Radiation Oncology Model An overview of CMS final

Radiation Oncology Model An overview of CMS’ final rule

RO aims to reduce spending while enhancing care quality CMS attempts prospective, site neutral, episode-based payment model Timeline and logistics Participants • CMS published final rule for Radiation Oncology (RO) Model in September 2020 • • RO will start on July 1, 2021 and run though 2026, with 90 • day episodes of care Model design • Prospective, site neutral, episode-based payments will cover RT services for 16 cancer types • Mandatory for all radiation therapy providers and suppliers within randomly selected Core-Based Statistical Areas (CBSAs), accounting for 30% of eligible episodes • • Reporting and performance on quality measures, clinical data, and patient experience are factored into payments to link payments to quality Model qualifies as an Advanced APM 1 and MIPS APM 1. Alternative Payment Model. 2. Ambulatory surgical centers 3. Critical access hospitals Professional participants: Physician groups billing under PFS that furnish the professional component (physician-dependent services) at a freestanding center or HOPD Technical participants: HOPD/freestanding centers furnishing only the technical component (equipment, overhead, etc. ) • Dual participants: When the physicians performing radiation also own the location where it is delivered (furnish both components) • Excludes: • Providers in MD, VT, U. S. territories, ASCs 2, CAHs 3, the Pennsylvania rural health model, and PPS-exempt cancer hospitals • Providers can opt out if they furnish fewer than 20 episodes across all selected CBSAs in the most recent year with claims available Source: “Radiation Oncology Model, ” CMS, https: //innovation. cms. gov/innovation-models/radiation-oncology-model. 2 © 2020 Advisory Board • All rights reserved • advisory. com Oncology Roundtable interviews and analysis.

Participants will be responsible for radiation-related costs Payment in two installments per episode Payment methodology Who are they paid for? What are they paid for? How are they paid? • • Participants are not responsible for total cost of care • • Modalities included: 3 D-CRT, IMRT, SRS, SBRT, proton, IGRT, and non-surgical brachytherapy (IORT was excluded) Participants are paid in two installments per episode—at the beginning and end—split into professional and technical components • CMS will issue new HCPCS codes and modifiers to signal start and end points • Participants can request second installment at the completion of the planned course of treatment (no earlier than 28 days after initial service was furnished) • Participants must submit encounter data claims for all RT services in bundle • All Medicare FFS patients enrolled in Part B who are receiving radiation services in a selected CBSA and have a qualifying ICD-10 diagnosis code for one of 16 cancer types (kidney cancer was excluded) Patients enrolled in a clinical trial for which CMS pays routine costs • Services excluded: E&M visits and low-volume radiation services, such as some brachytherapy surgical and electronic procedures, neutron beam therapy, and radiopharmaceuticals Source: “Radiation Oncology Model, ” CMS, https: //innovation. cms. gov/innovation-models/radiation-oncology-model. 3 © 2020 Advisory Board • All rights reserved • advisory. com Oncology Roundtable interviews and analysis.

Eight key steps for RO pricing methodology Potential to earn back quality and patient experience withholds based on AQS 1 1 2 3 National Trend factor Geographic base rates adjustment from historical average cost of care per episode, created from 2016 -18 FFS claims for professional and technical components for each cancer type 1. Aggregate quality score. 4 Case mix adjustments (professional and technical components) + historical experience adjustments (based on Winsorized payment amounts weighted with “blend” factor) 5 Discount factor (3. 75% for professional component, 4. 75% for technical component) 6 7 8 Beneficiary Sequestration Incorrect coinsurance adjustment payment (2%) (20%) withhold (1%, annual reconciliation process), quality withhold (2%, earned back based on AQS), and/or patient experience withhold (1% starting in PY 3, based on scores from the Cancer CAHPS for Radiation Therapy) Source: “Radiation Oncology Model, ” CMS, Final payment https: //innovation. cms. gov/innovation-models/radiation-oncology-model. 4 © 2020 Advisory Board • All rights reserved • advisory. com Oncology Roundtable interviews and analysis.

AQS is used to calculate the quality reconciliation payment AQS based on mix of pay-for-reporting and pay-for-performance measures AQS = quality measures + 0 -50 points based on weighted measure scores and reporting clinical data Quality reconciliation payment = 50 points when submitted for ≥ 95% of applicable beneficiaries Measures used to calculate AQS Measure Level of reporting Pay-forperformance Participants impacted Plan for care of pain Aggregate N/A PY 1 -5 Professional/dual Screening for depression and follow-up plan Aggregate N/A PY 1 -5 Professional/dual Advance care plan Aggregate N/A PY 1 -5 Professional/dual Treatment summary communication Aggregate PY 1 -2 PY 3 -5 Professional/dual CAHPS for Cancer Care survey Patient reported N/A PY 3 -5 All Clinical data elements describing cancer stage, disease characteristics, treatment intent, and specific treatment plan 1 Beneficiary-level PY 1 -5 N/A Professional/dual 1. For beneficiaries with prostate, breast, or lung cancer or bone or brain metastases. © 2020 Advisory Board • All rights reserved • advisory. com Source: “Radiation Oncology Model, ” CMS, https: //innovation. cms. gov/innovation-models/radiation-oncology-model. 5 Oncology Roundtable interviews and analysis.

Next steps to get access to CMS data Make sure to continue monitoring the RO website 1 Call the CMS help desk to receive your Model ID number 2 Register in the Radiation Oncology Administrative Portal (ROAP) 3 Access the RO Model Secure Data Portal Model ID number is needed to log into the ROAP, the RO Model Secure Data Portal, and the Radiation Oncology Connect Site. You will need: the name and email of your primary contact and your TIN or CCN number. Email: Radiation. Therapy@cms. hhs. gov; Phone: 1 -844 -711 -2664, option 5 ROAP allows you to: upload information, download and submit Data Request and Attestation (DRA) forms and model deliverables, access participant-specific data, attest to CEHRT, revise the Individual Practitioner List, attest to PSO, and determine eligibility for Opt-out. You will need: the name and email of primary contact and your TIN or CCN number. Login page: https: //app. innovation. cms. gov/ROAP/IDMLogin? start. URL=%2 FROAP The Secure Data Portal allows you to submit quality and clinical data measures and request data from CMS, including beneficiary line-level claims data, episode-level data, and participantlevel clinical and quality data. You will need: your Model ID number and a completed DRA form (from ROAP). Source: O’Reilly, M, “Specialty Listening Session October 8, 2020, ” CMS, https: //innovation. cms. gov/media/document/ro-model-special-listening-session-10 -08 -2020. 6 © 2020 Advisory Board • All rights reserved • advisory. com Oncology Roundtable interviews and analysis.

Key internal considerations to prepare for RO Model launch Strategic • Designate person or team to oversee organizational response • Educate people involved in strategic planning, revenue cycle management, IT, payer, and budgeting about Model and enlist their support preparing for change • Develop high-level timeline and assign tasks Financial • Understand requirements for billing compliance • Identify necessary revenue cycle workflow changes • • • (registration, prior auth) Collaborate with IT to identify beginning and end of treatment Figure out how to monitor revenue performance Build in new modifiers Discern impact on any existing pro formas and budgets Calculate and communicate financial impact of day-, week-, or month-long delays in timeline execution Clinical operations • Identify necessary workflow and documentation • • • changes Allocate care team responsibility for specific requirements Determine whether additional staff will be needed Collaborate with data extraction team to establish which clinical tasks need to be built into set processes Quality • Create dashboards to monitor progress • Put process in place to review progress regularly • Develop mechanism to hold care team accountable for performance IT • Help operationalize finance, clinical operations, quality • changes necessary for participation Review technology and data reporting requirements and assess organizational capabilities to meet them 7 © 2020 Advisory Board • All rights reserved • advisory. com Oncology Roundtable interviews and analysis.

Identify strategic, care delivery changes to ensure success Four “no-regret” strategies to improve quality and reduce costs Ensure adherence to evidence-based care Facilitate shared decision making Encourage the development of more clinical evidence and rapidly incorporate new information on cost and patient outcomes into treatment protocols. Engage patients in treatment decisions that factor in costs to the patient, outcomes, and their goals for care. After implementing clinical pathways, one cancer program increased its use of hypofractionation for breast patients from 8% to 77% in just three years. Jefferson Health's decision counseling program helps lowrisk prostate cancer patients select the treatment that aligns with their goals. 83% of participants in a pilot chose active surveillance. Find new ways to improve safety Revamp investment strategy Seek new opportunities to improve safety and compliance with processes and protocols. Invest in technologies that promote higher-value care. Northwell Health’s daily peer review conducted as part of its Smarter Radiation Oncology™ program corrected issues in 25% of cases over a 22 -month period, saving time in the long run by reducing the number of treatment plans that require modification later on. In the past, capital equipment's ROI was primarily determined by its impact on cash flow and capacity. These are still important, but cancer programs also need to consider nontraditional returns, such as cost avoidance resulting from reduced toxicities. Source: Innovations in Radiation Oncology, Oncology Roundtable, The Advisory Board Company, https: //www. advisory. com/-/media/Advisorycom/Research/OR/Resources/2017/35442 a-OR-Radiation-Oncology-Mar 2018. pdf. 8 © 2020 Advisory Board • All rights reserved • advisory. com Oncology Roundtable interviews and analysis.

Oncology Roundtable related resources Your top questions on the FINAL Radiation Oncology Model, answered Radiation Oncology Model readiness assessment Innovations in Radiation Oncology 9 © 2020 Advisory Board • All rights reserved • advisory. com Oncology Roundtable interviews and analysis.

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