Amidst the research presentations and showcases of cutting edge oncology care technology, the American Society of Radiation Oncology took time this week during its annual meeting to express its thoughts on the advanced alternative payment model proposed by the Centers for Medicare and Medicaid Services for radiation oncology.

First issued in July of this year, the proposal aims to further integrate value-based care in cancer treatment by encouraging the adoption of prospective site-neutral, episode-based payments. CMS claims that its model would reduce Medicare expenditures, while maintaining or enhancing the quality of care for Medicare beneficiaries. It is currently accepting commentary for potential adjustments that can be made to it.

“ASTRO appreciates CMS’ decision to move forward with an alternative payment model for radiation oncology and believes there are some positive elements in the proposed Radiation Oncology Model (RO Model),” said Paul Harari, M.D., FASTRO, chair of the ASTRO board of directors, in a statement. “We are concerned, however, that the proposal by the agency falls short of meeting three key goals established by ASTRO for the successful development of an alternative payment model.”

The goals in question include rewarding radiation oncologists for participation and performance in quality initiatives that improve the value of healthcare for patients; ensuring fairer, predictable payment for radiation oncologists in both hospital and freestanding cancer clinics to ensure patients in any setting have access to quality care; and incentivizing appropriate use of cancer treatments that result in the highest quality of care and best patient outcomes.

Based on its estimates, ASTRO claims that the model, if enacted, would cut payments to required participants by approximately $320 million during the first five years of its use, and recommends that CMS consider implementing specific changes to promote high-quality and efficient radiotherapy treatments that ensure value-based reform is met, and provide savings for Medicare.


Among its recommended changes are:

• Mandatory Participation: ASTRO claims requiring participation representing 40 percent of radiation oncology episodes is too much for an untested model. It suggests the model first be voluntary, and over time become mandatory on a limited basis, with opt-outs for low-volume practices and hardship exceptions.

• National Case Rates: The calculations for the national case rates would result in a significant and unfair payment penalty for participants, according to ASTRO. It says that the methodology does not appropriately account for a range of complex clinical scenarios and average treatment costs faced by many clinics. It asserts that CMS must include some physician fee schedule costs, properly attribute palliative care cases, and ensure adequate payments for patients receiving standard-of-care multi-modality treatments, such as combination therapy for gynecological cancer.

• Discount Factor and Efficiency Adjustment: The RO model’s proposed payment adjustments may lead to significant cuts to all participants and unfairly disadvantage "efficient" practices. CMS should adjust the efficiency factor to avoid penalizing these practices, and scale back the discount factors, which put access to care for patients at risk by creating financial issues for such a capital expenditure-intensive specialty.

• APM Incentive Payment: CMS should remove its selective waiver of the five percent APM incentive payment on freestanding center technical payments, because it undercuts MACRA’s encouragement of providers to assume risk and participate in APMs.

• Innovation: The RO Model does not adequately consider future advances in the delivery of radiation oncology. Practices should continue investing in innovations that provide clinical benefit for patients, and CMS should pay for new technology at fee-for-service rates, and adopt a rate review mechanism for new service lines and upgrades.

• Burden: The RO model would add more administrative tasks and costly requirements on already burdened radiation oncology practices that are required to participate in it. CMS should delay many of these requirements and instead go by recommendations from the radiation oncology community to ensure that the most meaningful and least burdensome information is collected.

Despite these critiques, ASTRO applauded CMS’ efforts to create a more efficient model, some of which, it admits, conforms with the recommendations of the Radiation Oncology Alternative Payment model concept paper submitted by ASTRO in April 2017. These include its views on prospective payment; the episode trigger mechanism, timeline and clean period; the establishment of distinct professional component and technical component payments; the inclusion of all modalities of treatment; and key quality measure elements.

“We believe the RO Model, with significant modifications, could represent a meaningful and viable first step toward enabling the field of radiation oncology to participate in the evolving world of health care payment reform as initiated by MACRA,” said Harari. “We are committed to working with the Agency to modify the model in such a way that it meets the stated goals.”

ASTRO's recommendations are based on feedback of ASTRO members. Should CMS’ RO model be enacted, its initiation is projected to begin in Jan. or April 2020 and end in December 2024.