FROM THE ABS:
Impact of Final Alternative Payment Model "RO Model" on Brachytherapy
Mitchell Kamrava, MD
Cedars-Sinai Medical Center
On September 18, 2020, the Centers for Medicare and Medicaid Innovation Center issued final rules for the Radiation Oncology Alternative Payment Model (RO Model), anticipated to go into effect January 1, 2021. The purpose of the RO Model is to determine if prospective 90-day episode-based payments will reduce Medicare healthcare expenditures while maintaining or enhancing quality of care. This is part of a larger mission to move our healthcare system away from fee for service and towards value-based medicine.
The final RO Model estimates it will save $230M over a 5-year period. To achieve this, the model requires 30% of radiation oncology episodes in pre-selected Core Based Statistical Areas (CBSAs) to participate in the model. It’s estimated this will include 500 physician group practices (PGPs) of which 275 are freestanding and 450 Hospital Outpatient Departments (HOPDs). CMS anticipates, on average, the RO Model will reduce Medicare FFS payments to PGPs by 6 percent and Medicare FFS to HOPDs by 4.7 percent. CMS estimates that the overall revenue impact for those participating in the RO Model will be less than 1 percent, given this only impacts Medicare FFS beneficiaries.
The full impact of the proposed RO Model will not be realized until many years after its implementation. Resources are being made available to assist practices preparing for the impending changes. There will be 16 disease sites included in the model.
Key policies in the RO Model that will impact brachytherapy include:
1) Brachytherapy sources will be bundled into the 90-day episode of payment
2) The brachytherapy applicator insertion codes listed below will be included in the bundled payment:
a. 57155 – Insertion of uterine tandem and/or vaginal ovoids for clinical brachytherapy
b. 57156 – preparing a patient and inserting and securing the vaginal applicator. It also includes the removal of the applicator after the procedure has been completed.
c. 55920 – Placement of needles of catheters into pelvic organs and/or genitalia (except prostate) for subsequent interstitial radioelement application
d. 53846 – Insertion of Heyman capsules for clinical brachytherapy
3) The brachytherapy applicator insertion codes listed below will be excluded from the RO Model:
a. 19296 – Breast brachytherapy balloon catheter placement
b. 19298 – Breast brachytherapy tube and button catheter placement
c. 20555 – Placement needles/catheters into muscle and/or soft tissue for subsequent interstitial radioelement application
d. 41019 – Placement needles/catheters into head and/or neck region for radioelement application
e. 55874 – Transperineal placement of biodegradable material, peri-prostatic, single or multiple injection(s), including image guidance, when performed
f. 55875 – Transperineal placement of needles or catheters into prostate for interstitial radioelement application, with or without cystoscopy
4) Brachytherapy needles (C1715) and catheters (C1728) are excluded from the RO Model
5) Electronic brachytherapy is excluded from the RO Model
6) Intraoperative radiation (IORT) and IORT management (77424, 77425, and 77469) are excluded from the RO Model
7) Ytrrium-90 as a radiopharmaceutical is excluded from the RO Model
8) An adjustment for multiple modalities that include brachytherapy (and EBRT) are not going to be accommodated. CMS will provide billing guidance to RO Model participants when separate providers deliver EBRT and brachytherapy services.
9) An estimated 83% of RO Model participants will qualify for Qualified Participant status, and would be eligible for a 5% incentive bonus payment on the professional component of each bundled payment
10) CMS’ reanalysis of the payment methodology did lead to increases in reimbursement for the professional and technical component for the included disease sites
The ABS SEC committee is gravely concerned that many of the requested changes to the RO Model from ABS’ previous comment letter and previous discussions with CMS have largely been ignored. ABS remains concerned regarding the potential negative impact this model may have on certain vulnerable patient populations, including cervical cancer patients. We have submitted additional questions and clarification to CMS, in another comment letter, regarding payment for multi-modal episodes (i.e. those episodes of care with multiple radiation oncology providers, some of who may be in and out of the model). We will provide more clarification regarding these episodes and payment processing for combined modality treatments as more information becomes available. We will also provide additional information on the payment methodology. We are working diligently to continue advocating for ABS members and, most importantly, for our patients to continue having access to brachytherapy as a life-saving treatment.
