Radiation Oncology Model

The Protecting Medicare and American Farmers from Sequester Cuts Act (P.L. 117-71) enacted on December 10, 2021 included a provision that prohibits implementation of the Radiation Oncology Model prior to January 1, 2023. Thus, the RO Model did not begin on January 1, 2022. 
 
On August 29, 2022, CMS published a final rule in the Federal Register, CMS-5527-F2, which finalized delaying the current start date of the RO Model to a date to be determined through future rulemaking. Please reference the final rule CMS-5527-F2 here: https://www.federalregister.gov/public-inspection/2022-18541/radiation-oncology-model

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 practices (PGPs), hospital outpatient departments (HOPD), and freestanding radiation therapy centers for RT episodes of care reduces Medicare expenditures while preserving or enhancing the quality of care for Medicare beneficiaries. The Consolidated Appropriations Act, 2021 (H.R. 133) enacted on December 27, 2020 includes a provision that prohibits implementation of the RO Model prior to January 1, 2022. CMS has addressed this delay through notice and comment rulemaking in the CY 2022 Hospital Outpatient Prospective Payment System (OPPS) and Ambulatory Surgical Center (ASC) Payment System final rule (CMS-1753-F).

Background

Since 2014, CMS has explored potential ways to test an episode-based payment model for RT services. In December 2015, Congress passed the Patient Access and Medicare Protection Act, which required the Secretary of Health and Human Services to submit to Congress a report on “the development of an episodic alternative payment model” for RT services. The report was published in November 2017. The report (PDF) identified three key reasons why RT is ready for payment and service delivery reform: the lack of site neutrality for payments; incentives that encourage volume of services over the value of services; and coding and payment challenges.

Model Design

The RO Model is a mandatory model that tests whether changing the way RT services are currently paid – via fee-for-service payments – to prospective, site neutral, modality agnostic, episode-based payments incentivizes physicians to deliver higher-value RT care. The design of the RO Model includes several key programmatic elements:

  1. Alternative Payment:
    1. Episode Payments: CMS makes prospective, episode-based (i.e., bundled) payments, based on a patient's cancer diagnosis, that cover RT services furnished in a 90-day episode for the included  cancer types meeting the included cancer type criteria described in the final rule;
    2. Site-neutrality: The Model uses site-neutral payment by establishing a common, adjusted national base payment amount for the episode, regardless of the setting where it is furnished;
    3. Professional and Technical Payment Components: Episode payments are split into professional and technical components to allow the current claims systems for the Physician Fee Schedule (PFS) and the Outpatient Prospective Payment System (OPPS) to be used to adjudicate RO Model claims and for consistency with existing business relationships.
  2. Linking Payment to Quality: The Model links payment to quality using reporting and performance on quality measures, clinical data reporting, and patient experience as factors when determining payment to RO participants. The Model meets the requirements to qualify as an Advanced Alternative Payment Model (APM) and a Merit-Based Incentive Payment System (MIPS) APM under QPP starting in performance year (PY) 1.
  3. RO Participants in a Mandatory Model: The RO Model requires participation from RT providers and RT suppliers that furnish RT services within randomly selected CBSAs.

RO Model Participants

An RO participant can be any of the following entities: 1) PGP (including freestanding radiation therapy centers) or 2) an HOPD. RO Model participants can participate in the Model as Professional participants, Technical participants, or Dual participants. Some RO participants, like PGPs, can be both Professional participants and Dual participants depending on the RT services they furnish during the RO episode.

  • A Professional participant is a Medicare-enrolled PGP, identified by a single Taxpayer Identification Number (TIN) that furnishes only the professional component (PC) of RT services at either a freestanding radiation therapy center or a HOPD.
  • A Technical participant is an HOPD or freestanding radiation therapy center, identified by a single CMS Certification Number (CCN) or TIN, which furnishes only the technical component (TC) of RT services during an RO episode.
  • A Dual participant furnishes both the PC and TC of an RO episode for RT services through a freestanding radiation therapy center, identified by a single TIN.

RO Model Episode Pricing

RO participant-specific payment amounts are determined based on national base rates, trend factors, and adjustments for each participant’s case-mix, historical experience, and geographic location. CMS further adjusts payment amounts by applying a discount factor. The discount factor, or the set percentage by which CMS reduces an episode payment amount, reserves savings for Medicare and reduces beneficiary cost-sharing. The discount factor for the PC is 3.5 percent, and the discount factor for the TC is 4.5 percent. The payment amount is also adjusted for withholds for incorrect payments (1 percent for PC and TC), quality (2 percent for PC), and patient experience (1 percent for TC starting in PY3). RO participants can earn back all or some of the incorrect withhold based on the amount of incorrect payments during the previous PY. RO participants have an opportunity to earn back a portion of the quality and patient experience withholds based on clinical data reporting, quality measure reporting and performance, and the beneficiary-reported Consumer Assessment of Healthcare Providers and Systems (CAHPS®) Cancer Care Radiation Therapy Survey. The standard beneficiary coinsurance and sequestration policies remain in effect.

RO Participant Payment

RO episode payments are paid prospectively in the RO Model, meaning that half of the episode payment amount is paid when the RO episode is initiated, and the second half is paid when the RO episode ends. Episode payments in the RO Model are split into a PC payment; which is meant to represent payment for the included RT services that may only be furnished by a physician; and the TC payment, which is meant to represent payment for the included RT services that are not furnished by a physician, including the provision of equipment, supplies, personnel, and costs related to RT services. This division reflects the fact that RT professional and technical services are sometimes furnished by separate providers or suppliers.

Advanced APM and MIPS APM

The RO Model is expected to qualify as an Advanced APM and a MIPS APM under QPP starting in PY1. To meet those requirements, the RO Model, starting in PY1, (1) requires RO participants to annually certify their intent to the use of Certified Electronic Health Record Technology (CEHRT), (2) includes quality measure performance as a factor when determining payments, and (3) requires RO participants bear more than a nominal amount of financial risk. The RO Model has three tracks related to QPP. Track One includes Professional participants and Dual participants who follow all RO requirements, including CEHRT, and we expect will qualify as an Advanced APM and a MIPS APM. Track Two includes Professional participants and Dual participants who follow all RO requirements except for CEHRT, and we expect will qualify as a MIPS APM only. Track Three is for all other RO participants and would not be an Advanced APM or MIPS APM.

Quality Measures

The RO Model includes four quality measures. The Consumer Assessment of Healthcare Providers and Systems (CAHPS®) Cancer Care Radiation Therapy Survey will be administered starting in PY1 to determine patient experience measures used in PY3-5. These measures allow the RO Model to apply a pay-for-performance methodology that incorporates performance measurement with a focus on clinical care and beneficiary experience with the aim of capturing a reduction in expenditures and preserving or enhancing quality of care for beneficiaries. To do this, the Model withholds 2 percent of the PC, and 1 percent of the TC payments for each episode starting in PY3. RO participants have the ability to earn back a portion of the quality and patient experience withholds based on clinical data reporting, quality measure reporting and performance, and the beneficiary reported CAHPS® Cancer Care Radiation Therapy Survey. Patient experience measures based on the CAHPS® Cancer Care Survey for Radiation Therapy will be proposed through future rulemaking. RO Participants are also required to submit clinical data elements for five cancer types (bone, brain, breast, lung, prostate) biannually. The clinical data requirements are included in the Quality Measure and Clinical Data Elements Guide. 

The four quality measures are:

  • Oncology: Medical and Radiation - Plan of Care for Pain - NQF #0383; CMS Quality ID #144
  • Treatment Summary Communication – Radiation Oncology
  • Preventive Care and Screening: Screening for Depression and Follow-Up Plan -NQF #0418; CMS Quality ID #134
  • Advance Care Plan -NQF #0326; CMS Quality ID #047

Please see the below section on the Extreme and Uncontrollable Circumstances (EUC) policy for more information.

Beneficiaries

CMS recognizes the importance of beneficiaries’ awareness that their RT providers and RT suppliers are participating in the RO Model. Therefore, all RO participants must provide a RO Model Beneficiary Notification Letter to RO beneficiaries who are included in the RO Model.

RO beneficiaries are still responsible for cost-sharing as under the traditional payment systems (e.g., typically 20 percent of the Medicare-approved amount for services), but because CMS is applying a discount to each of these components, beneficiary cost-sharing may be, on average, lower relative to what is typically paid under traditional Medicare FFS. As with all Innovation Center models, we monitor the RO Model to guard against any unintended consequences that might negatively impact beneficiaries.

Beneficiaries retain their freedom to choose any provider or supplier and, if they feel their care has been compromised, they should call 1-800-MEDICARE or contact their Quality Improvement Organization (QIO).

Extreme and Uncontrollable Circumstances (EUC) Policy

In the CY 2022 Medicare Hospital Outpatient Prospective Payment System (OPPS) and Ambulatory Surgical Center (ASC) Prospective Payment System (PPS) final rule, CMS finalized its proposal to adopt an EUC policy at 42 C.F.R. 512.294 for the Radiation Oncology (RO) Model. CMS has determined that there is currently an EUC based on the ongoing COVID-19 public health emergency (COVID-19 PHE). Unless the Secretary terminates his renewal of the COVID-19 PHE prior to January 1, 2022, CMS intends to invoke provisions of the EUC policy on the effective date of the CY 2022 OPPS/ASC final rule, on January 1, 2022.

Pursuant to the regulations at 42 C.F.R. 512.294(c), CMS intends to grant all RO participants certain exceptions to the RO Model requirements. Pursuant to our regulations at 42 CFR 512.294(e), CMS intends to revise the RO Model’s pricing methodology during the first performance year of the RO Model (2022). CMS does not intend to amend the model performance period under the EUC policy.

The specific RO Model flexibilities intended for PY 1 (January 1, 2022 through December 31, 2022) are as follows:

  • The requirement that RO participants collect and submit quality measures and clinical data elements will be optional in PY1 (2022).
    • Because this requirement will be optional, the 2-percent Quality Withhold will not be applied to RO Model professional episode payments in PY1 (2022).
  • The requirement that RO participants actively engage with an AHRQ-listed patient safety organization (PSO) will be optional in PY1 (2022).
  • The requirement that RO participants conduct Peer Review (audit and feedback) on treatment plans will be optional in PY1 (2022).

Additional information regarding the implementation of these changes will be provided to RO participants by CMS via upcoming learning events and materials.

The complete description of the EUC policy can be found in the CY 2022 OPPS/ASC final rule and at § 512.294.

Regulations and Notices

Events

Upcoming Events

  • RO Model QPP, APM and MIPS Webinar (Event Postponed)

Note: Timing and topics are subject to change based on ongoing trends of RO participant needs.

Additional Information

Technical Documents

Guides

User Manuals

Radiation Oncology Administrative Portal (ROAP)

The ROAP is an online platform that is used to track RO participant information through the participant profile page and to allow users to access and review organizational data; update participant information and contacts; download and submit Data Request and Attestation (DRA) forms; access participant specific data, including Case Mix and Historical Experience Adjustments and Performance Reports; attest to CEHRT, revise and attest to the Individual Practitioner List, and attest to participating with a Patient Safety Organization.

It is important that you access the ROAP to add/update points of contact and confirm the information in the participant list; as well as to indicate if you will choose the low-volume opt-out option, if you are eligible.

To register for ROAP, you will need your Model ID, TIN for PGPs including freestanding radiation therapy centers or CCNs for HOPDs and the first name, last name, and email address of the designated Primary Point of Contact. Once you’ve received your Model ID, please visit the ROAP login page.

If you do not know your RO Model ID, please contact the Help Desk. HOPDs should email RadiationTherapy@cms.hhs.gov or call the Help Desk, at 1-844-711-2664, option 5, with their CCN, so we may provide you with your Model ID. PGPs should call the Help Desk with their practice’s TIN to retrieve your Model ID. TINs should never be sent via email. You will also need to supply the first name, last name, and email address of a Primary Point of Contact.

For assistance with ROAP, please review the ROAP User Manual.

The RO Model Secure Data Portal

The RO Model Secure Data Portal is the platform via which RO participants have the opportunity to access different types of files from CMS, including: beneficiary line-level claims data, episode-level data, participant-level data, as well as submit quality measures and clinical data elements.

To request claims data, RO participants use a Data Request and Attestation (DRA) form, if appropriate for that RO participant’s situation, which is available on ROAP. Throughout the model performance period, RO participants may request to continue to receive these data until the final reconciliation and final true-up processes have been completed if they continue to use such data for care coordination and quality improvement purposes. At the conclusion of these processes, the RO participant would be required to maintain or destroy all data in its possession in accordance with the DRA and applicable law.

View the RO Model Secure Data Portal User Manual (PDF)

RO Connect

The RO Model Connect Site is a collaboration space for the RO participants. The RO Model Connect Site Library contains technical and operational resource documents important for program implementation, as well as audio-visual recordings and transcripts of RO Model learning events. The goal of this online learning community is to encourage innovation, peer-to-peer learning, collaboration and sharing of knowledge among participants in the RO Model.

RO participants will find the link to sign-up for RO Connect on the ROAP site. Once you log onto ROAP, please click the Connect link under the “Helpful Links” section. 

If are unable to access your account, or have any other questions regarding technical access or log-in issues for your Connect account, please contact the CMMI Connect Help Desk at CMMIConnectHelpDesk@cms.hhs.gov or 1-888-734-6433 (Select option 2 when prompted).

Questions that are directed to the RO Model Team, not other RO participants, should be sent to the RO Model Help Desk at RadiationTherapy@cms.hhs.gov.

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