Abstract
The implementation of the radiation oncology alternative payment model (RO-APM) has raised concerns regarding the development of MRI-guided adaptive radiotherapy (MRgART). We sought to compare technical fee reimbursement under Fee-For-Service (FFS) to the proposed RO-APM for a typical MRI-Linac (MRL) patient load and distribution of 200 patients. In an exploratory aim, a modifier was added to the RO-APM (mRO-APM) to account for the resources necessary to provide this care. Traditional Medicare FFS reimbursement rates were compared to the diagnosis-based reimbursement in the RO-APM. Reimbursement for all selected diagnoses were lower in the RO-APM compared to FFS, with the largest differences in the adaptive treatments for lung cancer (−89%) and pancreatic cancer (−83%). The total annual reimbursement discrepancy amounted to −78%. Without implementation of adaptive replanning there was no difference in reimbursement in breast, colorectal and prostate cancer between RO-APM and mRO-APM. Accommodating online adaptive treatments in the mRO-APM would result in a reimbursement difference from the FFS model of −47% for lung cancer and −46% for pancreatic cancer, mitigating the overall annual reimbursement difference to −54%. Even with adjustment, the implementation of MRgART as a new treatment strategy is susceptible under the RO-APM.
Highlights
In September 2020, the Centers for Medicare and Medicaid Services (CMS) submitted the revision to a new bundled reimbursement model for radiation oncology services provided to Medicare patients with a planned implementation date of 1 January 2022 [1]
As novel treatments and techniques tend to be more costly until efficiency is optimized, national committee (American Society for Radiation Oncology; ASTRO) recommendations have asked for a stay on including this new technology into the Radiation Oncology Alternative Payment Model (RO-APM) [3]
We proposed that the base rate of the modifier be the full reimbursement for the adaptive treatments under the current FFS model as delivered by modern volumetric modulated arc therapy (VMAT) technique with 2-arc plans
Summary
In September 2020, the Centers for Medicare and Medicaid Services (CMS) submitted the revision to a new bundled reimbursement model for radiation oncology services provided to Medicare patients with a planned implementation date of 1 January 2022 [1]. As novel treatments and techniques tend to be more costly until efficiency is optimized, national committee (American Society for Radiation Oncology; ASTRO) recommendations have asked for a stay on including this new technology into the RO-APM [3]. In this manuscript, we sought to explore the impact of the RO-APM on technical billing reimbursement and to determine a reimbursement strategy, whereby MR-guided adaptive radiotherapy (MRgART) may be viable
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