Hi everyone. My name is Connie Mantz. I'm a community-based radiation oncologist practicing in Florida, an immediate past chair of ASTRO's Health Policy Council. My co-authors for this paper are fellow radiation oncologist, James Yu, who practices in Connecticut, and Join Luh, who practices in California. Our paper summarizes the practical implications of ASTRO's proposal for a new Medicare payment system for radiation oncology called ROCR: the Radiation Oncology Case Rate Program. ROCR is a response to declining case payments in radiation therapy, largely predicated on decreasing fractionation in a fee for service system designed to reimburse each individual service during a course of care. A salient distinction to make between ROCR and the RO Model, which is a Medicare alternative payment model that was never launched and placed on indefinite hold, is that ROCR is a legislative proposal. This means that the Congress may enact this proposal into law and that CMS, as an agency of government, would be obligated to administer it without the authority to alter the method by which payments are determined. Dialysis care is currently paid under a similar system enacted by the Congress in 2010. ROCR would replace current fee for service with case rate payments for each of the 15 most common cancer types treated with radiation therapy. External beam and stereotactic radiation modalities would be included, and brachytherapy and protons would be excluded. What is expected as a result of this transition in payment systems, is the encouragement of shorter courses and the flexibility to use whatever technique is clinically best without financial penalty. In other words, medical decision making is uncoupled from payment, which would be similar regardless of the number of fractions for a case. One caveat is that new technologies, which do not yet have a procedure code such as adaptive radiotherapy, would be paid separately under fee-for-service once a new procedure code is established. ROCR would help enable development of new technologies through a dedicated and separate payment. The Case Rate payment would be distributed in equal portions at the initiation of care and the conclusion of treatment. Standard claims reporting would be used to indicate the start and end of the course and for reporting all services in between as done currently. Another key difference between ROCR and the RO Model is that ROCR assigns metastatic disease into 30-day episodes, after which new episodes may start and be paid separately. Nonmetastatic cases are assigned to a 90-day episode. Another key feature of ROCR is that its payments would be adjusted annually for inflation. Medicare currently doesn't inflation adjust payments to physicians and facilities, which is particularly harmful to a clinical service line, such as radiation oncology, with its very high and fixed cost structure. It should also be noted that the inflationary adjustment would be partially offset by savings adjustment necessary for congressional budgetary requirements. To help meet the needs of patients constrained by distance and resources, ROCR would make an additional payment of $500 to the facility to be applied to transportation assistance for eligible patients. For those facilities with full practice accreditation, or are in process of applying for accreditation, ROCR would issue a small bonus of 0.5% over the first three years. Exemptions to this quality requirement would be given to rural facilities. The quality requirement would replace current MIPS reporting as a lesser burdensome and more comprehensive, and perhaps meaningful indicator of clinical quality. To summarize, we are proposing ROCR to replace Medicare fee-for-service. Fee-for-service is not suitable in an era of diminishing utilization of radiation services and ongoing Medicare cuts. A more stable payment system is needed. ROCR would advance practice accreditation as a substitute for MIPS reporting. ACR, ACRO, and ASTRO's accreditation programs would all meet this quality requirement. Ultimately, ROCR's impact on practice financials would depend on payer mix for that practice. To model this impact, please download and use modeling tools available through the ASTRO website. Thank you.
