Radiation Oncology Alternative Payment Model Research Articles

Stereotactic Radiotherapy Deserts are Under-Represented among Radiation Oncology Alternative Payment Model Sites

In bundled payment models including the proposed Radiation Oncology Alternative Payment Model (RO-APM), reimbursement favors shorter treatment paradigms like stereotactic radiotherapy (SRT). However, SRT requires specialized equipment, staff, and quality assurance procedures not available across the US. To understand the geospatial distribution of SRT and its impact on bundled payment models, we investigated the interplay between SRT resources with sociodemographic characteristics and oncologic outcomes for an index site of prostate cancer (PC). We constructed an ecologic study model using data from the HRSA Area Health Resources, AMA Physician Masterfile, USDA Agriculture Economic Research Service, Medicare Provider and Service Files, and NIH Cancer State Profiles. SRT use was operationalized as the presence of Medicare SRT billing codes. Sociodemographic variables included county racial distributions, %poverty, and rural vs. urban classification. Provider to patient at risk density (PPRD) was defined as number of radiation oncologists per 100,000 males ≥65 years. PC incidence and death rates were evaluated. Uni- and multivariable logistic regressions examined links between SRT use, proposed RO-APM status, PPRD, sociodemographic variables, and PC oncologic outcomes at the US county level. All listed statistics demonstrated p <0.05. SRT use was identified in 13% of all 3140 counties and in 49% of counties with documented RO providers. In univariable analyses, odds of SRT use was higher in counties that were metro [odds ratio (OR) 19.9] and with higher %Black constituents (OR 6.95); odds decreased with higher %poverty (OR 0.92). Among counties with RO providers, odds of SRT use increased with higher PPRD (OR 1.01). Odds of SRT use was associated with higher PC incidence (1.01) but lower death rates (OR 0.99). SRT use was more common in participating RO-APM counties (OR 2.66); moreover, magnitude and direction of associations between sociodemographic variables and RO-APM participation were similar to those for SRT use. In multivariable analysis, SRT use remained significantly associated with metro status, %Black constituents, PPRD, and PC death rates. Both SRT use and proposed RO-APM participation were most prevalent in metro counties with higher PPRD and %Black populations, likely reflecting presence of densely populated cities with high health resources. If SRT is incentivized in future reimbursement models, then rural, lower resource communities without SRT may be disadvantaged. Lack of association between SRT and PC incidence indicates the presence of "SRT deserts"-counties with high oncologic need but no SRT. To enable visualization of SRT deserts and encourage interventions aimed at reducing disparities in SRT access, our results will be included in an interactive web platform (bit.ly/density maps).

Improving the Radiation Oncology Alternative Payment Model

The Centers for Medicare and Medicaid Services (CMS) proposed Radiation Oncology Alternative Payment Model (RO-APM) intends to introduce an episode-based compensation model and is currently delayed until further notice. We aimed to investigate cost implications of factors not considered in the initial model. We analyzed data from 10,226 patients who were treated with radiotherapy from 2018-2021 at Mayo Clinic in Minnesota, Florida, and Arizona. Mean total radiotherapy costs were calculated using inflation adjusted standardized Medicare rates for all codes in the RO-APM. Curative intent radiotherapy was delivered for 64.4% of patients while the remaining 35.6% was palliative intent. Patients receiving protons composed of 22.2% of all radiotherapy patients. Median number of fractions was 10. Mean cost for all curative treatments was $31,035 vs. $10,428 for all palliative patients (p<0.01). Mean cost for all patients treated with protons was $45,966 vs. $17,541 with photons (p<0.01). Mean costs for patients treated with 1-5 fractions, 6-10 fractions, 11-20 fractions, and >20 fractions were $11,261, $13,712, $21,793, and $45,672 respectively (p<0.01). Factors not considered in the final CMS RO-APM proposal such as treatment intent, utilization of proton therapy, and fractionation scheme all have significant cost implications and should be accounted for in future national base rate calculations.

Benchmarking the Radiation Oncology Alternative Payment Model: Changes in Medicare Reimbursement for 16 Common Radiation Therapy Treatment Courses

Radiation oncology (RO) has seen declines in Medicare reimbursement (MCR) in the past decade under the current fee-for-service model. Although studies have explored decline in reimbursement at a per-code level, to our knowledge there are no recent studies analyzing changes in MCR over time for common RO treatment courses. By analyzing changes in MCR for common treatment courses, our study had 3 objectives: (1) to provide practitioners and policymakers with estimates of recent reimbursement changes for common treatment courses; (2) to provide an estimate of how reimbursement will change in the future under the current fee-for-service model if current trends continue; and (3) to provide a baseline for treatment episodes in the event that the episode-based Radiation Oncology Alternative Payment Model is eventually implemented. Specifically, we quantified inflation- and utilization-adjusted changes in reimbursement for 16 common radiation therapy (RT) treatment courses from 2010 to 2020. Centers for Medicare & Medicaid Services Physician/Supplier Procedure Summary databases were used to obtain reimbursement for all RO procedures in 2010, 2015, and 2020 for free-standing facilities. Inflation-adjusted average reimbursement (AR) per billing instance was calculated for each Healthcare Common Procedure Coding System code using 2020 dollars. For each year, the billing frequency of each code was multiplied by the AR per code. Results were summed per RT course per year, and AR for RT courses were compared. Sixteen common RO courses for head and neck, breast, prostate, lung, and palliative RT were analyzed. AR decreased for all 16 courses from 2010 to 2020. From 2015 to 2020, the only course that increased in AR was palliative 2-dimensional 10-fraction 30 Gy, which increased by 0.4%. Courses using intensity modulated RT saw the largest AR decline from 2010 to 2020, ranging from 38% to 39%. We report significant declines in reimbursement from 2010 to 2020 for common RO courses, with the largest declines for intensity modulated RT. Policymakers should consider the significant cuts to reimbursement that have already occurred when considering future reimbursement adjustment under the current fee-for-service model or when considering mandatory adoption of a new payment system with further cuts and the negative effect of such cuts on quality and access to care.

Drivers of Medicare Spending: A 20-Year Review of Radiation Oncology Charges Allowed per Person as Compared to Other Specialties

<h3>Purpose/Objective(s)</h3> The rising cost of health care is a major concern in the United States. Though radiation oncology was targeted for cost reductions based on expenditure growth, subsequent analyses suggested stabilization of radiation oncology charges. In 2019, the Centers for Medicare and Medicaid Services (CMS) proposed a new radiation oncology model aimed at further reducing Medicare expenditures while potentially improving the quality of beneficiary care. In 2020, CMS issued a final rule establishing a Radiation Oncology Alternative Payment Model to begin Jan 1, 2022, although this was delayed to Jan 1, 2023 through the Supporting Health Care Providers During the COVID-19 Pandemic Act. We examined changes in aggregate Medicare charges allowed per person served and per Part B Enrollee to provide contemporary context to proposed changes and hypothesize that radiation oncology charges remained stable from 1999 through 2019. <h3>Materials/Methods</h3> Medicare physicians/suppliers' utilization, program payments and balance billing for original Medicare beneficiaries, by physician specialty, was analyzed from 1999 to 2019 through CMS program statistics. Total allowed physician charges per person with utilization, cost per original Medicare part B enrollee, inflation adjusted charges, and percent of total charges billed per specialty were examined, including hospital-based physician charges and free-standing center global charges. We adjusted for inflation using the consumer price index for medical care from the US Bureau of Labor Statistics. <h3>Results</h3> The average allowed charges per person served went from $2,065 in 1999 to $2,260 in 2019, when adjusting for inflation. The top three specialties accounting for the most charges per person served in 2019 were Hematology-Oncology, Medical Oncology, and Radiation Oncology with $1,706, $1,485, and $1,336 charges allowed per person served, respectively. Radiation oncology charges allowed by Medicare per person served decreased by 7% from 1999 to 2004 ($1,283 to $1,199), increased by 32% from 2004 to 2009 (from $1,199 to $1,588), decreased 3% from 2009 to 2014 ($1,588 to $1,544), and decreased another 13% from 2014 to 2019 ($1,544 to $1,336), when adjusted for inflation. Radiation oncology charges allowed per original Medicare part B enrollee was $53, or 1.4% of the $3,937 total for all specialties in 2019. <h3>Conclusion</h3> Oncology charges allowed by Medicare per person served are among the highest of all specialties. Radiation oncology physician charges per person served have decreased steadily from 2009 to 2019. Charges per original Medicare Part B enrollee represent a small fraction of total Medicare fee-for-service physician/supplier expenses. Thus, the need for an alternative payment model as a method to control radiation oncology physician charges may be overstated.

Changes Over Time for Radiation Oncology Reimbursement for Specific Treatment Courses

<h3>Purpose/Objective(s)</h3> Radiation oncology (RO) has seen declines in Medicare reimbursement (MCR) and will see an additional $300 million projected decline if the RO Alternative Payment Model (RO-APM) is implemented. To our knowledge there are no contemporary studies analyzing changes in MCR over time for common RO treatment courses. Understanding how reimbursement for RO courses has changed over time will provide a baseline comparison for the RO-APM, as MCR under RO-APM is episode-based. Our study aims to quantify changes in MCR for common photon RT treatment courses from 2010 to 2020. We hypothesize that the declines will be highest for IMRT treatment courses. <h3>Materials/Methods</h3> CMS Physician/Supplier Procedure Summary databases were used to obtain reimbursement for all RO procedures in 2010, 2015, and 2020 for free-standing facilities. Average reimbursement (AR) per billing instance was calculated for each Healthcare Common Procedure Coding System code using 2020-adjusted dollars. For each RT course, a RO billing expert selected the codes associated with that course along with the billing frequency of each code. For each year, the billing frequency of each code for a given treatment was multiplied by the AR per code and the results summed. AR for 15 common RO courses were analyzed: head and neck (HN), breast (B), prostate (P), lung (L), and palliative (Pa)(Table). <h3>Results</h3> AR decreased for all 15 courses from 2010 to 2020. From 2015 to 2020, the only course that increased in AR was palliative 2D 30 Gy/10 (0.4% increase). IMRT courses saw the largest AR decline from 2010 to 2020. The AR for a 37-fx prostate bed IMRT plan averaged $32.1K in 2010, $23K in 2015 (-28%), and $19.7K in 2020 (-39%). The AR for a 5-fx IMRT accelerated partial breast irradiation (APBI) averaged $6.9K in 2010, $5.2K in 2015 (-25%) and $4.2K in 2020 (-39%). <h3>Conclusion</h3> We report significant declines in MCR from 2010 – 2020 for common RO courses with the largest declines for IMRT. Hypofractionated regimens were not spared severe cuts, discouraging its broader adoption. Policymakers should consider the significant cuts to MCR that have already occurred when considering further cuts, and the negative impact of such cuts on quality and access to care.

Impact of Radiation Oncology Advanced Alternative Payment Model on Black Americans

<h3>Purpose/Objective(s)</h3> In January 2023, the Centers for Medicare and Medicaid Services (CMS) will implement the Radiation Oncology (RO) Alternative Payment Model (APM) to reform how cancer patients receive radiotherapy (RT) and standardize payments for services. The CMS asserts that the purpose of this model is to "reduce Medicare expenditures while preserving or enhancing the quality of care for Medicare beneficiaries." The RO Model requires mandatory participation for 16 cancer types and encompasses RT providers from "randomly" selected zip codes that includes approximately 30% of all eligible Medicare recipients for these RT claims, with a stated goal of saving $230 million over the initial 5 years the model is to be in place. The purpose of this study is to analyze the potential impact of this model on already existing demographic disparities in cancer care between APM-affected zip codes and unaffected zip codes. <h3>Materials/Methods</h3> Demographic data from the agency for Healthcare Research and Quality and data from Zip Code Tabulation Areas (ZCTAs) for affected zip codes were used to examine demographics within affected and unaffected zip codes. Specific social determinants of health (SDOH) variables such as education, food stamps, median household income, and Gini coefficient were also examined. Data collected from the Surveillance, Epidemiology, and End Results (SEER) Program was used to analyze the difference in 5-year cancer incidence based on race and gender. Each individual APM diagnosis code was analyzed according to race and gender in order to determine the number of people impacted for the 16 different cancer types included within the RO Model. <h3>Results</h3> In total, 20.2% more black persons (1.56 million) and 1.9% fewer (878,000) non-Hispanic white (NHW) persons are included in APM zip codes compared with a randomly-selected U.S. population. There was no significant difference in SDOH variables between affected and unaffected zip codes; however, there is a higher population density (1990 vs. 1273 per sq. mile) and average population (16,000 vs. 10,000 per ZCTA) in APM zip codes. When examining all cancer diagnoses, 7.9% more NHW persons (480.3 per 100,000) than black persons (445.2) were diagnosed with cancer; however, when looking at only APM cancers, 17% more black persons (391.5 per 100,000) than NHW persons (334.5 per 100,000) were diagnosed. A breakdown of race and gender disparities showed 17.4% more black men than NHW men were included in the APM diagnosis codes when compared with a randomly-selected U.S. population. Likewise, NHW women had 15.2% (456.6 per 100,000) more cancer diagnoses than black women (396.4), but when looking at only APM cancer diagnoses, that gap narrowed to 7.2% (319.2 NHW vs. 297.7 black). <h3>Conclusion</h3> These data indicate that the RO APM Model is heavily imbalanced in terms of the number of black persons mandated to participate and further optimization of this model is needed before widespread adoption.

Proton beam radiotherapy for esophageal cancer: challenges and opportunities in the modern era

AbstractAs the NRG GI006 and PROTECT trials seek to confirm results of the first randomized trial supporting the utility of proton beam therapy for esophageal cancer, several outstanding questions are discussed in this review. First, the applicability/extrapolation of the existing randomized trial is mentioned. This includes a potentially larger benefit of PBT at non‐high‐volume centers with less surgical expertise, along with the emerging use of active scanning PBT approaches that could further improve toxicity profiles. Patient selection for PBT is then discussed, including differential utility for patients based on the degree of baseline comorbidities, the extent/location of disease, and the surgical case volume at the treating institution. PBT in the setting of emerging techniques, such as minimally invasive esophagectomy, is also mentioned. Next, costs of PBT and insurance coverage hurdles are described, especially regarding pre‐specified agreements between providers/institutions and payors, the need for cost‐effectiveness analyses for PBT in this population, and effects of the new radiation oncology alternative payment model. Finally, immunotherapy has now become a standard option for esophageal cancer (resected or unresected/recurrent/metastatic cases). Therefore, in the context of immunotherapy for these patients, revisiting the role of radiation dose‐escalation and elective nodal irradiation may be required.

An Overview of the Radiation Oncology Alternative Payment Model and Impact on Practices Serving Vulnerable Populations.

Radiation oncology reimbursement methodology has been largely unchanged over the past 30 years, and new approaches are of great interest to practicing radiation oncologists and other health care stakeholders. Traditional radiation oncology reimbursement is based on a series of individual codes for evaluation and management (professional) and technical services, yielding a complex reimbursement system. In an attempt to move toward a simpler, episodic payment model, bundling all of the codes into a single payment, an alternative payment model for radiation oncology was developed. The radiation oncology alternative payment model is a revolutionary change in how radiation oncologic services will be reimbursed and has potential to affect all aspects of radiation oncologic care. Here, the authors review the origin of the currently proposed radiation oncology model and discuss potential implications of this model on the provision of care, especially as it relates to rural practices and other underserved and vulnerable patient populations.

Americans Deserve to Get a Better Value From CMMI.

The CMS Innovation Center was created in section 3021 of the Affordable Care Act (ACA) with the promise to test payment and delivery models expected to reduce costs while improving or maintaining quality of care for Medicare, Medicaid, and Children's Health Insurance Program (CHIP) beneficiaries. Doug Badger's analysis of the Center for Medicare and Medicaid Innovation (CMMI), published in Inquiry, described how the CMMI has failed to accomplish its goals and makes a case for reforms. As a practicing clinician in private practice who has followed the implementation of the components of the Affordable Care Act, including the CMMI, his conclusions are not surprising. An examination of the clinically unworkable and recently delayed Radiation Oncology Alternative Payment Model demonstrates serious flaws in current CMMI methods. Government agencies have difficulty directing innovation. Clinicians know that real innovation will arise in unpredictable ways from the ingenious communities, providers, and organizations that deliver the care. Innovation will occur when an atmosphere of transparency forces providers to respond to the demands of patients. The CMMI would do well to redesign its processes. If "value" is the goal of CMS, then America deserves a better "value" from its healthcare agencies.

Impact of Radiation Oncology Alternative Payment Model on Community Cancer Centers.

An episode-based payment model, the Radiation Oncology Alternative Payment Model (RO-APM), is scheduled to go into effect in January 2022. This article investigates the effects of RO-APM on hospital-based and freestanding community centers. Historical Medicare data used to generate the RO-APM base rates were reviewed. A sensitivity analysis was performed to show how the RO-APM reimbursements compare with current reimbursements for commonly accepted treatment schedules and with current reimbursements at a large community practice. The RO-APM base rates represent a 2.2% decrease in overall Medicare reimbursement. Freestanding centers have historically billed at higher rates than hospital-based centers, however, and the RO-APM base rates represent a 6% decrease in global reimbursement for freestanding centers. The sensitivity analysis showed that, except for proton therapy, moderately hypofractionated treatment schedules will receive comparable reimbursement under RO-APM. Treatments using higher numbers of fractions of intensity-modulated radiation therapy or protons will see larger decreases in reimbursement. Application of the RO-APM base rates to the 2020 Medicare treatments in our health care network would result in small changes in expected reimbursement, but our sensitivity analysis indicated that Medicare reimbursement reductions could be as large as 23%. Compared with historical Medicare reimbursement, RO-APM base rates provide lower reimbursement for many common treatment scenarios, and this will have a larger effect on centers that use complex treatment techniques and longer fractionation schedules or have a large Medicare population.

American Brachytherapy Society radiation oncology alternative payment model task force: Quality measures and metrics for brachytherapy

Brachytherapy is an essential technique to deliver radiation therapy and is involved in the treatment of multiple disease sites as monotherapy or as an adjunct to external beam radiation therapy. With a growing focus on the cost and value of cancer treatments as well as new payment models, it is essential that standardized quality measures and metrics exist to allow for straightforward assessment of brachytherapy quality and for the development of clinically significant and relevant clinical data elements. We present the American Brachytherapy Society consensus statement on quality measures and metrics for brachytherapy as well as suggested clinical data elements. Members of the American Brachytherapy Society with expertise in disease site specific brachytherapy created a consensus statement based on a literature review and clinical experience. Key quality measures (ex. workup, clinical indications), dosimetric metrics, and clinical data elements for brachytherapy were evaluated for each modality including breast cancer, cervical cancer, endometrial cancer, prostate cancer, keratinocyte carcinoma, soft tissue sarcoma, and uveal melanoma. This consensus statement provides standardized quality measures and dosimetric quality metrics as well as clinical data elements for each disease site to allow for standardized assessments of brachytherapy quality. Moving forward, a similar paradigm can be considered for external beam radiation therapy as well, providing comprehensive radiation therapy quality measures, metrics, and clinical data elements that can be incorporated into new payment models.

Radiation Oncology Alternative Payment Model (RO-APM) Monte Carlo Simulations to Predict Financial Impact and Viability for Common Practice Types

The RO-APM will trial an episode-based payment schema over a five-year period starting in 2022. Practices were randomly selected for mandatory inclusion in the RO-APM. Participating departments have different case mixes, patients, and clinical practices that will dictate the relative impact of the RO-APM. It is our aim to create a highly versatile Monte Carlo model to simulate RO-APM effects on reimbursement and practice financial stability. In this study, we specifically focus on suburban and rural settings.Monte Carlo simulations were developed in Python to model the effects of the RO-APM model over the 5-year trial period. The model requires a patient population, distribution of delivery techniques, and fractionation patterns per delivery technique for each of the 16 defined disease sites. This information was gathered from two non-associated regional clinics: one that serves primarily a suburban population (SP) while the other serves a mixed SP and rural population (MP). All fixed and variable financial expenses were collected and included. The inclusion of extra administrative work for the RO-APM submission was also included using time-driven activity-based costing methods. Considering each clinic's Medicare population, statistical analyses of how the patient population, delivery technique, and fractionation patterns impact reimbursement for this subset population was performed. The RO-APM model was also compared to the fee-for-service model (FFS-M).Disease site distributions were within 7.5% absolute difference between the two clinics. The four most common disease sites treated averaged between the two clinics were lung (20.1%), breast (16.9%), prostate (12.6%), and head & neck (H&N) (9.9%). Fractionation patterns were within 3 fractions (fx) across all disease site modalities except for bladder (MP +19fx) and lung (MP +13fx) IMRT, and 3D H&N (MP +3.4fx). Medicare population was 30% and 33% for the SP and MP, respectively. The SP had a 10.4% ± 0.5% higher reimbursement rate in the RO-APM when compared to the FFS-M for its set of patients seen. The MP had a 5.0% ± 0.3% higher reimbursement rate in the RO-APM when compared to the FFS-M for its patient population. Investigating fractionation impact further, the correlation between the number of fractions across all sites/modalities and reimbursement rate increase for the RO-APM compared to the FFS-M was r (498) = -.45, P < 0.01, meaning that a lower number of fractions leads to a higher return in the RO-APM across multiple disease sites. Finally, additional administrative work in the RO-APM is expected to cost approximately 0.8% of the total reimbursement rate.In our analysis using extracted clinical patterns from two separate clinics, lower fractionation patterns can lead to a higher return on investment in the RO-APM compared to the FFS-M, demonstrating viability of the proposed RO-APM.

Comparison of Cost vs. Reimbursement for Definitive Radiotherapy in Locally Advanced Cervical Cancer Using Time-Driven Activity-Based Costing

In the last several decades, utilization of standard of care brachytherapy (BT) for locally advanced cervical cancer has declined, with increasing use of external alternatives associated with suboptimal outcomes. Emerging evidence implicates under-reimbursement but is incomplete, as prior studies have relied on surveys and lacked indirect costs. The impact of the upcoming Radiation Oncology Alternative Payment Model (RO-APM) on these trends is also unclear. This study used time-driven activity-based costing (TDABC) to compare the true cost of standard of care external beam radiotherapy (EBRT) plus BT boost with current and proposed reimbursement policy. We hypothesized that TDABC would reveal under-reimbursement of BT, which will be worsened under the RO-APM.TDABC was used to map out the entire patient care cycle, accounting for both direct and indirect costs. Costs were estimated by multiplying prospectively collected timestamps from a 66-patient cohort with nationally derived capacity cost rates for personnel, space, equipment, consumables, and overhead. Current fee-for-service (FFS) and proposed RO-APM rates were derived from Current Procedural Terminology (CPT) codes and public notices and used to calculate reimbursement-cost ratios.The direct cost of standard of care radiotherapy was $16435. Indirect costs and MRI guidance added $6690 and $1280. BT and EBRT total costs were higher than previously estimated using direct cost, survey based TDABC ($13663 vs $8609 and $9462 vs $4090, respectively). Although BT cost 44% more than EBRT, under FFS policy, it was reimbursed 12% less ($16145 vs $19769; 45% vs 55% of total payment), resulting in a > 4-fold lower margin. The reimbursement-cost ratio for BT vs EBRT was 1.18 vs 2.09. Switching to the RO-APM reduced these ratios to 0.76 vs 1.34 (using the FFS 45% vs 55% split in payment). Physician payment was less than cost of care (BT = 0.70).Unlike traditional measurements indexed on charges, TDABC more accurately estimates the true cost of care, particularly when using prospective timestamps and indirect costs. Current FFS rates undervalue the cost of BT relative to EBRT, which may be exacerbated by the RO-APM, incentivizing external alternatives (such as external boosts) over definitive care. TDABC can help policymakers align reimbursement with cost to mitigate declining BT usage, which may be worsening patient outcomes in an already underserved population.

Radiation Oncology Alternative Payment Model and Large Urban Academic Centers: Future Implications for Patients and Providers.

The radiation oncology alternative payment model (RO-APM) was developed by the Center for Medicare and Medicaid Innovation, a part of the Centers for Medicare & Medicaid Services, as a vehicle to optimize value for patients undergoing radiation therapy. By shifting reimbursement away from fee-for-service and toward a prospective bundled payment system, the RO-APM is intended to bend the cost curve in radiation oncology while preserving or even enhancing outcomes. As with prior large-scale policy initiatives, the nature and magnitude of the RO-APM's impact on care delivery will vary substantially depending on a host of local factors, including practice setting. Urban academic centers play a key role in radiation oncology by spearheading innovation, managing the most complicated cases, training the next generation of radiation oncologists, and often caring for vulnerable patient populations. Thus, to protect patients' access to this high-quality cancer care, it will be crucial to characterize the RO-APM's projected impact on large urban academic institutions before its implementation, including possible unintended adverse consequences. Here, we provide an overview of this seismic change in radiation oncology reimbursement and discuss its unique potential implications for large urban academic institutions as a means to facilitate necessary preparations and inform future revisions to the model.

Assessment of MRI-Linac Economics under the RO-APM.

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.

Disproportionate Negative Impact of the Radiation Oncology Alternative Payment Model on Rural Providers: A Cost Identification Analysis of Medicare Claims.

The Radiation Oncology Alternative Payment Model (APM) is a Medicare demonstration project that will test whether prospective bundled payments to a randomly selected group of physician practices, hospital outpatient departments, and freestanding radiation therapy centers reduce overall expenditures while preserving or enhancing the quality of care for beneficiaries. The Model follows a complicated pricing methodology that blends historical reimbursements for a defined set of services made to professional and technical providers to create a weighted payment average for each of 16 cancer types. These averages are then adjusted by various factors to determine APM payments specific to each participating provider. This impact study segregates APM participants into rural and urban groups and analyzes the effect of the Radiation Oncology Alternative Payment Model on their fee-for-service reimbursements. The main findings of this study are (1) the greater net-negative revenue impact on rural facilities versus urban facilities that would have participated in the Model this year and (2) the relative lack of high-value treatment services (ie, stereotactic radiotherapy and brachytherapy) delivered by rural facilities that exacerbates their negative impact. As such, rural providers participating in the Model in its current form may face greater risk to their economic viability and greater difficulty in funding technology improvements necessary for the achievement of high-quality care compared with their urban counterparts.

PD25-09 IMPLICATIONS OF THE RADIATION ONCOLOGY ALTERNATIVE PAYMENT MODEL ON PROSTATE CANCER CARE: ESTIMATES FROM MEDICARE EPISODES

INTRODUCTION AND OBJECTIVE:The Center for Medicare & Medicaid Services (CMS) announced a mandatory radiation oncology alternative payment model (RO APM) for 2022 to test whether an episode-based pa...

Impact of the Radiation Oncology Alternative Payment Model on Brachytherapy Reimbursement

PURPOSEThe Radiation Oncology Alternative Payment Model (RO Model) will test prospective radiotherapy episode-based payments for 16 common disease sites. We created an automated analytics platform to calculate the impact of the RO Model vs historical fee-for-service episode reimbursements for brachytherapy treatments within five community oncology practices for prostate, uterine, and cervical cancer. METHODS AND MATERIALSClaims data between January 1, 2017 and October 2, 2019 for prostate, uterine, and cervical cancer were analyzed as per the RO Model Final Rule methodology. Expected professional and technical component (PC and TC) reimbursements were compared for episodes that utilized brachytherapy alone vs combination modality (external beam and brachytherapy) in the RO Model vs historical reimbursements. RESULTS6,022 RO Model-defined episodes (60% prostate, 28% uterine, 13% cervical) were generated. Brachytherapy monotherapy episodes (14%) would have an average positive reimbursement in the RO Model (+$2,163 for prostate, +$711 for uterine, +$533 for cervical for the PC; +$12,168 for prostate, +$8,181 for uterine, +$11,322 for cervical for the TC), while combination modality episodes (15%) would have an average negative reimbursement in the RO Model (-$183 for prostate, -$1,701 for uterine, -$2,195 for cervical for the PC; -$374 for prostate, -$5,026 for uterine, -$2,801 for cervical for the TC). CONCLUSIONSBrachytherapy monotherapy episodes for prostate, uterine, and cervical cancer will benefit from an increase in payment, whereas combination modality episodes will receive lower reimbursement. Large shifts in episodic payment may be related to practice-wide adjustments and pricing based on partial episodes of care that may ultimately limit access to care for vulnerable patient populations with cancer.

PP17 Presentation Time: 4:06 PM: Impact of the Radiation Oncology Alternative Payment Model on Brachytherapy Reimbursement

Purpose: The Radiation Oncology Alternative Payment Model (RO Model) will test prospective episode-based payments for radiotherapy episodes for 16 common disease sites. Most radiation modalities, including brachytherapy monotherapy, combination modality therapy, external beam radiation therapy and proton therapy, will be included in the model. We created an automated analytics platform to calculate the impact of the RO Model vs historical fee-for-service episode reimbursements for brachytherapy treatments within five community oncology practices for prostate, uterine, and cervical cancer.

PP18 Presentation Time: 4:15 PM: A Medicare Claims Based Analysis of the Radiation Oncology Alternative Payment Model upon Prostate Brachytherapy Reimbursement

Purpose: To estimate the impact of the finalized Radiation Oncology Alternative Payment Model (RO-APM) relative to current Medicare Fee-For-Service payments upon prostate brachytherapy technical reimbursement in the hospital outpatient practice setting.