Radiation Oncology Pre-Conference: Spotlight on Change

At the March 20 Radiation Oncology Pre-Conference to the ACCC 45^th Annual Meeting & Cancer Center Business Summit the message was clear: Change is coming, and it’s coming in bundles.

Presenter David C. Beyer, MD, FACR, FACRO, FASTRO, Medical Director, Cancer Centers of Northern Arizona Healthcare,  crystalized the conundrum: While change is central to the specialty and the practice of medicine, it is never welcome to the business of medicine. 

Takeaway #1: Welcome or not, change is looming, and radiation oncology programs, whether freestanding or hospital-based, need to prepare for alternative payment models (APMs).

Anne Hubbard, MBA, ASTRO Director of Health Policy, provided an update on the “knowns” and “unknowns” on radiation oncology alternative payment models emerging from the Centers for Medicare & Medicaid Services (CMS).

As the drive to value-based care ratchets up, radiation oncology programs need to ready themselves for a bundled payment model from CMS, ASTRO anticipates that CMS may release radiation model as part of the MPFS and HOPPS 2020 proposed rules.

Current "known" components of CMS' radiation bundled model include: 

• 17 disease sites
•  90-day episode of care
• prospective payment
• applicable in both freestanding and hospital-based setting
• mandatory for select CBSAs (Core-Based Statistical Areas).

Watch for more clarity on the “unknowns” which include whether or not the model will encompass global payment, what the payment methodology will be, and whether the model will be mandatory. 

Adding to the uncertainty, Hubbard said, is whether payers will wait for CMS to test its model(s) or jump ahead with their own APMs.

ASTRO will advocate that this model: 1) Allows radiation oncologists to participate in an advanced APM; 2) Rewards radiation oncologists for delivering high-quality care; and 3) Ensures patient access to appropriate radiation oncology services. 

Takeaway #2: Learn from existing experiences/models of bundled payment for radiation therapy services.

Presenter Constantine Mantz, MD, Chief Policy Officer, 21^st Century Oncology, shared insights from a six-year provider-commercial payer comprehensive bundled payment model for radiation therapy services.  

Today, 10 percent of 21st Century Oncology's business is covered under a bundled payment model, and there are many reasons why it has not been able to increase that percentage. Now that has Medicare has indicated it is developing a radiation oncology-specific APM, 21st Oncology believes that private payers will be compelled to follow, taking into account how CMS will execute payments and quality reporting. Like ASTRO, 21st Century Oncology expects CMS to release this APM sometime in 2020.

Takeaway #3: As your program prepares for change, would interim options help? Presenter David Chamberlain, Alliance Oncology, explored the potential for an interim radiation oncology system to serve as a bridge to change. For example, if your program is: 

• looking to maintain radiation oncology services during equipment upgrades or construction projects.
• interested in testing the market before permanently expanding services or add new modalities.
• seeking to avoid expensive downtime or patient backlog during high-volume periods.

Takeaway #4: "Bundled payments maybe the only way we are able to break the fee-for-service clinch," said Mark Sobczak, MD, Fox Chase Cancer Center.

Dr. Sobczak’s presentation focused the latest breakthrough therapies in radiation oncology. Fifty percent of Medicare spending is concentrated in breast, lung, and prostate cancer; it is logical to assume that these sites will be the ones targeted early in the launch of bundled payments. All three sites have seen significant progress in hypo-fractionated radiation, Dr. Sobczak said. Specifically, early stage lung cancer SBRT, prostate SBRT and hypo-fractionation, and breast hypo-fractionation all offer significant individual and societal savings. 
 
How have all of the changes the occurred in 2018 impacted radiation oncology? ASTRO-endorsed guidelines, when applied only to prostate and breast cancers, may result in a 27 percent to 78 percent decrease in reimbursement for prostate cancer; breast cancer care could see less severe, but still significant, reductions in reimbursement.

Expansion of care could recoup some of this lost revenue. STAMPEDE data supports the treatment of the prostate in men with limited metastatic disease. SABR-COMET could lead to expanded use of SBRT in the treatment of patients with limited metastatic disease in a variety of primary disease sites.

The big unknown is how bundled payments will impact the specialty; data show that efficiencies are possible in the "big three" diseases of lung, breast, and prostate cancer. 

Takeaway #5 Minimize dissatisfiers that maximize frustrations.Teri Bedard, BA, RT(R)(T), Coding Strategies, and Andrew Hertler, MD, FACP, Evolent Health/New Century Health, addressed approaches for  "Minimizing Tasks that Make Your Day Longer." Dr. Hertler cited results from the recent ASCO Practice Census Survey, which identified the top five dissatisfiers as:

 #1 Prior authorizations
#2 Coverage denials and appeals
#3 Peer-to-peer requests from medical directors
#4 Payment lag, timelines, amount
#5 Reporting burden (e.g., MIPS)

Bedard suggested practical tools staff can use to tackle these:
- Develop an authorization worksheet based on your clinical planning note.
- Do not treat until pre-authorization is reviewed by staff, a review similar to a chart check.
- Compile a payer profile binder of codes for authorizations, denial issues, and submission guidelines.

Takeaway #6 Denials cost money! 
Healthcare data indicate that 9 percent of claims are denied and the cost to collect was approximately $118 per claim; 1 out of every 10 claims is denied. Quick math: 1,000 claims per month, 9 percent denial is 90 claims, which costs $10,600/month ($127,200/year) to work and adjust or appeal. Take action to reduce denials by having staff: 

• Track the claims and payments,
• Figure out why a claim is denied, and
• Collect and provide data and information to refute the denial.

Help your staff work smarter by clearly identifying who is responsible for what work (tasks) and have tools available for them to use, ensure staff has access to the complete medical record, educate staff on radiation oncology procedures, and
assess or trends and patterns.