On July 10, 2019, the Centers for Medicare & Medicaid Services released a proposed rule that outlines two new proposed mandatory models: the Radiation Oncology Model (RO Model) and the End-Stage Renal Disease (ESRD) Treatment Choices Model (ETC Model). The proposed rule includes details about the payment, participation, and timeline of each model. Comments on the proposed rule are due on September 16, 2019.

For information on the ETC model, please see our coverage here.

The RO model is designed to promote quality and financial accountability for providers and suppliers of radiotherapy (RT). Participants will include hospital outpatient departments (HOPD), freestanding radiation therapy centers, and physician group practices (PGPs).

Participation in the RO Model would be mandatory for all RT providers and suppliers furnishing radiation therapy services within randomly selected Core Based Statistical Areas (CBSAs) as delineated by the Office of Management and Budget (OMB). RT providers and suppliers will be linked to a CBSA using the zip code where RT services are furnished. Certain providers and suppliers will be excluded from participation, including those classified as an ambulatory surgical center (ASC), critical access hospital (CAH), or Prospective Payment System (PPS)-exempt cancer hospital.

The RO Model will run for five calendar years beginning in 2020 and end on December 31, 2024. All episodes of care furnished within this period will be included in the model, but no new episodes will initiate after October 3, 2024. CMS notes that data collection, episode payments, and reconciliation will likely continue into calendar year 2025. However, CMS does say they are considering the alternative of delaying implementation to April 1, 2020 to give additional time to prepare. This will limit the length of performance year 1 to nine months while the remaining performance years (2-5) would be 12 months. CMs is seeking comments on this possible delay.

Seventeen types of cancer will be included in the model as determined by the following criteria:

• All are commonly treated with radiation;
• Make up the majority of all incidence of cancer types; and
• Have demonstrated pricing stability

The cancers in the table below are included in the RO Model.

 

Cancer Type	ICD-9 Codes	ICD-10 Codes
Anal Cancer	154.2x, 154.3x	C21.xx
Bladder Cancer	188.xx	C67.xx
Bone Metastases	198.5x	C79.5x
Brain Metastases	198.3x	C79.3x
Breast Cancer	174.xx, 175.xx, 233.0x	C50.xx, D05.xx
Cervical Cancer	180.xx	C53.xx
CNS Tumors	191.xx, 192.0x, 192.1x, 192.2x, 192.3x, 192.8x, 192.9x	C70.xx, C71.xx, C72.xx
Colorectal Cancer	153.xx, 154.0x, 154.1x, 154.8x	C18.xx, C19.xx, C20.xx
Head and Neck Cancer	140.xx, 141.0x, 141.1x, 141.2x, 141.3x, 141.4x, 141.5x, 141.6x, 141.8x, 141.9x, 142.0x, 142.1x, 142.2x, 142.8x, 142.9x, 143.xx, 144.xx, 145.0x, 145.1x, 145.2x, 145.3x, 145.4x, 145.5x, 145.6x, 145.8x, 145.9x, 146.0x, 146.1x, 146.2x, 146.3x, 146.4x, 146.5x, 146.6x, 146.7x, 146.8x, 146.9x 147.xx, 148.0x, 148.1x, 148.2x, 148.3x, 148.8x, 148.9x, 149.xx, 160.0x, 160.1x, 160.2x, 160.3x, 160.4x, 160.5x, 160.8x, 160.9x, 161.xx, 195.0x	C00.xx, C01.xx, C02.xx, C03.xx, C04.xx, C05.xx, C06.xx, C07.xx, C08.xx, C09.xx, C10.xx, C11.xx, C12.xx, C13.xx, C14.xx, C30.xx, C31.xx, C32.xx, C76.0x
Kidney Cancer	189.0x	C64.xx
Liver Cancer	155.xx, 156.0x, 156.1x, 156.2x, 156.8x, 156.9x	C22.xx, C23.xx, C24.xx
Lung Cancer	162.0x, 162.2x, 162.3x, 162.4x, 162.5x, 162.8x, 162.9x, 165.xx	C33.xx, C34.xx, C39.xx, C45.xx
Lymphoma	202.80, 202.81, 202.82, 202.83, 202.84, 202.85, 202.86, 202.87, 202.88, 203.80, 203.82, 200.0x, 200.1x, 200.2x, 200.3x, 200.4x, 200.5x, 200.6x, 200.7x, 200.8x, 201.xx, 202.0x, 202.1x, 202.2x, 202.4x, 202.7x, 273.3x	C81.xx, C82.xx, C83.xx, C84.xx, C85.xx, C86.xx, C88.xx, C91.4x
Pancreatic Cancer	157.xx	C25.xx
Prostate Cancer	185.xx	C61.xx
Upper GI Cancer	150.xx, 151.xx, 152.xx	C15.xx, C16.xx, C17.xx
Uterine Cancer	179.xx, 182.xx	C54.xx, C55.xx

 

Payment will cover select RT services furnished to Medicare fee-for-service (FFS) beneficiaries during 90-day episodes. CMS is proposing to include treatment planning, technical preparation and special services (simulation), treatment delivery, and treatment management as the included RT services in an episode. RO Model payments would only replace current FFS payment for the included services furnished during an episode. The agency specifically notes they are not proposing to include E&M services as part of the episode payment.

The payment will be site-neutral and episode-based. Episode payments are split into two components: professional component (PC), which is intended to reflect services delivered by the physician, and a technical component (TC), which includes costs incurred by the practice for delivering such services. The rule notes that payment is being split into the two components to reflect that these services are sometimes furnished by separate providers and suppliers and paid for under difference payment systems.

The PC will include RT services that may only be provided by a physician while the TC includes services not furnished by a physician, such as provision of equipment, supplies, personnel, and costs related to RT services. Participating providers can choose to furnish both the PC and TC by electing as a dual participant through one entity, such as a freestanding radiation therapy center. An episode is triggered if both of the following conditions are met:

• An initial treatment planning service is furnished by a professional or dual participant; and
• At least one radiation treatment delivery service is furnished by a technical or dual participant within the following 28 days.

A new episode would not initiate until at least 28 days after the end of the previous episode.

CMS is proposing to set a separate payment amount for each PC and TC for each of the cancer types. The payments will be based on proposed national base rates, trend factors, participant case-mix adjustments, historical experience, and geographic location. The payment will include withholds for incomplete episodes, quality, and, starting with performance year (PY) 3, beneficiary experience. Participating providers can earn back some of this withhold based on reporting of clinical data, reporting and performance on quality measures, and, as of PY 3, performance on the beneficiary-reporting CAHPS Cancer Care Radiation Therapy Survey.

Four quality measures are being proposed for adoption in the RO model. Three of these measures are also approved for the Merit-based Incentive Payment System (MIPS). CMS believes the chosen measures are applicable for all of the proposed included cancer types. Providers will be paid for performance based on three of the measures and paid for reporting based on one measure for the first two performance years. Patient experience measures based on the CAHPS survey will be added for PY 3. The four quality measures are:

• Oncology: Medical and Radiation- Plan of Care for Pain (NQF 0383, CMS Quality ID 144)
• Preventive Care and Screening: Screening for Depression and Follow-Up Plan (NQF 0418, CMS Quality ID 134)
• Advance Care Plan (NQF 0326, CMS Quality ID 047)
• Treatment Summary Communication- Radiation Oncology

CMS anticipates that the RO Model would be both an Advanced APM and a MIPS APM.

CMS believes that the proposed RO Model is compatible with existing models and programs, including the Oncology Care Model (OCM). The agency does note that they will work to resolve any overlaps between the RO Model and other models and programs that might result in repetitive services, duplicative payment, and duplicative counting of savings or other reductions in expenditures.

Beneficiary coinsurance amounts will remain in effect with this model. Beneficiaries enrolled in Medicare Advantage plan will be excluded from the RO model. Provider participants will have to notify a beneficiary of their inclusion in the model using a standardized written notice during the treatment planning session. CMS plans to provide a notification template.