Oncology providers have come out against a proposed rule to bundle Medicare payments for radiation therapy, claiming it will put them at excessive financial risk and stifle innovation.
Freestanding radiation therapy centers, physician group practices and hospital outpatient departments that provide radiotherapy services for 17 types of cancer in specific parts of the country would be required to accept bundled payments under the proposed rule. The fees would cover some services like CT scans, dose planning and treatment aids over the first 90 days, but it wouldn't pay for the total cost of care provided to Medicare beneficiaries.
The CMS said the radiation oncology model would test whether making prospective episode payments for radiation therapy maintains or improves the quality of care that Medicare beneficiaries receive and reduces Medicare spending at the same time. The agency said the payments could achieve both objectives by increasing providers' financial accountability.
Providers and suppliers have financial incentives to provide prolonged courses of radiation therapy under the existing payment model because they receive additional funds for providing more treatment, the CMS said in its proposal. It believes that value-based payments would remove the financial incentive to provide more care without reducing quality.
"The latest clinical evidence suggests that shorter courses of (radiation therapy) for certain types of cancer would be equally effective and could improve the patient experience, potentially reduce costs for the Medicare program and lead to reductions in beneficiary cost-sharing," the CMS said in the proposed rule.
But providers think that the model would expose them to undue financial risk and cripple care innovation, as they would have to immediately accept full risk for radiotherapy services without any stop-loss protection or adjustments for their actual vs. historical case mix.
"This 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," the American Hospitals Association said in its comments.
Providers and suppliers are concerned that fixed, site-neutral payments for radiation therapy will lower investments in new technologies and equipment, as well as reduce access to new types of care.
They're especially concerned about how it could affect proton therapy, which uses a beam of protons instead of x-rays to destroy cancer cells. It's far more expensive to provide than other radiation therapies. Under the proposed rule, the CMS would reimburse it at the same rates as other types of radiation.
Several providers alleged that would hinder the quality goals of the new payment model by exposing patients to more radiation and increasing their risk of developing cancer in the future.
"By establishing payment rates that reimburse all modalities the same, CMS, by its own logic, is financially incentivizing providers to use the cheapest modalities which also tend to be those that deposit the greatest amount of radiation in healthy tissue," said Provision CARES Proton Therapy Center, which has locations in Knoxville and Orlando. "This entirely ignores side effects and potential secondary cancer profiles, running afoul of the desire to improve quality and patient care."
Similarly, the New York Proton Center called the rates "woefully inadequate" and said the changes would put patients at risk.
The CMS anticipated resistance to its inclusion of proton therapy in the new payment model. At the time, it cited evidence that the treatment wasn't cost-effective. The agency also noted that the Medicare Payment Advisory Commission in June 2018 said the CMS could use payment models to reduce low-value service use.
The American Hospital Association in its comment called the program "complicated" and said providers shouldn't be required to participate in the mandatory bundle for five years as proposed.
The CMS suggested that the program should go into effect on January 1, 2020. The agency is considering extending the start date to April 2020 to allow providers to prepare for its implementation. However, most providers don't think that's enough time.
Some providers wondered how they would implement the new model on the ground, including how beneficiaries would be notified that they're participating in the model. Under the proposed rule, the CMS would require providers to alert Medicare patients of their status during their first visit. But the CMS won't pay providers to inform patients and it wants to require them to confirm the diagnosis and a patient's participation in the model before that first visit is over.
"There is too much going on during an initial visit with a patient to be dealing with CMS payment models," said Valerie Rennell, Practice Administrator and Manager for Peachtree Radiation Oncology Services in Atlanta.