ROCR: Modernizing Radiation Oncology Payment to Embrace Innovation and Better Care.

Data demonstrates that hypofractionation is increasingly utilized based on evidence-based guidelines. The outdated Medicare fee-for-service approach penalizes radiation oncology (RO) practices from adopting hypofractionation, even as many patients benefit. To address the flawed fee-for-service payment system, which rewards volume over value, ASTRO introduced the Radiation Oncology Case Rate (ROCR) Value-Based Payment Program. ROCR shifts payment for RO services from fee-for-service to payment per patient or per episode. To address disparities, ROCR provides an evidence-based approach through the Health Equity Achievement in Radiation Therapy (HEART) initiative, providing transportation assistance payment for the underserved. Additionally, ROCR allows practices sufficient capital to maintain existing equipment and invest in new technology. This increases patient access to technological advancements allowing for more efficient, targeted, and personalized care with improved patient outcomes at a lower overall cost.

Insurance Denials and Patient Treatment in a Large Academic Radiation Oncology Center.

Importance: Insurance barriers to cancer care can cause significant patient and clinician burden. Objective: To investigate the association of insurance denial with changes in technique, dose, and time to delivery of radiation oncology treatment. Design, Setting, and Participants: In this single-institution cohort analysis, data were collected from patients with payer-denied authorization for radiation therapy (RT) from November 1, 2021, to December 8, 2022. Data were analyzed from December 15, 2022, to December 31, 2023. Exposure: Insurance denial for RT. Main Outcomes and Measures: Association of these denials with changes in RT technique, dose, and time to treatment delivery was assessed using χ2 tests. Results: A total of 206 cases (118 women [57.3%]; median age, 58 [range, 26-91] years) were identified. Most insurers (199 [96.6%]) were commercial payers, while 7 (3.4%) were Medicare or Medicare Advantage. One hundred sixty-one patients (78.2%) were younger than 65 years. Of 206 cases, 127 (61.7%) were ultimately authorized without any change to the requested RT technique or prescription dose; 56 (27.2%) were authorized after modification to RT technique and/or prescription dose required by the payer. Of 21 cases with required prescription dose change, the median decrease in dose was 24.0 (range, 2.3-51.0) Gy. Of 202 cases (98.1%) with RT delivered, 72 (34.9%) were delayed for a mean (SD) of 7.8 (9.1) days and median of 5 (range, 1-49) days. Four cases (1.9%) ultimately did not receive any authorization, with 3 (1.5%) not undergoing RT, and 1 (0.5%) seeking treatment at another institution. Conclusions and Relevance: In this cohort study of patients with payer-denied cases, most insurance denials in radiation oncology were ultimately approved on appeal; however, RT technique and/or effectiveness may be compromised by payer-mandated changes. Further investigation and action to recognize the time and financial burdens on clinicians and clinical effects on patients caused by insurance denials of RT is needed.

Addressing challenges in low-income and middle-income countries through novel radiotherapy research opportunities.

Although radiotherapy continues to evolve as a mainstay of the oncological armamentarium, research and innovation in radiotherapy in low-income and middle-income countries (LMICs) faces challenges. This third Series paper examines the current state of LMIC radiotherapy research and provides new data from a 2022 survey undertaken by the International Atomic Energy Agency and new data on funding. In the context of LMIC-related challenges and impediments, we explore several developments and advances-such as deep phenotyping, real-time targeting, and artificial intelligence-to flag specific opportunities with applicability and relevance for resource-constrained settings. Given the pressing nature of cancer in LMICs, we also highlight some best practices and address the broader need to develop the research workforce of the future. This Series paper thereby serves as a resource for radiation professionals.

Optimizing Outpatient Radiation Oncology Consult Workflow by Using Time-Driven Activity-Based Costing: Efficiency and Financial Impacts.

PURPOSE: Clinical efficiency is a key component of value-based health care. Our objective here was to identify workflow inefficiencies by using time-driven activity-based costing (TDABC) and evaluate the implementation of a new clinical workflow in high-volume outpatient radiation oncology clinics. METHODS: Our quality improvement study was conducted with the Departments of GI, Genitourinary (GU), and Thoracic Radiation Oncology at a large academic cancer center and four community network sites. TDABC was used to create process maps and optimize workflow for outpatient consults. Patient encounter metrics were captured with a real-time status function in the electronic medical record. Time metrics were compared using Mann-Whitney U tests. RESULTS: Individual patient encounter data for 1,328 consults before the intervention and 1,234 afterward across all sections were included. The median overall cycle time was reduced by 21% in GI (19 minutes), 18% in GU (16 minutes), and 12% at the community sites (9 minutes). The median financial savings per consult were $52 in US dollars (USD) for the GI, $33 USD for GU, $30 USD for thoracic, and $42 USD for the community sites. Patient satisfaction surveys (from 127 of 228 patients) showed that 99% of patients reported that their providers spent adequate time with them and 91% reported being seen by a care provider in a timely manner. CONCLUSION: TDABC can effectively identify opportunities to improve clinical efficiency. Implementing workflow changes on the basis of our findings led to substantial reductions in overall encounter cycle times across several departments, as well as high patient satisfaction and significant financial savings.

Practical Implications of the American Society for Radiation Oncology Radiation Oncology Case Rate Program Proposal for Radiation Oncologists.

The American Society for Radiation Oncology has proposed the Radiation Oncology Case Rate Program (ROCR) to advocate for fair reimbursement for radiation oncologists. ROCR would replace Medicare fee-for-service with a case rate payment for each of the 15 most common cancer types treated with external beam or stereotactic radiation therapy. This topic discussion attempts to provide a concise overview of the practical implications for radiation oncologists should the ROCR payment program be legislated by Congress and subsequently implemented by the Center for Medicare and Medicaid Services. This topic discussion covers the practical changes to billing and reimbursement, the Health Equity Achievement in Radiation Therapy payment, the Quality of Care requirement, and the available tool to calculate the effect of the ROCR based on an individual practice's case mix.

Drivers of Medicare Spending: A 15-Year Review of Radiation Oncology Charges Allowed by the Medicare Physician/Supplier Fee-for-Service Program Compared With Other Specialties.

PURPOSE: In 2019, the Centers for Medicare and Medicaid Services proposed a new radiation oncology alternative payment model aimed at reducing expenditures. We examined changes in aggregate physician Medicare charges allowed per specialty to provide contemporary context to proposed changes and hypothesize that radiation oncology charges remained stable through 2017. METHODS AND MATERIALS: Medicare physician/supplier utilization, program payments, and balance billing for original Medicare beneficiaries, by physician specialty, were analyzed from 2002 to 2017. Total allowed charges under the physician/supplier fee-for-service program, inflation-adjusted charges, and percent of total charges billed per specialty were examined. We adjusted for inflation using the consumer price index for medical care from the US Bureau of Labor Statistics. RESULTS: Total allowed charges increased from $83 billion in 2002 to $138 billion in 2017. The specialties accounting for the most charges billed to Medicare were internal medicine and ophthalmology. Radiation oncology charges accounted for 1.2%, 1.6%, and 1.4% of total charges allowed by Medicare in 2002, 2012, and 2017, respectively. Radiation oncology charges allowed increased 44% from 2002 to 2012 ($987.6 million to $1.42 billion) but decreased by 19% from 2012 to 2017 ($1.15 billion), adjusted for inflation. Total charges allowed by internal medicine decreased 2% from 2002 to 2012 ($8.53 to $8.36 billion), adjusted for inflation, and decreased 16% from 2012 to 2017 ($7.05 billion). When adjusting for inflation, ophthalmology charges increased 18% from 2002 to 2012 ($4.53 to $5.36 billion) and increased 3% from 2012 to 2017 ($5.5 billion). CONCLUSIONS: Radiation oncology physician charges represent a small fraction of total Medicare expenses and are not a driver for Medicare spending. Aggregate inflation-adjusted charges by radiation oncology have dramatically declined in the past 5 years and represent a stable fraction of total Medicare charges. The need to target radiation oncology with cost-cutting measures may be overstated.

Merit-Based Incentive Payment System (MIPS) Participation in Radiation Oncology Practices - A Simple Survey.

PURPOSE: Our purpose was to survey nationwide radiation oncology practices on their participation in, burden of, and satisfaction with the Medicare Access and Children's Health Insurance Program Reauthorization Act of 2015 (MACRA) payment programs. METHODS AND MATERIALS: All radiation oncology practices accredited by a national specialty organization were invited to participate in a voluntary online survey from December 2018 to January 2019. Questions focused on participation in the Merit-based Incentive Payment System (MIPS) in 2017 and 2018, as by the time of this survey, radiation oncology did not yet have a specialty-specific advanced Alternative Payment Model. RESULTS: Of n = 705 solicited practices, n = 199 completed the survey for an overall response rate of 28.2%. Practices varied significantly in their duration of participation in MACRA programs, means of data submission, and reported improvement activities under MIPS. Forty-nine percent of respondents described being either somewhat or extremely dissatisfied with the ease of submitting measures and data in 2018. The estimated cost to the practices of compliance with MACRA was queried in bins; of users able to estimate the cost of compliance for 2018, the median reported bin was $10,001 to $20,000 (range, less than $1000-100,000 or more). CONCLUSIONS: The participation style in MACRA among radiation oncology practices varied substantially in the years 2017 and 2018. The Center for Medicare & Medicaid Services gave no precise estimates on the cost of compliance for MIPS, but estimated a $3019.47 cost of compliance with the mandated Radiation Oncology Alternative Payment Model in the 2020 Final Rule for selected practices. In this survey, respondents commonly reported the cost of compliance with MACRA significantly exceeded this estimate.

Current challenges facing pediatric radiation oncology viewed through an economics lens.

This commentary addresses two problems facing pediatric radiation oncology: workforce education and the cost of technology. The tools of economics can help us understand these problems. Because cancer in children is relatively infrequent and the role of pediatric radiotherapy (RT) is limited, there are a small number of cases of children requiring RT in the US compared to the number of radiation oncology trainees. This creates a paucity of necessary clinical training material. Proton RT, rather than photon RT, is being recommended in many situations when RT is indicated in children. Cost, however, is a significant concern. The arguments for and against proton RT continue and a consensus on this matter has not emerged.

Time-Driven Activity-Based Costing Analysis of Telemedicine Services in Radiation Oncology.

PURPOSE: Health systems have increased telemedicine use during the SARS-CoV-2 outbreak to limit in-person contact. We used time-driven activity-based costing to evaluate the change in resource use associated with transitioning to telemedicine in a radiation oncology department. METHODS AND MATERIALS: Using a patient undergoing 28-fraction treatment as an example, process maps for traditional in-person and telemedicine-based workflows consisting of discrete steps were created. Physicians/physicists/dosimetrists and nurses were assumed to work remotely 3 days and 1 day per week, respectively. Mapping was informed by interviews and surveys of personnel, with cost estimates obtained from the department's financial officer. RESULTS: Transitioning to telemedicine reduced provider costs by $586 compared with traditional workflow: $47 at consultation, $280 during treatment planning, $237 during on-treatment visits, and $22 during the follow-up visit. Overall, cost savings were $347 for space/equipment and $239 for personnel. From an employee perspective, the total amount saved each year by not commuting was $36,718 for physicians (7243 minutes), $19,380 for physicists (7243 minutes), $17,286 for dosimetrists (7210 minutes), and $5599 for nurses (2249 minutes). Patients saved $170 per treatment course. CONCLUSIONS: A modified workflow incorporating telemedicine visits and work-from-home capability conferred savings to a department as well as significant time and costs to health care workers and patients alike.

Radiation Oncology in Oman: Current Status and Future Challenges.

Oman is a high-income Middle Eastern country. Over the past 50 years, the country's health care system has undergone revolutionary changes to meet the health care needs of its population, driven by high oil and gas revenues. It currently has a very efficient universal health care system. There are 2 linear accelerators in the country and 6 radiation oncologists. A new cancer research center is currently under construction. The major challenge that could affect the delivery of radiation therapy in the future is sustenance of the health care achievements in view of a growing population and the reliance on public funding for health care delivery.