RO Model Update July 2021

[Chartreuse Wombat]

Bullet points from CMS Website

Proposals to Address the RO Model Timing and Design

The CY 2022 OPPS and ASC Payment System proposed rule includes the following proposals to modify the RO Model’s timing and design:

• To begin the RO Model on January 1, 2022, with a 5-year Model performance period (ending December 31, 2026).
• To change the baseline period from 2016-2018 to 2017-2019.
• To lower the discounts to 3.5 percent (Professional Component) and 4.5 percent (Technical Component).
• To remove brachytherapy from the list of included modalities under the RO Model so that it would still be paid FFS.
• To revise the cancer inclusion criteria under the RO Model.
• In cases where a beneficiary switches from traditional Medicare to Medicare Advantage during an episode before treatment is complete, CMS would consider this an incomplete episode and RT services would be paid the traditional Medicare rate instead of being paid under the RO Model.
• To adopt an extreme and uncontrollable circumstances policy. This policy would provide flexibility to reduce administrative burden of Model participation, including reporting requirements, and/or adjust the payment methodology as necessary when extreme and uncontrollable circumstances exist.
• To exclude hospital outpatient departments participating in the Community Transformation track of the CHART Model from participation in the RO Model. For the CHART ACO Transformation track, we would follow the same policy for overlap between the RO Model and the Medicare Shared Savings Program ACOs.
• That only hospital outpatient departments that are participating in the Pennsylvania Rural Health Model (PARHM) would be excluded from the RO Model, rather than those that are eligible to participate in PARHM.
• To remove liver cancer from the RO Model as it does not satisfy the model’s cancer inclusion criteria.

Looks like brachytherapy is outside of the Model but protons appear to be in

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[medgator]

Protons in. Nice

 

[deleted941485]

Bullet points from CMS Website

Proposals to Address the RO Model Timing and Design

The CY 2022 OPPS and ASC Payment System proposed rule includes the following proposals to modify the RO Model’s timing and design:

• To begin the RO Model on January 1, 2022, with a 5-year Model performance period (ending December 31, 2026).
• To change the baseline period from 2016-2018 to 2017-2019.
• To lower the discounts to 3.5 percent (Professional Component) and 4.5 percent (Technical Component).
• To remove brachytherapy from the list of included modalities under the RO Model so that it would still be paid FFS.
• To revise the cancer inclusion criteria under the RO Model.
• In cases where a beneficiary switches from traditional Medicare to Medicare Advantage during an episode before treatment is complete, CMS would consider this an incomplete episode and RT services would be paid the traditional Medicare rate instead of being paid under the RO Model.
• To adopt an extreme and uncontrollable circumstances policy. This policy would provide flexibility to reduce administrative burden of Model participation, including reporting requirements, and/or adjust the payment methodology as necessary when extreme and uncontrollable circumstances exist.
• To exclude hospital outpatient departments participating in the Community Transformation track of the CHART Model from participation in the RO Model. For the CHART ACO Transformation track, we would follow the same policy for overlap between the RO Model and the Medicare Shared Savings Program ACOs.
• That only hospital outpatient departments that are participating in the Pennsylvania Rural Health Model (PARHM) would be excluded from the RO Model, rather than those that are eligible to participate in PARHM.
• To remove liver cancer from the RO Model as it does not satisfy the model’s cancer inclusion criteria.

Looks like brachytherapy is outside of the Model but protons appear to be in

Depts are shedding brachy like crazy. Protons? Wonder how thats gonna work out.

Is this model still mandatory?

 

[Chartreuse Wombat]

Depts are shedding brachy like crazy. Protons? Wonder how thats gonna work out.

Is this model still mandatory?

It is mandatory for the 35% practices with the "lucky" zipcodes

 

[elementaryschooleconomics]

Hopefully this alleviates the potential payment disaster for (mainly) cervical cases if EBRT was done at one site and brachy is done at another?

Regardless, brachy out and protons in? That ASCENDE-RT data looking better and better...

 

[deleted941485]

It is mandatory for the 35% practices with the "lucky" zipcodes

If your a big hospital system that covers many zip codes how does that work?

 

[Ray D. Ayshun]

Nobody bringing up the last line about hcc. What's that even mean?

 

[deleted941485]

Nobody bringing up the last line about hcc. What's that even mean?

They don’t care if they save a few bucks on a liver case. Most ROs don’t even see enough to justify collecting data on it.

They want the common **** your prostates breast and lungs.

 

[Upgrayedd]

wait so if I do brachy does this mean that there will be better job options?

 

[Chartreuse Wombat]

If your a big hospital system that covers many zip codes how does that work?

I am in a large practice with multiple locations. Some are in and some are out. I think it means that the billing will be handled differently. Enormous headache but CMS doesn't care.

 

[deleted941485]

I am in a large practice with multiple locations. Some are in and some are out. I think it means that the billing will be handled differently. Enormous headache but CMS doesn't care.

Do you own the linacs too? I mean could shunt patients to non participating zip codes

 

[medgator]

If your a big hospital system that covers many zip codes how does that work?

You're sending pts across town to get treated on the exempt Linac

 

[deleted941485]

Precisely...unless it’s brachy Ofcourse or some weird malignancy not included

You're sending pts across town to get treated on the exempt Linac

 

[Gfunk6]

ASTRO is unhappy

CMS Makes Changes to RO Model; Major Issues Persist​

The Centers for Medicare and Medicaid Services (CMS) announced plans to launch the Radiation Oncology Model on January 1, 2022, with minimal reductions to discount factor payment cuts and the removal of brachytherapy services from the model. According to an initial ASTRO analysis of the proposed changes, CMS did little to address the underlying punitive nature of the model on mandated participants, as the discount factor payment cuts and participation burden remain serious concerns. ASTRO is disappointed that CMS continues to largely ignore recommendations from the radiation oncology community, cancer patients, health policy experts and Congress. The discount factors decrease from 3.75% to 3.5% for professional component services and from 4.75% to 4.5% for technical component services, due to the Agency’s proposal to remove brachytherapy and liver cancer from the model. CMS recognized ASTRO’s concerns about the model’s impact on cases involving both brachytherapy and external beam radiation therapy. CMS also is adopting an extreme and uncontrollable circumstances policy for significant events, such as the COVID-19 public health emergency. ASTRO will provide a more detailed summary of changes in coming days and conduct in depth data analysis to help assess the financial impact on practices. ASTRO also will engage in advocacy to drive additional reforms to the RO Model.

 

[RadOncDoc21]

ASTRO is unhappy

Oh no! Big bad ASTRO... I'm sure they are scared!

 

[DebtRising]

If your a big hospital system that covers many zip codes how does that work?

Facilities within the zip code follows the model and facilities outside do not. So yes, billing within the same system is different but your network was (most likely) already billing different at different facilities (makes some assumptions, based on my experience on my multiple site center).

The brachy change is good. But the rest is a mandatory reimbursement cut of what looks like 10-15% in 6 years when it is mandatory for everyone with no quality or outcome metric. Enjoy that “APM expertise” fellowship wave that will pop up. I’m looking at you Columbia.

 

[deleted941485]

Oh no! Big bad ASTRO... I'm sure they are scared!

CMS has gotten to the point where they realize they don’t need to
Listen to physician advocacy groups...at all. Oh wanna stop taking Medicare? Haha sorry you can’t bill the patient anymore.

They can do what they want. Gtfo of RO

 

[deleted941485]

Facilities within the zip code follows the model and facilities outside do not. So yes, billing within the same system is different but your network was (most likely) already billing different at different facilities (makes some assumptions, based on my experience on my multiple site center).

The brachy change is good. But the rest is a mandatory reimbursement cut of what looks like 10-15% in 6 years when it is mandatory for everyone with no quality or outcome metric. Enjoy that “APM expertise” fellowship wave that will pop up. I’m looking at you Columbia.

APM expertise fellowship? Wtf? Do tell

 

[deleted941485]

Facilities within the zip code follows the model and facilities outside do not. So yes, billing within the same system is different but your network was (most likely) already billing different at different facilities (makes some assumptions, based on my experience on my multiple site center).

The brachy change is good. But the rest is a mandatory reimbursement cut of what looks like 10-15% in 6 years when it is mandatory for everyone with no quality or outcome metric. Enjoy that “APM expertise” fellowship wave that will pop up. I’m looking at you Columbia.

Brachy is dying. APM won’t resurrect that despite some hospitals and groups thinking it will

 

[TheWallnerus]

ASTRO is unhappy

The wonderful top-notch high-tier specialty of rad onc... so, so vital to cancer care across the US as administered by America's "real oncologists"... continues to get b**ch slapped by CMS. Can we put some new people in charge, like yesterday?

 

[TheWallnerus]

protons appear to be in

Protons in.

If protons HADN'T been in, the only explanation would have been: bribe.

 

[seper]

I guess it’s good news for busy brachytherapists

 

[RickyScott]

If protons HADN'T been in, the only explanation would have been: bribe.

Many of the pps exempt centers have proton, so plenty of major proton centers outside of the apm. Also

 

[deleted941485]

Many of the pps exempt centers have proton, so plenty of major proton centers outside of the apm. Also

View attachment 340733

itll kill what ever venture capital places exist and also any PP groups that still exist

 

[TheWallnerus]

Imagine if you will a hallway at CMS headquarters. The people in this hallway have been doing one thing and one thing only for about the last 5-6 years (would have pre-dated Trump I think): figuring out how to curb rad onc payments. Rad onc comprises a relatively small part of the CMS budget, about 2-2.5% at most, but this is somewhat disproportionate as <1% of US physicians are rad oncs.

In this hallway one finds about 30 people, maybe 40, who've made the RO-APM their life. Imagine that. About 30 to 40 people, many with just bachelor's and MBAs, have been slowly and studiously plotting this RO-APM and are now ready to unleash it on America's 5500-6000 radiation oncologists. These ~40 US citizens control (ultimately, once it's totally rolled out) the lives of thousands of rad onc MDs and the million patients per year they treat.

And the rules? The APM rubric? It's arbitrary. It is not based on any data whatsoever or pre-existing "best practices" honed by previous misfires. Nope. This is a WAG. On a wing and a prayer, CMS blithely assumes a sea change in the realm of rad onc will just be seamless. Inconsequential.

If you are a med student, I wouldn't go into this field just on the basis of APM alone. Will it extremely financially hurt? No. But morally, the APM is wrong. It's anti-capitalism, anti-freedom, the government picking winners and losers and every other Fox News talking point that, like a broken clock, is right (but only two times a day). Spite CMS. Don't join rad onc. The government overseers... those 40 twenty- and thirty-somethings in that hallway...don't care about you. So you should not care about them. Like Joshua in "War Games," the only way to win the game is not to play.

But what of us already committed to global thermonuclear warfare? I think I have a potential solution. Let's try the Tyler Durden approach: "Hitting bottom isn't a weekend retreat, it's not a seminar. Stop trying to control everything and just let go!" To the world of rad onc, and to ASTRO: all the signs are there. Med students are backing out. Hypofractionation is coming like bullet train. APM is here to have sexy time. EviCore controls clinical rad onc, more or less. Many rad oncs, not just SDN rad oncs, have been calling for a massive paring of rad onc numbers for a long time.

So use this.

Let's cut our numbers. Let's quit it with the over-supply. Let's make a rad onc as rare as a hen's tooth. People will not die. People will still get good care. We will have to work more. But maybe in a few years we can with plausible deniability go to the CMSs and EvicCores and say "See what you a-holes have done? You ruined it. No one wants to be a rad onc and people are hurting." I think some approach like this is the only way forward.

 

[deleted941485]

Imagine if you will a hallway at CMS headquarters. The people in this hallway have been doing one thing and one thing only for about the last 5-6 years (would have pre-dated Trump I think): figuring out how to curb rad onc payments. Rad onc comprises a relatively small part of the CMS budget, about 2-2.5% at most, but this is somewhat disproportionate as <1% of US physicians are rad oncs.

In this hallway one finds about 30 people, maybe 40, who've made the RO-APM their life. Imagine that. About 30 to 40 people, many with just bachelor's and MBAs, have been slowly and studiously plotting this RO-APM and are now ready to unleash it on America's 5500-6000 radiation oncologists. These ~40 US citizens control (ultimately, once it's totally rolled out) the lives of thousands of rad onc MDs and the million patients per year they treat.

And the rules? The APM rubric? It's arbitrary. It is not based on any data whatsoever or pre-existing "best practices" honed by previous misfires. Nope. This is a WAG. On a wing and a prayer, CMS blithely assumes a sea change in the realm of rad onc will just be seamless. Inconsequential.

If you are a med student, I wouldn't go into this field just on the basis of APM alone. Will it extremely financially hurt? No. But morally, the APM is wrong. It's anti-capitalism, anti-freedom, the government picking winners and losers and every other Fox News talking point that, like a broken clock, is right (but only two times a day). Spite CMS. Don't join rad onc. The government overseers... those 40 twenty- and thirty-somethings in that hallway...don't care about you. So you should not care about them. Like Joshua in "War Games," the only way to win the game is not to play.

But what of us already committed to global thermonuclear warfare? I think I have a potential solution. Let's try the Tyler Durden approach: "Hitting bottom isn't a weekend retreat, it's not a seminar. Stop trying to control everything and just let go!" To the world of rad onc, and to ASTRO: all the signs are there. Med students are backing out. Hypofractionation is coming like bullet train. APM is here to have sexy time. EviCore controls clinical rad onc, more or less. Many rad oncs, not just SDN rad oncs, have been calling for a massive paring of rad onc numbers for a long time.

So use this.

Let's cut our numbers. Let's quit it with the over-supply. Let's make a rad onc as rare as a hen's tooth. People will not die. People will still get good care. We will have to work more. But maybe in a few years we can with plausible deniability go to the CMSs and EvicCores and say "See what you a-holes have done? You ruined it. No one wants to be a rad onc and people are hurting." I think some approach like this is the only way forward.

You **** it attitude is missing one big thing...leaving leaving your employer overloads and dumping medicare.

 

[TheWallnerus]

You **** it attitude is missing one big thing...leaving leaving your employer overloads and dumping medicare.

Maybe won't have to dump Medicare if you double your patient load by halving the number of docs!

 

[DebtRising]

Never made any sense to focus this much on our basket and avoid immunotherapy outside this really being Azar doing his pharma bros a huge favor and shrinking the onc payments without touching Med onc.

https://www.fightcancer.org/sites/default/files/National%20Documents/Costs-of-Cancer-2020-10222020.pdf

Has a good breakdown of the amount of costs by modality on page 24 via their patient vignettes meant to illustrate care by disease site. Good thing we are getting cut, that’s going to move the needle for patients. Oh wait, it won’t. Another pharma win. They needed it too.

Hard not to have a bad attitude when CMS has a bulls-eye on us and our senior vanguard is busy trying to figure out how to best exploit record residency classes and fellowships to pad the end of their careers as much as possible. Our ASTRO president SOAPed at a new program. ASTRO’s got our back guys and gals.

 

[RadOncDoc21]

 

[Reaganite]

itll kill what ever venture capital places exist and also any PP groups that still exist

I think the private practice job market is going to shrink substantially, but the guys who already own the centers are actually gonna be better off. Everyone will massively hypofractionate which means they will essentially be getting paid more per fx than they did pre-APM. This will also lead to smaller clinic volumes which will translate to lower overhead particularly on the staffing side. Getting rid of a therapist and an associate or two is gonna recoup much if not all of the APM-related losses. I don't see how any supervision works with APM since supervision is tied to daily charges not an entire treatment course. So more days off for the existing docs (and if you're really worried, NPs and PAs are gonna be allowed to do pretty much anything soon enough). So yeah, the new grad job market in private practice is gonna absolutely f'n die, but the guys we love to hate are gonna be fine if not better until they sell their practices and ride off into the sunset.

 

[CaesarRO]

Anybody have any insight as to how APM translates to RVUs?

 

[yesmaster]

Zip codes haven’t changed?

So, 5 years to FIRE and/or grow a reasonable side hustle

What is an OPPS payment adjustment and why is it +51% for special snowflake MDA?

 

[BobbyHeenan]

Do these increases wipe out any savings from this program?

Can someone explain why everyone else wouldn’t riot/strike about these cuts while the elect get price increases?

maybe I’m not fully understanding?

 

[Grubbe-a-dub-dub]

Anybody have any insight as to how APM translates to RVUs?

Yes - someone please post a breakdown. I already hypofx anything I could so curious how this really will effect me and those on a straight forward RVU compensation model.

 

[udrag14]

Anybody have any insight as to how APM translates to RVUs?

They don't. Most hospitals will keep the same RVU system pre APM to keep track of RVUs.

However they will be paid lump sum based on RO APM.

The only issue is the <90 day re treatment situations where you would potentially get RVUs but wouldn't be paid under RO APM. I wonder if hospital will remove the RVUs if they aren't paid.

 

[deleted941485]

They don't. Most hospitals will keep the same RVU system pre APM to keep track of RVUs.

However they will be paid lump sum based on RO APM.

The only issue is the <90 day re treatment situations where you would potentially get RVUs but wouldn't be paid under RO APM. I wonder if hospital will remove the RVUs if they aren't paid.

I guess you could try different diagnosis codes like brain and bone if patient is metastatic. Or if they have multiple bone Mets pick the most painful one or two and hobble along on opioids until 90 days elapsed...should be great

 

[mheat3]

If protons somehow get an exemption once all the lobbying/bribing/massaging (currently ongoing and still happening) is done then we know once and for all where our dear leaders stand. The lack of pharma oversight that has been brought up already exposes the influence of $$$ on those making the decisions.

 

[deleted1111261]

Yes - someone please post a breakdown. I already hypofx anything I could so curious how this really will effect me and those on a straight forward RVU compensation model.

Ask Jordan Johnson

 

[deleted1111261]

Do these increases wipe out any savings from this program?

Can someone explain why everyone else wouldn’t riot/strike about these cuts while the elect get price increases?

maybe I’m not fully understanding?

View attachment 340739

Yes, someone smart please explain this.

 

[DoctwoB]

Yes - someone please post a breakdown. I already hypofx anything I could so curious how this really will effect me and those on a straight forward RVU compensation model.

#notaradonc but my guess is it will be figured into your RVU conversion factor. Right now you get paid X/RVU which will be related to total collections - overhead/admin / # RVUs. So if your revenue goes down under APM but RVUs stays the same, within a few years they will adjust the $/RVU to reflect that.

 

[RSAOaky]

Do these increases wipe out any savings from this program?

Can someone explain why everyone else wouldn’t riot/strike about these cuts while the elect get price increases?

maybe I’m not fully understanding?

View attachment 340739

I think that someone can make a very strong argument that a cancer center getting preferential payments from the government is monopolistic and stifles competition.

Let's say you have a clinic in rural Texas. You have 30 patients on treatment but require 20 to stay afloat. MD Anderson comes in and now you split the pot, treating 15 each. Except MD Anderson is paid more per patient than you and they're still able to be profitable treating 15 whereas you are not. You close your practice.

Now MD Anderson is treating all 30 patients. The government pays more, the consumer pays more and has fewer choices, and the corporation profits more at the expense of everyone else.

 

[TheWallnerus]

#notaradonc but my guess is it will be figured into your RVU conversion factor. Right now you get paid X/RVU which will be related to total collections - overhead/admin / # RVUs. So if your revenue goes down under APM but RVUs stays the same, within a few years they will adjust the $/RVU to reflect that.

correct

"RVU" is just a euphemism for "dollars," it's a contrivance

 

[Radonc90]

Looks like brachy just dodged a bullet, for now...

 

[MegaVoltagePhoton]

Brachy is an important part of my cervical cancer practice. I was worried that if brachy was included, it would incentivize omission of brachy. Maybe that is ok, but I have not seen convincing data that SBRT is good enough. So that's a positive here.

 

[BobbyHeenan]

I think that someone can make a very strong argument that a cancer center getting preferential payments from the government is monopolistic and stifles competition.

Let's say you have a clinic in rural Texas. You have 30 patients on treatment but require 20 to stay afloat. MD Anderson comes in and now you split the pot, treating 15 each. Except MD Anderson is paid more per patient than you and they're still able to be profitable treating 15 whereas you are not. You close your practice.

Now MD Anderson is treating all 30 patients. The government pays more, the consumer pays more and has fewer choices, and the corporation profits more at the expense of everyone else.

What exactly has been the ROI on these sorts of set ups?

Are we really seeing better cancer research come out of some place like Roswell Park versus UMich or Wisconsin or *insert some other big NCI non-exempt center?

Are we seeing innovation at MDA that is spreading far and wide, or just proliferation of a model of care that only MDA has the revenue to produce and run?

 

[Reaganite]

I think that someone can make a very strong argument that a cancer center getting preferential payments from the government is monopolistic and stifles competition.

Let's say you have a clinic in rural Texas. You have 30 patients on treatment but require 20 to stay afloat. MD Anderson comes in and now you split the pot, treating 15 each. Except MD Anderson is paid more per patient than you and they're still able to be profitable treating 15 whereas you are not. You close your practice.

Now MD Anderson is treating all 30 patients. The government pays more, the consumer pays more and has fewer choices, and the corporation profits more at the expense of everyone else.

Dude, you nailed it. These NCI designated centers get paid so much per patient they can keep satellite clinics open with 5 patients and just wait for the local guy to go out of business or sell. It's almost impossible for their satellite clinics to fail at the rates they get paid, and it is complete BS they are allowed to expand into the community and bill at cancer center rates. Not only that, some of these guys are also coming up with crooked schemes to differentially bill cancer center vs. foundation rates in the same center because some local insurers won't pay their inflated rates. It's a total racket.

 

[RSAOaky]

What exactly has been the ROI on these sorts of set ups?

Are we really seeing better cancer research come out of some place like Roswell Park versus UMich or Wisconsin or *insert some other big NCI non-exempt center?

Are we seeing innovation at MDA that is spreading far and wide, or just proliferation of a model of care that only MDA has the revenue to produce and run?

Well based on the paucity of practice changing RadOnc trials in the last decade that didn't end with the line "5+5 is roughly equal to 3+7 and should be the new standard of care" I can tell you that the research ROI has been quite poor. As far as patient outcomes go, I'd venture to guess that my prostates and breasts do just as well and my pancreases and GBMs do just as poorly.

 

[Radonc90]

Wait, is 77427 bundled in? If so, it does not look good bc 77427 is the backbone of radonc...

 

[Chartreuse Wombat]

Wait, is 77427 bundled in? If so, it does not look good bc 77427 is the backbone of radonc...

Yup everything not excluded (e.g. brachytherapy is bundled)

Slight variations based on historical billing but this is all you get.

SBRT everything!

 

[seper]

OMG OTV's are going away??