Is Radiation Oncology Ready for Alternative Payments?
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HHS Secretary Alex M. Azar II’s recent speech to the Patient-Centered Primary Care Collaborative in Washington, DC, indicated that there is a significant change in thinking of CMS about value-based-care and voluntary vs. mandatory participation in alternative payment model (APM) programs.
“We need results, American patients need change, and when we need mandatory models to deliver it, mandatory models are going to see a comeback… (CMS will) revisit some of the episodic cardiac models that we pulled back, and are actively exploring new and improved episode-based models in other areas, including radiation oncology,” according to Secretary Azar.
What will this mean for radiation oncology healthcare providers and the vendors that service them? A foundational and operational re-think will be needed to manage new challenges in documentation, records management, financial analytics and reimbursement.
Although it has not yet been revealed what the new payment model will be for radiation oncology, there are clues. Both the American Society of Radiation Oncology (ASTRO) and the Large Urology Group Practice Association (LUGPA) submitted payment models to CMS to consider. The proposal by LUGPA was specific to prostate cancer and has been rejected by CMS.
It is highly probable that the new oncology radiation model will be similar to the already ongoing voluntary Oncology Care Model (OCM), but based on ASTRO’s Radiation Oncology Alternative Payment Model (RO-APM) (PDF link) and unlike the OCM, it will be mandatory. ASTRO’s RO-APM incentivizes adherence to clinical guidelines for several cancers, including breast, prostate, lung, colorectal, and head and neck cancers. It also applies to two secondary disease sites: bone metastases and brain metastases. This RO-APM is based on an episodic payment that is triggered by a clinical treatment planning CPT (rather than with the actual delivery of treatment such as with the current OCM model) and concludes 90 days after the last radiation treatment.
Regarding payment structure, ASTRO’s RO-APM is very similar to the OCM in that it would also include a monthly fee called a Patient Engagement and Care Coordination Fee (PECC), and retrospective performance-based payment incentives. The activities and goals of the PECC and retrospective measures reflect those of the OCM.
However, one of the most significant differences between the OCM model and ASTRO’s RO-APM involves the payment of fees. The RO-APM is based on an episodic model that pays a portion at the beginning of treatment planning and a final payment at the end of treatment; which, for many practices, will be a fundamental change from fee-for-service radiation oncology reimbursement, and require an overhaul of billing systems and workflows.
Healthcare IT vendors, including EHR vendors, are not yet ready with one, single solution to meet all the requirements of a healthcare provider participating in OCM.
Secretary Azar’s remarks indicate a complete about-face concerning mandatory vs. voluntary participation for APM programs by the Trump administration that may affect not only radiation oncology but all aspects of medicine.
Healthcare IT vendors, including EHR vendors, are not yet ready with one, single solution to meet all the requirements of a healthcare provider participating in OCM. While some vendors can meet various quality measure reporting components, there is not one single vendor today that can address all the financial and operational obligations inherent in this type of APM.
More than two dozen IT vendors, including several EMR vendors, have made the OCM Vendor Pledge this year, which is a step toward a comprehensive IT solution. However, the complexities of the system pose significant barriers which will take several years to overcome.
Want to learn more about the state of the IT industry regarding bundled payments and APMs? Look for our Bundled Payments report coming out in the next couple weeks (or our blog for a short primer on the state of the market) and our Payment Integrity report slated for release in mid-2019.
Matt Guldin · 2 years ago
Chilmark Team · 2 months ago
John Moore · 1 month ago
Matt Guldin · 2 months ago