Utilizing Episodic Payments to Improve Access and Quality in Cancer Care

Anne Hubbard, MBA, Director of Health Policy, American Society for Radiation Oncology (ASTRO), discusses the Radiation Oncology (RO) Model, which may pave a path from fee-for-service systems into value-based care by achieving rate stability, the use of proper technology, and representation of the needs of the individual patient.

Transcript

Can you briefly describe the RO Model and the development process?

The RO Model is an episode-based payment model. The idea is that radiation oncology, because it is a distinct component within the broader cancer care continuum, makes for an ideal episode-based payment concept. The model initially was started back in 2017 as kind of a concept that ASTRO had started thinking about as a result of the CMMI effort around the Oncology Care Model as something that would really kind of be specific to radiation oncology, allow the radiation oncologist to be kind of accountable for and in control of radiation oncology services within a value-based payment mechanism. And so we initially put together kind of a concept that we shared with the CMS Center for Medicare and Medicaid Innovation that was a 90-day episode of care that was disease site-specific that included the cost associated with the delivery of professional and technical services.

The agency issued a report to Congress in response to a request in the Patient Access and Medicare Protection Act that passed back in 2015, and there was a lot of alignment with what we had recommended. However, when the agency issued a proposed rule in 2019, it became clear that at that point, that's where there were a lot of differences between what we had recommended and what the agency actually produced. The biggest challenges, of course, with the RO Model were the fact that it included a series of payment cuts that, starting with a discount factor as well as other components within the payment methodology, would've made it very difficult for practices to not only just participate in the model, but also participate successfully in such a way that they'd be able to continue to provide care to their cancer patient communities.

How do you see the final rule to delay the start of this model impacting patients, payers, and/or providers?

The decision to delay the payment model is really quite bittersweet. Radiation oncology is an ideal service to be included in an episode-based type payment model. We continue to believe that the value-based payment makes a lot of sense for radiation oncology, particularly given the great interest in shifting from standard courses of treatment to hyperfractionated courses of treatment. And there were a number of providers who were selected to participate in the model, who had spent the last several years really working towards implementing the model and participating in it. And so to some extent, I know that there's a bit of frustration that so much time and effort was put into participating in the payment model. It had a mandatory participation requirement so those who were selected really did spend a lot of time trying to ready themselves for it despite all the flaws that the model had.

The bittersweet component to this is that we spent a significant amount of time working with the agency to identify those areas within the payment methodology and associated with the reporting requirements that were particularly burdensome and problematic. Yet unfortunately, our recommended changes fell on deaf ears. And while we had hoped that we'd be able to work with the agency to make necessary changes so that those members could put all that hard work to use, at this point, the model is indefinitely delayed. It's not a cancellation, but it does demonstrate that the agency is really shifting its focus right now.

ASTRO is working on the development of a new alternative payment model. What are some key similarities or differences in the new payment model compared to the previous one?

So the work that we're doing at this point, I can share a little bit of high-level kind of information, and really it's around the construct of what an ideal model would look like. And an ideal payment model would establish a simplified payment methodology that ensures spare and stable payment, recognizing the efficient delivery of care. We're also focused on the development of a concept in which there are investments in cancer treatment infrastructure needs. Radiation oncology relies on the use of very expensive technology and equipment in order to deliver treatment. And so there needs to be recognition for the investment involved in that, really to ensure that all patients have access to high-quality care using that advanced technology. And then we also want to make sure that we're tackling the unnecessary and burdensome reporting requirements that don't really contribute to improved patient outcomes, including the reliance on prior authorization, which has been used as really a blunt tool for reducing cost.

We also are looking to craft something that has mechanisms that allow it to identify and support patient populations with limited access to radiation therapy. And I'm really kind of focusing on those patients who experience health care disparities, making sure that we're supporting patient populations with limited access to radiation therapy, really ensuring that they're able to not only initiate, but also complete their courses of treatment, which take place over the course of several weeks. We're also looking to establish a model that is committed to evidence-based approaches to care and really investing in those wraparound services, including patient navigation and transportation, that improve care for patients who have been historically marginalized.

And then finally, our hope is that we can come up with an episode-based payment concept that could potentially be nested in some of these larger total cost-of-care models that the agency seems to be focusing on right now. CMMI has really shifted away from episode-based payment towards total cost of care and accountable care organizations, which I can appreciate from the big picture perspective, but it would be shortsighted not to recognize the unique high-value role that radiation oncology, in particular an episode of radiation oncology, plays in the cancer care continuum.

What is ASTRO's end goal or goals with value-based care? And is there anything else in the pipeline?

So our end goal with value-based payment is really to give radiation oncology stable footing in a value-based payment world. It is clear that CMS is making the experience in the existing Medicare physician fee schedule, as well as the hospital outpatient perspective payment system, more and more difficult for radiation oncologists to exist in. And so it really does compel us to find a way to shift from those fee-for-service systems into value-based care. And our goal is to make sure that it's done in such a way that it achieves that rate stability that we want to see, invest in the technology that is necessary to deliver high-value radiation therapy, and then also addresses the unique needs that historically marginalized populations have experienced with regard to cancer treatments. And so our hope is that we can help our members make that necessary shift into value-based payments through a payment model that really is thoughtfully constructed and recognizes all of those components.