Impact of the Radiation Oncology Alternative Payment Model on Brachytherapy Reimbursement.

PURPOSE: The Radiation Oncology Alternative Payment Model (RO Model) will test prospective radiotherapy episode-based payments for 16 common disease sites. We created an automated analytics platform to calculate the impact of the RO Model vs historical fee-for-service episode reimbursements for brachytherapy treatments within five community oncology practices for prostate, uterine, and cervical cancer. METHODS AND MATERIALS: Claims data between January 1, 2017 and October 2, 2019 for prostate, uterine, and cervical cancer were analyzed as per the RO Model Final Rule methodology. Expected professional and technical component (PC and TC) reimbursements were compared for episodes that utilized brachytherapy alone vs combination modality (external beam and brachytherapy) in the RO Model vs historical reimbursements. RESULTS: 6,022 RO Model-defined episodes (60% prostate, 28% uterine, 13% cervical) were generated. Brachytherapy monotherapy episodes (14%) would have an average positive reimbursement in the RO Model (+$2,163 for prostate, +$711 for uterine, +$533 for cervical for the PC; +$12,168 for prostate, +$8,181 for uterine, +$11,322 for cervical for the TC), while combination modality episodes (15%) would have an average negative reimbursement in the RO Model (-$183 for prostate, -$1,701 for uterine, -$2,195 for cervical for the PC; -$374 for prostate, -$5,026 for uterine, -$2,801 for cervical for the TC). CONCLUSIONS: Brachytherapy monotherapy episodes for prostate, uterine, and cervical cancer will benefit from an increase in payment, whereas combination modality episodes will receive lower reimbursement. Large shifts in episodic payment may be related to practice-wide adjustments and pricing based on partial episodes of care that may ultimately limit access to care for vulnerable patient populations with cancer.

Automated Big Data Analytics for the Radiation Oncology Alternative Payment Model Proposal Using a Novel Health Care Software Technology.

INTRODUCTION: The proposed Radiation Oncology Alternative Payment Model (RO-APM) aims to test prospective episode-based payments for radiotherapy episodes. Practices will need a tool that can calculate historical episode reimbursements to succeed in this new model. An automated software-based technology was created to calculate historical episode reimbursements within a large Network of community oncology practices. MATERIALS AND METHODS: Claims data between January 1, 2017, and July 31, 2019, were cleaned, organized into episodes, and analyzed with a series of Python computer programs per proposed RO-APM methodology. Averaged Winsorized historical episode reimbursements were first calculated over the entire Network, then over 24 of the largest Practices, and then rerun after application of Clinical Rules to remove misattributed episodes. RESULTS: A total of 79,418 RO-APM-defined episodes were generated from 6,512,375 claims lines. A total of 7,086 episodes (8.9%) were removed because of no treatment delivery code within 28 days of treatment planning. The Network of practices had more bone metastases, and breast, cervical, and uterine cancers but less lung and prostate cancer than the RO-APM dataset. Combination-modality episodes were more costly and required more providers than single-modality episodes. Clinical Rules reattributed 2,495 episodes (3.4%) and increased episode reimbursement by +5.8% over all disease sites (+3.7% using volume weighting; P = .001). CONCLUSION: As payment models continue to shift from volume to value, practices will need an automated analytics technology to measure historical costs and prepare for operational and financial transformation. This automated approach can be adapted to future versions of the RO-APM. Our analysis suggests that future iterations of the RO-APM could incorporate Clinical Rules to remove misattributed palliative care episodes and could implement a separate payment for episodes with multiple radiation therapy modalities.