by MACRA.”

And in the same year, ASTRO outlined their own program, which includes more-modest reimbursement reductions, incentivizes for guideline adherence, and permits fee-for-service reimbursement for new technology and services.

Given this enthusiasm, numerous health plans are expected to consider iterations of the bundled payment model that better align with ASTRO recommendations, while still streamlining reimbursement for commercial beneficiaries being treated by high-volume providers.

Make the pivot to value

The CMS Radiation Oncology APM sets the stage for health plans to introduce similar value-based oncology models in their market.

But pivoting from volume to value also requires pivoting to new expertise and capabilities.

Our solutions and our people can help.

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