ROCR and the Fight for Equity in Radiation Oncology

Why Exemptions and Accreditation Are the Key Issues

ROCR is an alternative payment program for Medicare patients that ASTRO and APEX are trying to get passed through Congress. It establishes “case rates” for 9 common cancer types. Instead of fee-for-service—where payments are made per individual charge (e.g., simulation, planning, treatment delivery, image guidance)—ROCR bundles the entire case into a fixed rate. The rate was created based on historical averages - it isn’t the lowest you’d receive or the highest, but somewhere in the middle. There are some other features that they tout - $500 for transportation for patients with needs, the rate will (possibly) keep up with inflation, it stabilizes payments and keep us out of the RUC program and Medicare crosshairs for continued cuts. There is value in this - I have been convinced. We have faced cuts of 20% over the last decade and more are coming. Yet, People who spend most of their time putting out fires are usually also the arsonists.

The same group of people pushing ROCR have:

1. Allowed tremendous growth in the number of radiation oncologists and this has led to underemployment

2. They have had opportunities for payment reform in the past but have squandered them due to half-baked ideas and limited communication and involvement with the at-large radiation oncology community.

3. They do not support the most inexpensive site of care - free standing centers and instead promote hospital outpatient departments and academic centers, while maintaining support for the PPS-exemption. This has increased the cost of care.

4. They push expensive treatments like proton therapy that tend to be based at academic centers and PPS-exempt centers, while hassling community practices about fractions and IMRT.

However, I am starting to believe in case rates and a program similar to ROCR. There are issues and I will go over them. However, there is one “red line” that keeps me from voicing reluctant support - mandated accreditation. This is something that effects most small practices (like where I currently work) and if this remains, I will continue to voice opposition.

PPS Exempt Institution Exclusion

The most expensive cancer centers in the country do not have to participate and can still charge FFS at higher prices. This is a slap in the face to the rest of us. I have recently written about the PPS exemption. The argument against including PPS-exempt centers is that it requires legislation. But so does ROCR itself.. Well, guess what - ROCR requires legislation to pass, as well. In any case, ASTRO and ACRO and others say they want to reduce disparities and create equity, but not supporting legislation that would include PPS exempt programs in ROCR increases disparities and creates further inequities, so I don’t take them at face-value. I have not heard one good argument to keep them out of the program and I wish leadership would take a deeper look into this. I know that because of the recent opinion pieces, we are at least having the discussion. It would be better if this were led by the societies, rather than them saying “legislative issue so forget about it”. This is a failure of leadership to even have the conversation. I give Chirag Shah and Sean McBride credit for bringing this out of the shadows.

Exclusion of Proton Therapy

Proton therapy is not included in the model. Proton therapy is one of the fastest growing costs in radiation medicine. It can be a great treatment, but if you look in the pro forma for center development, it requires prostate and breast treatment to work in the community. These cancers are treated very well with photons. Can these patients benefit from protons? For prostate cancer, this is unlikely based on retrospective and prospective RCT data, but some patients will some request and some payors will still approve. In addition, ASTRO leadership continues to say that protons are a valid choice, even at nearly double the cost for no improvement in cure rate or decrease in toxicity. This is simply kowtowing to the proton-industrial complex.

For breast, we don’t have a great answer yet, but there are patients where anatomy, age and other factors lead clinicians to believe that every cGy matters and OAR dose reduction is paramount. We will get more data, but in the mean time, exclusion of protons is a problem. The people I’ve spoken to say that protons cannot be in the model for CMS reasons, but again, we are in a new world with this administration and what was considered impossible is changing very quickly. If we do care about cost containment, we should find a way to include proton therapy in the model.

Limited Cost Containment

Despite the administration’s push for spending cuts, this program offers minimal savings. Unelected policy groups targeting ‘low-value’ spending won’t see ROCR as a meaningful cost-control measure.. Getting rid of PPS-exemption would save us $500 million a year, while this program is promising $200 million in savings over 10 years, but they do not include upfront costs to change how this is billed, administrative costs and costs of accreditation. At best, it is 25 times less cost-effective than removing the PPS exemption. If the CBO accounts for these additional costs, the score may actually show an increase in costs. Also, $20 million per year accounts for just 0.36% of the Medicare budget for radiation therapy spending (about $5.6 billion / year). So, this ends up being a pittance, even if it does save the money they say it will.

Continued Documentation Burden

The documentation requirements are unclear. Are we going to have to continue to submit the mountains of data that we do for fee-for service - sim orders / notes, weekly notes for asymptomatic patients, planning documents that nobody at Medicare reads, etc.? If ROCR wants to make things easier for physicians and stabilize payments, they should actually make things easier for us. If they require us to retain the same burden of documentation, even though it won’t impact reimbursement, then this is a net negative for many practices. This is obviously not a huge issue, as we will have to do for all non-Medicare patients anyway, but it could lead the way in reducing our documentation burden. They should clarify what will be necessary to get reimbursed.

Accreditation

I will spend the rest of the post discussing this in detail. The ROCR programs requires practices to be accredited by ACR, ASTRO (APex) or ACRO. The majority of practices at this point in time are not accredited. I have only worked for practices that are accredited. I have also, for a short time, been a reviewer for ACR. The rationale for accreditation is that it improves quality. Well, let’s define quality in health care terms:

From the Institute of Medicine, this is how we define quality:

• Safe – Avoiding harm to patients during the delivery of care.

• Effective – Providing services based on scientific evidence and ensuring care is beneficial.

• Patient-Centered – Respecting individual patient preferences, needs, and values.

• Timely – Reducing delays in care delivery to improve outcomes.

• Efficient – Avoiding waste of resources, including time, money, and equipment.

• Equitable – Providing care that does not vary in quality based on personal characteristics such as gender, ethnicity, geographic location, or socioeconomic status.

Accreditation programs do not report safety, efficacy, timeliness, efficiency, or patient-centered outcomes. I’ve looked. There is no data proving accreditation improves radiation oncology quality.. There are no comparisons between accredited programs and unaccredited programs showing any benefits. There are not even single arm outcomes showing any evidence that these programs do anything. These programs may be easy for large systems to adhere to, but they are a huge burden on smaller practices. They cost significant amounts of money, time and energy. When I reviewed, I was ticking off checkboxes about documentation. ACR practice parameters do not actually look at what most clinicians would consider quality metrics. If I found that a practice was doing 60 Gy in 60 Fx BID for early stage breast cancer, they would still pass. But, if the same practice did not list performance status somewhere, they would get a ding. A practice could do 3D for head and neck cancers and pass, but if they did not include stage groupings (I, II, III, IV) instead of TNM staging, they would get a ding. This accreditation checklist did not review dose, contours, DVHs, doses to OARs, doses to targets. But, if you didn’t get your end of treatment summaries out by X days after end of treatment, you got a ding.

I have asked ASTRO many times why they created APex (as ACR and ACRO preceded them) and they are unable to say why their program was necessary or better. If you look at APex’s standards, none of what I am discussing is actually reviewed. But, they do want to know if you have a radiation oncology nurse instead of an LPN or an MA (which many practices use, as their physician is very involved in patient care). They don’t care if you hypofractionate most of your breasts, but someone better be named Medical Director, or you get a ding. I can continue to list out what they do and do not care about, but I think you get the idea - there is no inherent measurement of quality in any of these programs. There is no measurement of efficiency. There is no measurement of equity. There is no one checking if treatment of cervical cancer was completed in 8 weeks or less, i.e. timeliness.

So why is this being tied to reimbursement? No other specialty faces Medicare penalties or bonuses based on third-party accreditation. This is unprecedented—manufactured from thin air. The stated reasons are that any new payment program must have a quality program. So, they decided to use these three program as their quality program, despite a lack of evidence that they have any effect on quality. Now, please don’t read this as “Simul wants a free for all out there”. No, I actually care about quality. I care about peer-review. I care about treating per guidelines. I care about tracking outcomes. I care about resources being used efficiently. All of what IOM says is what I believe in - all 6 of their bullet points above are meaningful.

Under ROCR:

• In the first three years, practices that are accredited—or in the process of getting accredited—by ASTRO (APEx), ACR, or ACRO will receive a 0.5% increase in Technical Component payments.

• After this period, practices without accreditation will face a 1% reduction in payments.

• The program states that "smaller practices" may be exempt and instead undergo external audits, but it has not actually defined what qualifies as a "small" practice.

I have discussed with people at ASTRO and ACRO about who will be exempt. This remains undefined and HHS will ultimately decide. Unelected bureaucrats shouldn’t get to decide who qualifies for an exemption. This is ‘pass the bill to find out what’s in it’ governance. This needs to be defined by our specialty. Many small practices will take a hit - and the entire point of this program was to protect us.

Accreditation is a huge opportunity cost for practices. Every dollar and hour spent on accreditation is a dollar and hour not spent on patient care. If we knew that accreditation ultimately benefits patients, then this trade-off may be worth it. Instead of spending time streamlining treatment workflows or budgeting for patients with financial needs, we use resources for accreditation. It may not sound like much, but the $10-15k cost would help us provide transportation, generic medications and supportive care for our patients. Instead, we do accreditation with uncertain and unproven benefits.

Who benefits? Obviously, these organizations do financially. I am not going to say this a “money grab” because that is not fair. The people involved do feel that their work is meaningful, otherwise, I don’t think they would spend their time doing it. Being an ACR reviewer did not pay well - I think it may have been travel costs + $1000. That is less than a half day of locums. But, the organizations themselves receive a large amount of the fees and we don’t see what comes from this. There are no reports or publications. There are nothing to show for it, other than the certificate with a seal that we hang in our offices. This is, frankly, not enough.

An Alternative to ACR/APex/ASTRO Accrediation

As I said, I am not anti-quality. There are organizations doing this in a better way. MROQC, a Michigan based non-profit partners with Blue Cross Blue Shield MI and University of Michigan to create a quality program. As an example, they measure how many patients with breast and prostate cancer get hypofractionation and use that as part of their “Gold Card” program that eases the burden of prior authorization for practices that participate. In addition, they provide financial incentives for meeting their standards. And, they publish their amazing work. They have shortened courses of treatment in patients with bone metastases. They have developed a program that led to breast cancer patients having meaningful dose reductions to their heart. They have evaluated which prostate cancer patients get salvage RT and ADT. So, they: 1) Have meaningful quality metrics 2) Measure them 3) Provide education to attain their metrics 4) Bonus you for meeting them 5) Ease your prior authorization burden. It is a phenomenal program, as compared to ACR/ACRO/APex. This is a state-based program that has done more for quality than any of the national societies and a model for how we should look at quality and ways we can reward centers.

So, why are we forcing practices to utilize accreditation that has not proven to be meaningful when there are programs they can use that actually benefit patients and providers? I don’t have the answer to this question, but I hope the powers that be ask this same question to themselves before forcing these burdensome mandates upon us.

Friends, I am almost there on ROCR. Payment stabilization is something we truly need - the cuts could be quite damaging. But, as mentioned above:

• Not including PPS exempt centers increases the gap between the haves and have nots and actually reduces equity and increases disparities. We should include them.

• Excluding proton therapy makes it difficult to contain costs and in this current administration, new programs need to show value. Without including protons, this is challenging.

• Overall, the program does very little in terms of cost containment - it is small ball. It is 25 times less effective than rescinding the PPS exemption. And, that cost has been described by McBride, et. al as that a drop in the bucket.

• Our prior authorization and documentation burden is overwhelming. This program, as described, does nothing to help us.

• Linking reimbursement to mandated accreditation by unproven programs that are costly in terms of time, money and resources does not make sense. They should include a waiver to allow practices to choose alternate proven quality programs.

In addition, there are other questions that ROCR supporters need to address:

• But given the history of Medicare payment reforms, what guarantees do we have that CMS won’t cut case rates in the future?

• Is there precedent for alternative payment models (APMs) that initially stabilized payments but later saw reductions? I don’t know answer to this, but maybe ne of you does?

• What safeguards should be built into ROCR to prevent future rate erosion? Is there anything in the bill that protect us in the future?

We have some time to make changes or at least talk about them. I think we can improve this program. If these changes aren’t made, we need to scrap ROCR and start over—with a program that prioritizes community practices instead of burdening them and their patients. In addition, let’s understand that in 2025, cost containment/austerity matters and if we are blind to that, we may not be able to DOGE incoming changes that we will not be able to control.

Love you all,

Sim