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CMS Proposes Mandatory Payment Models for Radiation Oncology, Kidney Disease Treatment

For CFOs, Government Relations Staff, CMOs, Strategic Planning/Development Staff

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The Centers for Medicare & Medicaid Services (CMS) issued a proposed rule that would establish two new mandatory payment models: the Radiation Oncology Model (RO model) and the End-Stage Renal Disease (ESRD) Treatment Choices Model (ETC model).

The RO model would require participation from radiotherapy (RT) providers and suppliers — including hospital outpatient departments, physician group practices, and freestanding radiation therapy centers — that furnish RT services within randomly selected core-based statistical areas (CBSAs). For the ETC model, CMS would select ESRD facilities and managing clinicians to participate according to their location in randomly selected geographic areas. Notably, CMS will announce the randomly selected CBSAs and geographic areas when the final rule is published. Comments on the proposed rule will be due 60 days following publication in the Federal Register.

RO Model Summary

Under the RO model, participants treating beneficiaries with one of 17 types of cancer — including breast, lung, kidney, pancreatic, prostate, and colorectal cancer — would receive prospective, site-neutral episode-based payment amounts for radiation therapy services furnished during a 90-day episode of care. These site-neutral bundled payments would be made instead of regular Medicare fee-for-service payments throughout the model performance period, which would consist of five calendar years, beginning in 2020 and ending Dec. 31, 2024.

Model episode payments would be split into a professional component and a technical component. Participant-specific payment amounts would be determined based on proposed national base rates, trend factors, and adjustments for each participant’s case-mix, historical experience, and geographic location. CMS would further adjust payment amounts by applying a discount factor, which could be adjusted upward depending on performance on quality measures and patient experience survey. In addition, the RO model would qualify as an Advanced Alternative Payment model (APM) and a Merit-based Incentive Payment System APM for the clinician Quality Payment Program.

ETC Model Summary

Under the ETC model, new incentives would be provided to encourage dialysis in the home. Medicare payments would be adjusted for ESRD facilities and managing clinicians in the selected geographic areas, with an aim to include 50% of Medicare ESRD beneficiaries. The geographic unit of selection would be the hospital referral region, rather than CBSAs, in order to include rural areas.

The first type of payment adjustment would be a uniformly positive adjustment on Medicare claims for home dialysis and home dialysis-related services during the initial three years of the model. The second adjustment would apply to both home and in-center dialysis related claims, and could be either positive or negative. The adjustments would be based on the home dialysis rate and transplant rate performance and would be made to the per treatment base rate under the ESRD prospective payment system for selected ESRD facilities and to the monthly capitation payment for managing clinicians. Payment adjustments would apply to applicable Medicare claims with dates from Jan. 1, 2020, through June 30, 2026.

In addition to the ETC model, CMS also announced four voluntary models: the Kidney Care First Model and the Comprehensive Kidney Care Contracting (CKCC) Graduated, CKCC Professional and Global models. These optional models are designed to reduce the cost and improve the quality of care for patients with late-stage chronic kidney disease and ESRD, delay the need for dialysis and encourage kidney transplantation. The kidney disease payment models are in response to President Trump’s executive order on advancing kidney health.