Radiation Oncology Alternative Payment Model (RO APM)

What is the RO APM?

The RO APM is a proposed advanced alternative payment model developed by the Centers for Medicare and Medicaid Services (CMS) in conjunction with their Center for Medicare and Medicaid Innovation. Under the proposed pilot, Medicare pays providers a predetermined, site-neutral bundled rate for most radiation therapy services provided within a 90-day episode of care, rather than paying for each service individually. As proposed, the model would be mandatory for providers selected to participate. The intended goal is to incentivize providers to deliver radiation therapy services more cost-effectively while maintaining or improving the quality of care delivered.

Elekta is actively evaluating MOSAIQ Plaza, our suite of digital tools, to develop solutions that will support customers through the transition and implementation of the RO APM. CLICK HERE to request a demo and learn how MOSAIQ Plaza can help you today.

 

Education & Training


Once the final rule is released, Elekta will provide a comprehensive webinar discussing the final rule and what Elekta is doing to assist our customers with this alternative payment model.

Elekta’s pre-RO APM webinar: What you need to know

FAQs

A: The RO APM is a proposed advanced alternative payment model developed by the Centers for Medicare and Medicaid Services (CMS) in conjunction with their Center for Medicare and Medicaid Innovation. Under the proposed pilot, Medicare pays providers a predetermined, site-neutral bundled rate for most radiation therapy services provided within a 90-day episode of care, rather than paying for each service individually. As proposed, the model would be mandatory for providers selected to participate. The intended goal is to incentivize providers to deliver radiation therapy services more cost-effectively while maintaining or improving the quality of care delivered.

A: The RO APM is several years in the making, starting in December 2015, when Congress passed the Patient Access and Medicare Protection Act (PAMPA), 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. In November 2017, CMS released a report to Congress detailing options for an episodic model for RT services and then, in July 2019, CMS released a proposed rule detailing the specification for the model, which were open to comment until September 16, 2019. Elekta, along with over 300 other providers, patient groups, industry groups, and physician specialty societies, namely ASTRO, submitted comments supporting or disagreeing with various aspects of the model and recommending changes that should be made in the final rule, which is anticipated to be released in 2020.

A: All technologies used during a radiation therapy episode are included in the RO APM per the proposed rule. This includes external beam (3D, IMRT, SRS, SBRT, IGRT), brachytherapy, and proton beam. The proposed rule indicates that CMS is considering an exemption for patients undergoing proton beam therapy that enrolled in a federally funded randomized control trial.

A: Participation in the RO will be determined by core based statistical area (CBSA) which draws geographically similar areas by zip code. CMS stated in the proposed rule that their goal is include 40 percent of all episodes of care for RT in the model and hopes to geographically match CBSAs both in and outside the model. If selected, all providers, hospitals, and freestanding centers furnishing RT services within a given CBSA will be required to participate.

A: This is only for Medicare fee for service patients. Patient with Medicare Advantage, Medicaid, or commercial insurance are not paid under this model. Sites in Maryland and Vermont, prospective payment system exempt cancer hospitals, ambulatory surgical centers, and critical access hospitals and those with the Pennsylvania Rural Health designation are exempt from participating in the model.

A: Payment under the RO APM will be assigned based on the diagnosis of the patient instead of the technology used to deliver care, meaning that payment will be technology agnostic. There are 17 cancer types covered by the RO APM which will be tracked via ICD 10 codes. These sites are inclusive of all standard cancer disease sites except for skin. RT services furnished for the treatment of diseases outside of these disease sites, including skin cancer, are excluded from the RO APM and will be paid under traditional Medicare FFS.

The proposed disease sites are:

Anal Cancer CNS Tumors Lung Cancer
Bladder Cancer Colorectal Cancer Lymphoma
Bone Metastases Head and Neck Cancer Pancreatic Cancer
Brain Metastases Kidney Cancer Prostate Cancer
Breast Cancer Liver Cancer Upper GI Cancer
Cervical Cancer Uterine Cancer  

A: CMS calculated national base rates for the technical and professional component for each of the 17 cancer types under the model using historical hospital outpatient billing data from 2015 to 2017. Payment under the RO APM will be site neutral, meaning that payments in the freestanding radiation therapy centers will be calculated using the same methodology as hospital outpatient departments.

A: Under the RO APM, participants will receive a single bundled payment for almost every radiation oncology service provided in a 90-day episode of care. A treatment planning code will trigger the start of the 90-day episode. Participants will receive 50 percent of the bundled payment at the start of the episode and 50 percent of the bundled payment at the end of the episode. The 90-day episode will be followed by a 28-day clean period in which any services delivered will be paid fee for service (FFS). After the 28-day clean period, a new bundle can be triggered.

A: Despite an erroneous news article stating otherwise, the RO APM has not been officially delayed until 2022. When CMS released the rule in July 2019, they intended to implement the rule in early to mid-2020. However, due to a high volume of comments on the proposed rule, the final rule was not released in 2019. We anticipate the final rule to be released in early or mid-2020, with mid-to-late 2020 or early 2021 implementation, although exact timing and implementation deadlines are still unknown. ASTRO put out an official statement on the timing of the final rule, which provides additional perspective on final rule release and implementation timing.

A: According to CMS, the RO Model would be an Advanced APM and a MIPS APM under QPP. According to the proposed rule, RO APM participants need to annually certify their intent to use of Certified Electronic Health Record Technology (CEHRT), include quality measure performance as a factor when determining payments, and bear more than a nominal amount of financial risk. RO Model participants who are APM Entities and eligible clinicians seeking Qualifying APM Participant (QP) status in an Advanced APM must comply with all RO Model requirements in order to be eligible for Advanced APM incentive payments. Participants who do not meet the QP threshold would not qualify for the Advanced APM incentive payment and instead would be in a MIPS APM.

A: As a qualified advanced RO APM under MIPS/MACRA, MOSAIQ can be used to report on and submit on the four quality measures required under the RO APM. Because exact requirement for requirements are still being determined, additional information will be needed to determine exactly how CMS would like the quality measures and data submission requirements uploaded for review. Elekta is working closely with ASTRO and others to determine what data elements will be required for reporting and determine appropriate submission vehicles.

A: Elekta is wholly engaged in understanding the requirements of the RO APM and is in the process of updating our MOSAIQ software to allow for reporting and submission of the four quality measures and data submission requirements for the RO APM. In addition, Elekta is making enhancements to other solutions to better allow for our customers to track, submit, and optimize work flows to better accept a bundled payment arrangement.

Additional Resources

Disclaimer

Responsibility for compliance with the Radiation Oncology Alternative Payment Model’s (RO APM) regulations and guidelines rests entirely with the eligible professional or delegate.

Elekta makes no representation of expertise in the Radiation Oncology Alternative Payment Model (RO APM). Elekta advises each eligible professional or delegate to seek its own counsel or advisors in determining how best to interpret, apply, and comply with the Radiation Oncology Payment Model (RO APM) objectives.

Any training and documentation provided by Elekta are for informational and reference purposes only. Elekta makes no representation, warranty, or guarantee of completeness, accuracy, applicability, or validity of the training and documentation provided. Elekta disclaims liability for any loss or claimed damages that may arise from reliance on or use of information contained in any training and documentation provided by Elekta.

Elekta makes no representation, warranty, or guarantee that an end user of the MOSAIQ® oncology information system will meet the requirements for RO APM or demonstrate adequate compliance with the Radiation Oncology Alternative Payment Model (RO APM).