Providers raise concerns that the mandatory CMMI payment models will create unnecessary burdens and challenges.
The American Hospital Association and other key stakeholders are raising concerns about a proposed mandatory alternative payment model for radiation oncology that is scheduled to take effect in less than four months.
The Centers for Medicare & Medicaid Services announced in July that the five-year model would make prospective payments to cover radiotherapy services, in 90-day episodes, for patients diagnosed with 17 types of cancer.
The model would link payment to quality metrics and would require participation from physician group practices, hospital outpatient departments and freestanding radiation therapy centers in randomly selected geographic areas. It would also qualify as an Advanced Alternative Payment Model (APM) and Merit-based Incentive Payment System (MIPS) APM under the Quality Payment Program (QPP), CMS said.
A CMS fact sheet issued with the proposed rule said that the model would test whether episodic payments in a prospective and site-neutral fashion would reduce the amount Medicare spends on radiation services while maintaining or even improving quality.
In written comments, AHA called on CMS to a delay of the Jan. 1, 2020 starting date for the model, make the model voluntary, and "balance the risk versus reward equation much more appropriately."
"Our members support moving toward the provision of more accountable, streamlined care and are redesigning delivery systems to increase value and better serve patients," AHA wrote.
However, AHA added that hospitals and health systems "should not be required to participate in such a complicated program ... if they do not believe it will benefit the patients they serve. Moreover, other providers that may have the systems in place to excel under this new model could be excluded based on geographic location."
AHA said the proposed rule's requirement that model participants take on 100% risk immediately, without any stop-loss protections or adjustment for actual versus historical case mix "places too much risk and burden on providers with little opportunity for reward in the form of shared savings, especially in light of the significant investments required."
Those concerns were echoed by the Community Oncology Alliance. The nonprofit association said it supports efforts to transition away from fee-for-service to value-based payment models. However, COA said it "absolutely does not support mandatory CMMI models."
"CMMI should be working closely with COA and other organizations to develop a radiation oncology model that will first test and then implement the model on a broader scale," COA said in its formal comments. "We strongly believe that no provider, nor their patients, should be forced into any transformative model."
American Society for Radiation Oncology Board Chair Paul Harari, MD, acknowledged "some positive elements" in the model but raised concerns that it "falls short" of three key goals advocated by ASTRO; Rewarding radiation oncologists for quality initiatives that improve the value of healthcare; ensuring fair payment in both hospital and freestanding clinics to protect patient access; and incentivizing the appropriate use of cancer treatments.
"An ASTRO analysis estimates that the RO Model would cut payments to required participants by approximately $320 million during the 5-year period—an excessive amount that would undermine this unique opportunity," Harari said.
For the model to be successful, ASTRO recommended launch the model on a voluntary basis and trasition to mandatory on a limited basis, including opt-outs for low-volume practices and hardship cases.
ASTRO also identified what it called "serious flaws in the calculation approach for the national case rates," which it said would result in significant payment penalty for participants.
"We are concerned that the methodology fails to appropriately account for a range of complex clinical scenarios and average treatment costs for many clinics," Harari said.
To solve that, ASTRO recommended that CMS "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."
Harari said the payment adjustments proposed in the model could result in significant cuts to all participants and unfairly disadvantage "efficient" practices.
ASTRO recommended that CMS adjust the efficiency factor to avoid penalizing efficient practices and scale back the discount factors, and that CMS should pay for new technology at fee-for-service rates and adopt a rate review mechanism for new service lines and upgrades.
"The proposed RO Model would heap additional administrative tasks and costly requirements on already burdened radiation oncology practices that are required to participate in the model," Harari said.
ASTRO recommended that CMS delay many of these requirements and rely input from the radiation oncology community "to ensure that only information that is most meaningful and least burdensome is collected."
“We strongly believe that no provider, nor their patients, should be forced into any transformative model”
Community Oncology Alliance
John Commins is a content specialist and online news editor for HealthLeaders, a Simplify Compliance brand.
AHA called on CMS to a delay of the Jan. 1, 2020 starting date for the model, make the model voluntary, and "balance the risk versus reward equation much more appropriately."
COA says it supports a transition away from fee-for-service to value-based payment models, but "absolutely does not support mandatory CMMI models."
ASTRO says the proposal has 'some positive elements' but 'falls short' in several key areas.