RO APM Dies!

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Radiation Oncology (RO) Model Fact Sheet | CMS

The Radiation Oncology (RO) Model is an innovative payment model that aims to improve the quality of care for cancer patients receiving radiotherapy treatment, and move toward simplified and predictable payments.
www.cms.gov www.cms.gov

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Glanced at it. Looks like no proton exemption.

Is this still being looked at to roll out to 30% of zip codes for ?5 years? then decide about everyone after that?
 
Oh wow... I looked up the participating zip code list and we are in!

Radiation Oncology Model | CMS

The Radiation Oncology (RO) Model aims to improve the quality of care for cancer patients receiving radiotherapy (RT) and move toward a simplified and predictable payment system. The RO Model tests whether prospective, site neutral, modality agnostic, episode-based payments to physician group...
innovation.cms.gov innovation.cms.gov
go towards the bottom and click on participating zip codes...

 
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GI_RadOnc said:
Oh wow... I looked up the participating zip code list and we are in!

Radiation Oncology Model | CMS

The Radiation Oncology (RO) Model aims to improve the quality of care for cancer patients receiving radiotherapy (RT) and move toward a simplified and predictable payment system. The RO Model tests whether prospective, site neutral, modality agnostic, episode-based payments to physician group...
innovation.cms.gov innovation.cms.gov
go towards the bottom and click on participating zip codes...

Click to expand...

Whew, I was all worried about complicated billing in our practice with 5 different sites and 5 different zip codes, but they're all included! Thanks CMS!
 
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GI_RadOnc said:
Oh wow... I looked up the participating zip code list and we are in!

Radiation Oncology Model | CMS

The Radiation Oncology (RO) Model aims to improve the quality of care for cancer patients receiving radiotherapy (RT) and move toward a simplified and predictable payment system. The RO Model tests whether prospective, site neutral, modality agnostic, episode-based payments to physician group...
innovation.cms.gov innovation.cms.gov
go towards the bottom and click on participating zip codes...

Click to expand...
How do you search it
 
Our hospital system has several sites, it looks like the least busy stand alone clinic (about 10 under treatment and super rural) is the only site on this zip code list. Wonder how that will play out.
 
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How long will they trial this before a decision is made regarding nationwide adoption?
 
My zip code is in. I see no proton exemption...One poster has commented in this regard. Let's make sure there are no loopholes
 
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Zipcode list attached
 

Attachments

  • RO-Model Participating ZIP Code List.xls
    435 KB · Views: 159
It will be something to see, yet entirely and wholly predictable using theories of economic (negative) incentives, how this essentially on-its-face "unmedical" government mandate is poised to affect in a dramatic way radiation medicine care in America.
 
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This is a fascinating document... and frankly above my paygrade to understand completely. Being an employed doc; I quickly typed in the approximate professional fees per diagnosis from the national base rates. {This is not the overall payment, that has a way more complicated formula!}. It's going to be an interesting new economy. Three bone mets > cervical cancer ! Pivoting our clinical resources to increase throughput and efficiency for palliative cases may be quite worthwhile!



DzProf(hundreds)
Bone
14​
Brain
16​
Lymph
17​
Breast
21​
Liver
21​
Lung
22​
Colorectal
24​
Pancreatic
24​
Uterine
24​
CNS
25​
UpperGI
26​
Bladder
27​
Anal
30​
HN
30​
Prostate
33​
Cervical
38​
 
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Members don't see this ad :)
GI_RadOnc said:
This is a fascinating document... and frankly above my paygrade to understand completely. Being an employed doc; I quickly typed in the approximate professional fees per diagnosis from the national base rates. {This is not the overall payment, that has a way more complicated formula!}. It's going to be an interesting new economy. Three bone mets > cervical cancer ! Pivoting our clinical resources to increase throughput and efficiency for palliative cases may be quite worthwhile!



DzProf(hundreds)
Bone
14​
Brain
16​
Lymph
17​
Breast
21​
Liver
21​
Lung
22​
Colorectal
24​
Pancreatic
24​
Uterine
24​
CNS
25​
UpperGI
26​
Bladder
27​
Anal
30​
HN
30​
Prostate
33​
Cervical
38​
Click to expand...

Totally agree - I'm not sure I have the background to absorb this fully...
 
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Relevant (I think) proton section:

1600439567477.png

1600439585458.png
 
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GI_RadOnc said:
This is a fascinating document... and frankly above my paygrade to understand completely. Being an employed doc; I quickly typed in the approximate professional fees per diagnosis from the national base rates. {This is not the overall payment, that has a way more complicated formula!}. It's going to be an interesting new economy. Three bone mets > cervical cancer ! Pivoting our clinical resources to increase throughput and efficiency for palliative cases may be quite worthwhile!



DzProf(hundreds)
Bone
14​
Brain
16​
Lymph
17​
Breast
21​
Liver
21​
Lung
22​
Colorectal
24​
Pancreatic
24​
Uterine
24​
CNS
25​
UpperGI
26​
Bladder
27​
Anal
30​
HN
30​
Prostate
33​
Cervical
38​
Click to expand...
Not an expert but i know many on SDN are...so please answer this question

Brain metastasis

20 gy 5 fractions
30 gy 10 fractions
SRS (1-5 fractions)

In this model do all of these treatments pay the same?
 
PPS-Exempt Cancer Hospitals seem to be excluded (https://www.cms.gov/Medicare/Medica...ment/AcuteInpatientPPS/PPS_Exc_Cancer_Hospasp).

I saw this comment in the document that I thought many on here would appreciate (pg 121-122):

"A couple of commenters suggested that CMS expand the exclusion list to include all National Cancer Institute (NCI) Designated Comprehensive Cancer Centers. One of these commenters stated that this policy would align with CMS’ proposal to exempt PCHs. CMS-5527-F 122 Another commenter stated that NCI-designated centers deliver innovative cancer treatments to patients in communities across the United States, and dedicate significant resources toward developing multidisciplinary programs and facilities that lead to better and innovative approaches to cancer prevention, diagnosis, and treatment. This commenter stated that introducing an APM based on complex calculations and historical rates would represent a significant burden that would negatively impact the innovation and discovery missions of NCI designated centers."
 
If you treat a bone met...then 60 days later they need another bone met treated. Is that all bundled in one episode?

Or is each new course a new episode?
 
BobbyHeenan said:
If you treat a bone met...then 60 days later they need another bone met treated. Is that all bundled in one episode?

Or is each new course a new episode?
Click to expand...

I've been under the impression it would be in one episode - in the initial proposal, people were concerned that in patients with say, SCLC who underwent PCI, you would only get reimbursed for the thoracic episode if the PCI took place in the initial 90 day window. So I'd be concerned that if you treat an additional bone met while in the window of the first bone met episode, you will not get additional reimbursement.

We'll see though...
 
If protons are truly included in this draft (eg. they are bundled), I would love to be a lobbyist for the proton industry right about now.

I would be getting a massive cash infusion to lobby CMS to reverse this decision in the next 3 months.
 
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GI_RadOnc said:
This is a fascinating document... and frankly above my paygrade to understand completely. Being an employed doc; I quickly typed in the approximate professional fees per diagnosis from the national base rates. {This is not the overall payment, that has a way more complicated formula!}. It's going to be an interesting new economy. Three bone mets > cervical cancer ! Pivoting our clinical resources to increase throughput and efficiency for palliative cases may be quite worthwhile!



DzProf(hundreds)
Bone
14​
Brain
16​
Lymph
17​
Breast
21​
Liver
21​
Lung
22​
Colorectal
24​
Pancreatic
24​
Uterine
24​
CNS
25​
UpperGI
26​
Bladder
27​
Anal
30​
HN
30​
Prostate
33​
Cervical
38​
Click to expand...
I'd like to know what this means. There's no reason prostate should be between HN and cervical on any list.
 
This might be a stupid question but the zip codes are location of the practice.... no home address of the patient correct?
 
I'd check if any of the proton centers actually fall within the zip codes listed before getting too excited. If not, astro will have plenty of time to lobby on their behalf.
 
Reaganite said:
I'd check if any of the proton centers actually fall within the zip codes listed before getting too excited. If not, astro will have plenty of time to lobby on their behalf.
Click to expand...

This is a good question.

In theory we should see 30% of them impacted, no?
 
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Reaganite said:
I'd check if any of the proton centers actually fall within the zip codes listed before getting too excited. If not, astro will have plenty of time to lobby on their behalf.
Click to expand...

Excellent point. I put in zip codes for about a half dozen non-academic proton centers that I’m aware of. None of them appear to be on the included zip code list.

San Diego, Tulsa, Miami, Nashville, Loma Linda, Somerset all not on list
 
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Gfunk6 said:
Excellent point. I put in zip codes for about a half dozen non-academic proton centers that I’m aware of. None of them appear to be on the included zip code list.

San Diego, Tulsa, Miami, Nashville, Loma Linda, Somerset all not on list
Click to expand...

And some of the other ones may be PPS exempt anyway.
 
One proton center in the state is in the APM; the other one isn't. I bet that's going to be interesting!
 
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If Biden wins (sorry mods), I question whether he would want to cut medicare reimbursement for cancer care, given his emphasis on the "moonshot" when he was VP.
 
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GI_RadOnc said:
One proton center in the state is in the APM; the other one isn't. I bet that's going to be interesting!
Click to expand...

Ouch.

Definitely could see this being held up in court, no? It's basically the government picking and choosing winners and losers over this "trial period."

Can you get a FOIA request on to how the technique for "random" zip code selection was done?
 
Major population centers in NorCal and SoCal are not on the list. However a lot of other parts of CA are included. Found one instance of competing centers in same metro area where one is included and one is not. Fun times ahead, a true randomized controlled trial! If one of those practices “dies” we can choose the winning arm for the rest of the country. Thanks for taking one for the team guys!
 
Last edited:
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GI_RadOnc said:
One proton center in the state is in the APM; the other one isn't. I bet that's going to be interesting!
Click to expand...

It looks like all 3 in Jacksonville, FL plus the one in Delray in the APM. But the 3 in Orlando are not.
 
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Tigerstang said:
One of them does not take assignment of Medicare (Mayo, the one not yet built)
Click to expand...

My admittedly nihilistic concern is that this will marginalize Medicare patients in a much more widespread manner than is seen now. Ostensibly, this is trying to discourage the unscrupulous provider from doing 25 fractions for a single, simple bone met, yes? Alright, so if someone was willing to do that in the current era - commit a fairly egregious sin of fractions to make more money - who knows what else they'll do?

For me, the most obvious choice would be - patient with metastatic disease is referred for bone met palliation. That provider treats with 8x1, because it's the same reimbursement no matter what. In 60 days, patient develops a new lesion which is painful. Patient is re-referred. Based on the current wording, each episode is 90 days with a 28 day "clean period" at the end of the episode. So, is that provider going to rush to see that patient again, knowing they won't be reimbursed FFS? Or is that patient going to get bumped to a much later date, a date when a new episode can be billed? Will there be "second class citizen" patients, where people with private insurance get priority and people with Medicare are seen with less enthusiasm, the easiest/quickest treatment regimen is chosen, and re-referrals are pushed to when a new episode of care can be started?

Pessimistic, I know...but people do what money incentivizes.
 
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elementaryschooleconomics said:
My admittedly nihilistic concern is that this will marginalize Medicare patients in a much more widespread manner than is seen now. Ostensibly, this is trying to discourage the unscrupulous provider from doing 25 fractions for a single, simple bone met, yes? Alright, so if someone was willing to do that in the current era - commit a fairly egregious sin of fractions to make more money - who knows what else they'll do?

For me, the most obvious choice would be - patient with metastatic disease is referred for bone met palliation. That provider treats with 8x1, because it's the same reimbursement no matter what. In 60 days, patient develops a new lesion which is painful. Patient is re-referred. Based on the current wording, each episode is 90 days with a 28 day "clean period" at the end of the episode. So, is that provider going to rush to see that patient again, knowing they won't be reimbursed FFS? Or is that patient going to get bumped to a much later date, a date when a new episode can be billed? Will there be "second class citizen" patients, where people with private insurance get priority and people with Medicare are seen with less enthusiasm, the easiest/quickest treatment regimen is chosen, and re-referrals are pushed to when a new episode of care can be started?

Pessimistic, I know...but people do what money incentivizes.
Click to expand...

No disagreement here. Can you elaborate on the 28 day period?
 
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elementaryschooleconomics said:
My admittedly nihilistic concern is that this will marginalize Medicare patients in a much more widespread manner than is seen now. Ostensibly, this is trying to discourage the unscrupulous provider from doing 25 fractions for a single, simple bone met, yes? Alright, so if someone was willing to do that in the current era - commit a fairly egregious sin of fractions to make more money - who knows what else they'll do?

For me, the most obvious choice would be - patient with metastatic disease is referred for bone met palliation. That provider treats with 8x1, because it's the same reimbursement no matter what. In 60 days, patient develops a new lesion which is painful. Patient is re-referred. Based on the current wording, each episode is 90 days with a 28 day "clean period" at the end of the episode. So, is that provider going to rush to see that patient again, knowing they won't be reimbursed FFS? Or is that patient going to get bumped to a much later date, a date when a new episode can be billed? Will there be "second class citizen" patients, where people with private insurance get priority and people with Medicare are seen with less enthusiasm, the easiest/quickest treatment regimen is chosen, and re-referrals are pushed to when a new episode of care can be started?

Pessimistic, I know...but people do what money incentivizes.
Click to expand...

This is a legit concern.

What if you palliative lung mass, then 3 months later they have a bone met? If you're within 90 days is that no payment period or if you have a new ICD 10 code (bone met versus lung mass) can you start a new episode?
 
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Tigerstang said:
So it seems to allow you to initiate a new course of treatment under FFS during that period? Very confusing
Click to expand...

Agreed - super confusing.

Actually, you bring up a great point with this wording. Here's my revised hack:

Patient comes with 3 bone mets, 1 painful, the other 2 are equivocal. At the first consult I could focus just on the very painful met, and trigger the episode for that single met. The other 2 worsen in pain, MedOnc refers the patient back within 90 days. I then happily treat one of the mets, bill FFS. The 3rd met worsens, MedOnc refers again, still within 90 days - I happily bill FFS for the 3rd met.

Who knows how this will shake out. I'm definitely not in love with this rolling out in 2021 for everyone trying to find a job in an oversupplied market strained tremendously by a global pandemic...
 
scarbrtj said:
It will be something to see, yet entirely and wholly predictable using theories of economic (negative) incentives, how this essentially on-its-face "unmedical" government mandate is poised to affect in a dramatic way radiation medicine care in America.
Click to expand...

Wonder what the hiring practices will be.

APM: no new attendings. NPs to see anything not billable and sign off on new consults.
 
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elementaryschooleconomics said:
Patient comes with 3 bone mets, 1 painful, the other 2 are equivocal. At the first consult I could focus just on the very painful met, and trigger the episode for that single met. The other 2 worsen in pain, MedOnc refers the patient back within 90 days. I then happily treat one of the mets, bill FFS. The 3rd met worsens, MedOnc refers again, still within 90 days - I happily bill FFS for the 3rd met.
Click to expand...
 
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I wonder if any of the "non-profits" that are very profitable will have the courage to challenge this in court.
 
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elementaryschooleconomics said:
Agreed - super confusing.

Actually, you bring up a great point with this wording. Here's my revised hack:

Patient comes with 3 bone mets, 1 painful, the other 2 are equivocal. At the first consult I could focus just on the very painful met, and trigger the episode for that single met. The other 2 worsen in pain, MedOnc refers the patient back within 90 days. I then happily treat one of the mets, bill FFS. The 3rd met worsens, MedOnc refers again, still within 90 days - I happily bill FFS for the 3rd met.

Who knows how this will shake out. I'm definitely not in love with this rolling out in 2021 for everyone trying to find a job in an oversupplied market strained tremendously by a global pandemic...
Click to expand...

I take my hack back, I don't think it will work:

1600451758432.png


"An RO episode includes all included RT services furnished to an RO beneficiary with an included cancer type during the 90 day episode"

You can only bill FFS within an episode if you're treating for something not on the list of 16 cancers. I dunno about y'all but I will be personally responsible for the renaissance of XRT for OA in America.
 
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Been out now what a few years. I don’t think waiting another 5 to see how this shakes out is worth the risk.

Already running budget simulations for retraining and how much money I would lose.
 
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elementaryschooleconomics said:
I take my hack back, I don't think it will work:

View attachment 318556

"An RO episode includes all included RT services furnished to an RO beneficiary with an included cancer type during the 90 day episode"

You can only bill FFS within an episode if you're treating for something not on the list of 16 cancers. I dunno about y'all but I will be personally responsible for the renaissance of XRT for OA in America.
Click to expand...

I honestly don’t understand why you bother lol. Trying to hack CMS is like trying to get into Fort Knox except instead of gold you get a plastic buzz lightyear.
 
A few phrases that I see over and over in the very large Q&A portion of this document:

1. "We rely on Medical providers and suppliers to furnish appropriate care to our beneficiaries" - TRANSLATION: We are not dictating what you can do . . . you can do anything, but we only pay you what we want.

2. "Based on analysis of Medicare claims data . . . 99% of beneficiaries" - TRANSLATION: You can't make an omelet without breaking a few eggs. Occasionally Medicare providers will get screwed because we didn't feel like carving out an exception. That is a sacrifice CMS is willing to make.

3. "We plan to carefully monitor the RO Model for unintended consequences . . . - TRANSLATION: In the immortal words of Ivan Drago

1600452299892.png
 
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