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Bush A, Liu CM, Rula EY, Luh J, Yu NY, Laack N, Attia A, Waddle M. Caught Between a Radiation Oncology Case Rate (ROCR) and a Hard Place: Improving Proposed Radiation Oncology Alternative Payment Models. Int J Radiat Oncol Biol Phys 2024:S0360-3016(24)02585-9. [PMID: 38986915 DOI: 10.1016/j.ijrobp.2024.06.034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2024] [Revised: 06/24/2024] [Accepted: 06/26/2024] [Indexed: 07/12/2024]
Abstract
PURPOSE The Radiation Oncology Case Rate (ROCR) aims to shift radiation reimbursement from fee-for-service (FFS) to bundled payments, which would decouple fractionation from reimbursement in the United States. This study compares historical reimbursement rates from 3 large centers and a national Medicare sample with proposed base rates from ROCR. It also tests the impact of methodological inclusion of treatment and disease characteristics to determine if any variables are associated with greater rate differences that may lead to inequitable reimbursement. METHODS AND MATERIALS Using Mayo Clinic electronic medical record data from 2017 to 2020 and part B claims from the Medicare 5% research identifiable files, episodic 90-day historical reimbursement rates for 15 cancer types were calculated per the ROCR payment methodology. Mayo Clinic reimbursement rates were stratified by disease and treatment characteristics and multiple linear regression was performed to assess the association of these variables on historical episode reimbursement rates. RESULTS From Mayo Clinic, 3498 patient episodes were included and 480,526 from the research identifiable files. From both data sets, 25% of brain metastases and 13% of bone metastases episodes included ≥2 treatment courses with an average of 51 days between courses. Accounting for all 15 cancer types, ROCR base rates resulted in an average -2.4% and -2.9% reduction in rates for Mayo Clinic and the research identifiable files respectively compared with historical reimbursement. On multivariate analysis of Mayo Clinic data, treatment intent (curative vs palliative) was associated with higher historical reimbursement (+$477 to +$7417; P ≤.05) for 12 out of 12 applicable cancer types. Stage (III-IV vs I-II) was associated with higher historical reimbursement (+$1169 to +$3917; P ≤ .05) for 8 out of 12 applicable cancer types. CONCLUSIONS Our data suggest ROCR base rates introduce an average ≤3% reimbursement rate decrease compared with historical FFS reimbursement per cancer type, which could produce the Medicare savings required for congressional approval of ROCR. Estimating comparisons with future FFS reimbursement would require consideration of additional factors such as the increased utilization of hypofractionation, proposed FFS rate cuts, and inflationary updates. A distinct rate and shortened episode duration (≤30 days) should be considered for palliative episodes. Applying a base rate modifier per cancer stage may mitigate disproportionate reductions in reimbursement for facilities with a higher volume of curative advanced-stage patients such as freestanding centers in rural settings.
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Affiliation(s)
| | - Chi-Mei Liu
- Neiman Health Policy Institute, Reston, Virginia
| | | | - Join Luh
- St. Joseph Hospital, Eureka, California
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Price AT, Canfield C, Hugo GD, Kavanaugh JA, Henke LE, Laugeman E, Samson P, Reynolds-Kueny C, Cudney EA. Techno-Economic Feasibility Analysis of a Fully Mobile Radiation Oncology System Using Monte Carlo Simulation. JCO Glob Oncol 2022; 8:e2100284. [PMID: 35609229 PMCID: PMC9173580 DOI: 10.1200/go.21.00284] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Disparities in radiation oncology (RO) can be attributed to geographic location, socioeconomic status, race, sex, and other societal factors. One potential solution is to implement a fully mobile (FM) RO system to bring radiotherapy to rural areas and reduce barriers to access. We use Monte Carlo simulation to quantify techno-economic feasibility with uncertainty, using two rural Missouri scenarios.
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Affiliation(s)
- Alex T Price
- Department of Radiation Oncology, Washington University School of Medicine in St Louis, St Louis, MO.,Department of Engineering Management and Systems Engineering, Missouri University of Science and Technology, Rolla, MO
| | - Casey Canfield
- Department of Engineering Management and Systems Engineering, Missouri University of Science and Technology, Rolla, MO
| | - Geoffrey D Hugo
- Department of Radiation Oncology, Washington University School of Medicine in St Louis, St Louis, MO
| | - James A Kavanaugh
- Department of Radiation Oncology, Washington University School of Medicine in St Louis, St Louis, MO
| | - Lauren E Henke
- Department of Radiation Oncology, Washington University School of Medicine in St Louis, St Louis, MO
| | - Eric Laugeman
- Department of Radiation Oncology, Washington University School of Medicine in St Louis, St Louis, MO
| | - Pamela Samson
- Department of Radiation Oncology, Washington University School of Medicine in St Louis, St Louis, MO
| | - Clair Reynolds-Kueny
- Department of Psychological Science, Missouri University of Science and Technology, Rolla, MO
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Ning MS, Boyce-Fappiano D, Thaker NG. Oligometastatic Disease in Context of the Radiation Oncology Alternative Payment Model: Implications for Local Consolidative Therapy. JCO Oncol Pract 2021; 17:773-776. [PMID: 34767465 DOI: 10.1200/op.21.00549] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Affiliation(s)
- Matthew S Ning
- The University of Texas MD Anderson Cancer Center, Houston, TX
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Luh JY, Jones RT, Thaker NG, Hubbard A, Mohideen N, Golding LP, Rosenthal SA. An Overview of the Radiation Oncology Alternative Payment Model and Impact on Practices Serving Vulnerable Populations. J Am Coll Radiol 2021; 19:53-60. [PMID: 34762833 DOI: 10.1016/j.jacr.2021.09.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2021] [Revised: 09/10/2021] [Accepted: 09/13/2021] [Indexed: 11/25/2022]
Abstract
Radiation oncology reimbursement methodology has been largely unchanged over the past 30 years, and new approaches are of great interest to practicing radiation oncologists and other health care stakeholders. Traditional radiation oncology reimbursement is based on a series of individual codes for evaluation and management (professional) and technical services, yielding a complex reimbursement system. In an attempt to move toward a simpler, episodic payment model, bundling all of the codes into a single payment, an alternative payment model for radiation oncology was developed. The radiation oncology alternative payment model is a revolutionary change in how radiation oncologic services will be reimbursed and has potential to affect all aspects of radiation oncologic care. Here, the authors review the origin of the currently proposed radiation oncology model and discuss potential implications of this model on the provision of care, especially as it relates to rural practices and other underserved and vulnerable patient populations.
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Affiliation(s)
- Join Y Luh
- Co-Chair Radiation Oncology Focus Group, Providence Health, St. Joseph Hospital, Eureka, California.
| | | | | | - Anne Hubbard
- Director of Health Policy, American Society for Radiation Oncology, Arlington, Virginia
| | | | - Lauren P Golding
- Chief Executive Officer, Triad Radiology Associates, Winston-Salem, North Carolina
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Meeks SL, Mathews R, Mojica J, Shah AP, Kelly P, Dvorak T. Impact of Radiation Oncology Alternative Payment Model on Community Cancer Centers. JCO Oncol Pract 2021; 17:e1949-e1957. [PMID: 34460290 DOI: 10.1200/op.21.00298] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE An episode-based payment model, the Radiation Oncology Alternative Payment Model (RO-APM), is scheduled to go into effect in January 2022. This article investigates the effects of RO-APM on hospital-based and freestanding community centers. METHODS Historical Medicare data used to generate the RO-APM base rates were reviewed. A sensitivity analysis was performed to show how the RO-APM reimbursements compare with current reimbursements for commonly accepted treatment schedules and with current reimbursements at a large community practice. RESULTS The RO-APM base rates represent a 2.2% decrease in overall Medicare reimbursement. Freestanding centers have historically billed at higher rates than hospital-based centers, however, and the RO-APM base rates represent a 6% decrease in global reimbursement for freestanding centers. The sensitivity analysis showed that, except for proton therapy, moderately hypofractionated treatment schedules will receive comparable reimbursement under RO-APM. Treatments using higher numbers of fractions of intensity-modulated radiation therapy or protons will see larger decreases in reimbursement. Application of the RO-APM base rates to the 2020 Medicare treatments in our health care network would result in small changes in expected reimbursement, but our sensitivity analysis indicated that Medicare reimbursement reductions could be as large as 23%. CONCLUSION Compared with historical Medicare reimbursement, RO-APM base rates provide lower reimbursement for many common treatment scenarios, and this will have a larger effect on centers that use complex treatment techniques and longer fractionation schedules or have a large Medicare population.
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Affiliation(s)
- Sanford L Meeks
- Department of Radiation Oncology, Orlando Health Cancer Institute, Orlando, FL
| | - Ryan Mathews
- Department of Radiation Oncology, Orlando Health Cancer Institute, Orlando, FL
| | - Jennifer Mojica
- Department of Radiation Oncology, Orlando Health Cancer Institute, Orlando, FL
| | - Amish P Shah
- Department of Radiation Oncology, Orlando Health Cancer Institute, Orlando, FL
| | - Patrick Kelly
- Department of Radiation Oncology, Orlando Health Cancer Institute, Orlando, FL
| | - Tomas Dvorak
- Department of Radiation Oncology, Orlando Health Cancer Institute, Orlando, FL
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Luh JY. Radiation Oncology Alternative Payment Model's Impact on Small and Rural Practices. JCO Oncol Pract 2021; 17:765-769. [PMID: 34406819 DOI: 10.1200/op.21.00286] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Affiliation(s)
- Join Y Luh
- Providence Health, St Joseph Hospital, Eureka, CA
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Impact of the Radiation Oncology Alternative Payment Model on Brachytherapy Reimbursement. Brachytherapy 2021; 21:55-62. [PMID: 34238689 DOI: 10.1016/j.brachy.2021.05.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2021] [Revised: 05/01/2021] [Accepted: 05/03/2021] [Indexed: 11/24/2022]
Abstract
PURPOSE The Radiation Oncology Alternative Payment Model (RO Model) will test prospective radiotherapy episode-based payments for 16 common disease sites. We created an automated analytics platform to calculate the impact of the RO Model vs historical fee-for-service episode reimbursements for brachytherapy treatments within five community oncology practices for prostate, uterine, and cervical cancer. METHODS AND MATERIALS Claims data between January 1, 2017 and October 2, 2019 for prostate, uterine, and cervical cancer were analyzed as per the RO Model Final Rule methodology. Expected professional and technical component (PC and TC) reimbursements were compared for episodes that utilized brachytherapy alone vs combination modality (external beam and brachytherapy) in the RO Model vs historical reimbursements. RESULTS 6,022 RO Model-defined episodes (60% prostate, 28% uterine, 13% cervical) were generated. Brachytherapy monotherapy episodes (14%) would have an average positive reimbursement in the RO Model (+$2,163 for prostate, +$711 for uterine, +$533 for cervical for the PC; +$12,168 for prostate, +$8,181 for uterine, +$11,322 for cervical for the TC), while combination modality episodes (15%) would have an average negative reimbursement in the RO Model (-$183 for prostate, -$1,701 for uterine, -$2,195 for cervical for the PC; -$374 for prostate, -$5,026 for uterine, -$2,801 for cervical for the TC). CONCLUSIONS Brachytherapy monotherapy episodes for prostate, uterine, and cervical cancer will benefit from an increase in payment, whereas combination modality episodes will receive lower reimbursement. Large shifts in episodic payment may be related to practice-wide adjustments and pricing based on partial episodes of care that may ultimately limit access to care for vulnerable patient populations with cancer.
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Boyce-Fappiano D, Ning MS, Gjyshi O, Mesko S, Pasalic D, Chang AJ, Orio PF, Thaker NG. Payment Methodology for the Radiation Oncology Alternative Payment Model: Implications for Practices and Suggestions for Improvement. JCO Oncol Pract 2021; 17:761-764. [PMID: 34097458 DOI: 10.1200/op.21.00200] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Affiliation(s)
| | - Matthew S Ning
- The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Olsi Gjyshi
- The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Shane Mesko
- The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Dario Pasalic
- The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Albert J Chang
- David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA
| | - Peter F Orio
- Dana-Farber Cancer Institute, Brigham and Women's Hospital, Boston, MA.,Harvard Medical School, Boston, MA.,Department of Radiation Oncology, Dana-Farber Cancer Institute, Brigham and Women's Hospital, Boston, MA
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Shah C, Kamrava M, Thaker NG. Evaluating reimbursement of skin radiation therapy: Technique and fractionation. Brachytherapy 2020; 19:700-704. [DOI: 10.1016/j.brachy.2020.06.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2020] [Revised: 06/06/2020] [Accepted: 06/09/2020] [Indexed: 11/28/2022]
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