By Anne Hubbard, ASTRO Health Policy Director
On June 17, the Medicare Payment Advisory Commission (MedPAC) issued the 2018 Medicare and Health Care Delivery System report to Congress, which contains three key issues that could impact radiation oncology. MedPAC makes Medicare policy recommendations to Congress and the Centers for Medicare and Medicaid Services (CMS); however, not all MedPAC proposals become law or regulations. Nonetheless, the body is very influential and ASTRO monitors its actions closely.
Medicare coverage policy on proton beam therapy
The report analyzes selected services, including proton beam therapy (PBT), which the Commission deems “low value” and notes increased Medicare spending on proton therapy for prostate cancer. According to the report, low-value services “have little or no clinical benefit or care in which the risk of harm from the service outweighs the potential benefit.” MedPAC identifies multiple tools to address low-value care, including requiring prior authorization for certain types of services; implementing clinician decision support and provider education; altering beneficiary cost sharing; establishing new payment models that foster delivery of system reform; revisiting coverage determinations on an ongoing basis; and linking fee-for-service coverage and payment to clinical comparative effectiveness and cost-effectiveness information.
While ASTRO agrees with efforts to address inappropriate utilization of services that do not benefit patient care, ASTRO is very concerned with the broad-brush approach that led MedPAC to single out PBT. PBT is an effective, evidence-based treatment for a specific group of clinical indications.
ASTRO strongly urges MedPAC and policymakers to avoid expanding prior authorization to Medicare fee-for-services, as the practice is already leading to inappropriate delays and denials of care. The existing ASTRO PBT model policy and Choosing Wisely recommendations serve as excellent resources for guiding appropriate utilization, without interfering in individual physician-patient decision-making. These tools can also be used to inform National and Local Coverage Determinations, which should be regularly updated through stakeholder engagement.
Additionally, new payment models, such as the ASTRO-proposed Radiation Oncology Alternative Payment Model (RO-APM), can be used to encourage the delivery of high-value care. These mechanisms are more effective for changing incentives and behavioral patterns than prior authorization.
Modifications to beneficiary cost sharing should be considered with much caution, as they have the potential to significantly impact cancer patients, who frequently experience financial distress due to the expenses associated with cancer care.
Rebalancing Medicare’s physician fee schedule (MPFS) toward ambulatory E&M services
MedPAC has long expressed concern that Medicare values for ambulatory evaluation and management (E&M) services are underpriced compared to specialty procedures. To address this issue, MedPAC is recommending a one-time rebalancing of the fee schedule to increase payment rates for E&M services by 10 percent, resulting in decreases to specialties, including a 3.2 percent reduction to radiation oncology rates.
Cancer care often begins with screening and diagnosis that takes place in the primary care setting. These services deserve adequate reimbursement; however, reducing reimbursement for cancer treatment is shortsighted and a clear case of robbing Peter to pay Paul. A cut of this magnitude, coupled with existing payment uncertainty on key radiation therapy code values, could challenge the financial viability of radiation oncology clinics. MedPAC should consider whether plugging a hole in primary care could create access to care issues for cancer patients.
Medicare ACOs: Recent performance and long-term issues
MedPAC’s report also assesses the savings generated by Medicare Accountable Care Organizations (ACOs), noting that two-sided risk models (those with both upside risk and downside risk) save more money. However, those savings come at the risk of diminishing returns over time, which can be traced back to the use of “benchmarks” based on historical payment rates. MedPAC asserts that benchmarks may not be a useful tool because ACOs must continuously improve over their past performance to achieve savings, which potentially discourages participation in the ACO program.
MedPAC also questions whether meeting the Medicare payment and patient thresholds are necessary for Advanced Alternative Payment Model (A-APM) participants to receive the 5 percent bonus on all MPFS payments. The Commission suggests that application of the 5 percent bonus on MPFS payments derived from an A-APM will make the incentive more equitable. ASTRO agrees with this approach. It will encourage greater physician participation and it removes the uncertainty of meeting the threshold requirements.
ASTRO will continue advocating with MedPAC and other policymakers for fair and stable Medicare payments for radiation oncology, as well as opportunities for radiation oncologists to fully and meaningfully participate in value-based payment models, such as a RO-APM. ASTRO welcomes your feedback regarding the impact of this MedPAC decision. Comment here with how these changes could affect your practice.
On June 17, the Medicare Payment Advisory Commission (MedPAC) issued the 2018 Medicare and Health Care Delivery System report to Congress, which contains three key issues that could impact radiation oncology. MedPAC makes Medicare policy recommendations to Congress and the Centers for Medicare and Medicaid Services (CMS); however, not all MedPAC proposals become law or regulations. Nonetheless, the body is very influential and ASTRO monitors its actions closely.
Medicare coverage policy on proton beam therapy
The report analyzes selected services, including proton beam therapy (PBT), which the Commission deems “low value” and notes increased Medicare spending on proton therapy for prostate cancer. According to the report, low-value services “have little or no clinical benefit or care in which the risk of harm from the service outweighs the potential benefit.” MedPAC identifies multiple tools to address low-value care, including requiring prior authorization for certain types of services; implementing clinician decision support and provider education; altering beneficiary cost sharing; establishing new payment models that foster delivery of system reform; revisiting coverage determinations on an ongoing basis; and linking fee-for-service coverage and payment to clinical comparative effectiveness and cost-effectiveness information.
While ASTRO agrees with efforts to address inappropriate utilization of services that do not benefit patient care, ASTRO is very concerned with the broad-brush approach that led MedPAC to single out PBT. PBT is an effective, evidence-based treatment for a specific group of clinical indications.
ASTRO strongly urges MedPAC and policymakers to avoid expanding prior authorization to Medicare fee-for-services, as the practice is already leading to inappropriate delays and denials of care. The existing ASTRO PBT model policy and Choosing Wisely recommendations serve as excellent resources for guiding appropriate utilization, without interfering in individual physician-patient decision-making. These tools can also be used to inform National and Local Coverage Determinations, which should be regularly updated through stakeholder engagement.
Additionally, new payment models, such as the ASTRO-proposed Radiation Oncology Alternative Payment Model (RO-APM), can be used to encourage the delivery of high-value care. These mechanisms are more effective for changing incentives and behavioral patterns than prior authorization.
Modifications to beneficiary cost sharing should be considered with much caution, as they have the potential to significantly impact cancer patients, who frequently experience financial distress due to the expenses associated with cancer care.
Rebalancing Medicare’s physician fee schedule (MPFS) toward ambulatory E&M services
MedPAC has long expressed concern that Medicare values for ambulatory evaluation and management (E&M) services are underpriced compared to specialty procedures. To address this issue, MedPAC is recommending a one-time rebalancing of the fee schedule to increase payment rates for E&M services by 10 percent, resulting in decreases to specialties, including a 3.2 percent reduction to radiation oncology rates.
Cancer care often begins with screening and diagnosis that takes place in the primary care setting. These services deserve adequate reimbursement; however, reducing reimbursement for cancer treatment is shortsighted and a clear case of robbing Peter to pay Paul. A cut of this magnitude, coupled with existing payment uncertainty on key radiation therapy code values, could challenge the financial viability of radiation oncology clinics. MedPAC should consider whether plugging a hole in primary care could create access to care issues for cancer patients.
Medicare ACOs: Recent performance and long-term issues
MedPAC’s report also assesses the savings generated by Medicare Accountable Care Organizations (ACOs), noting that two-sided risk models (those with both upside risk and downside risk) save more money. However, those savings come at the risk of diminishing returns over time, which can be traced back to the use of “benchmarks” based on historical payment rates. MedPAC asserts that benchmarks may not be a useful tool because ACOs must continuously improve over their past performance to achieve savings, which potentially discourages participation in the ACO program.
MedPAC also questions whether meeting the Medicare payment and patient thresholds are necessary for Advanced Alternative Payment Model (A-APM) participants to receive the 5 percent bonus on all MPFS payments. The Commission suggests that application of the 5 percent bonus on MPFS payments derived from an A-APM will make the incentive more equitable. ASTRO agrees with this approach. It will encourage greater physician participation and it removes the uncertainty of meeting the threshold requirements.
ASTRO will continue advocating with MedPAC and other policymakers for fair and stable Medicare payments for radiation oncology, as well as opportunities for radiation oncologists to fully and meaningfully participate in value-based payment models, such as a RO-APM. ASTRO welcomes your feedback regarding the impact of this MedPAC decision. Comment here with how these changes could affect your practice.