Disproportionate Negative Impact of the Radiation Oncology Alternative Payment Model on Rural Providers: A Cost Identification Analysis of Medicare Claims

2021 ◽  
pp. OP.21.00330
Author(s):  
Constantine A. Mantz ◽  
Nikhil G. Thaker ◽  
Praveen Pendyala ◽  
Anne Hubbard ◽  
Thomas J. Eichler ◽  
...  
Keyword(s):  
Radiation Oncology ◽  
Negative Impact ◽  
Quality Care ◽  
Fee For Service ◽  
Current Form ◽  
Payment Model ◽  
Physician Practices ◽  
Bundled Payments ◽  
Treatment Services ◽  
Rural And Urban

PURPOSE: The Radiation Oncology Alternative Payment Model (APM) is a Medicare demonstration project that will test whether prospective bundled payments to a randomly selected group of physician practices, hospital outpatient departments, and freestanding radiation therapy centers reduce overall expenditures while preserving or enhancing the quality of care for beneficiaries. The Model follows a complicated pricing methodology that blends historical reimbursements for a defined set of services made to professional and technical providers to create a weighted payment average for each of 16 cancer types. These averages are then adjusted by various factors to determine APM payments specific to each participating provider. METHODS: This impact study segregates APM participants into rural and urban groups and analyzes the effect of the Radiation Oncology Alternative Payment Model on their fee-for-service reimbursements. RESULTS: The main findings of this study are (1) the greater net-negative revenue impact on rural facilities versus urban facilities that would have participated in the Model this year and (2) the relative lack of high-value treatment services (ie, stereotactic radiotherapy and brachytherapy) delivered by rural facilities that exacerbates their negative impact. CONCLUSION: As such, rural providers participating in the Model in its current form may face greater risk to their economic viability and greater difficulty in funding technology improvements necessary for the achievement of high-quality care compared with their urban counterparts.

Republished: Big Things Come in Bundled Packages: Implications of Bundled Payment Systems in Health Care Reimbursement Reform

2019 ◽  
Vol 34 (5) ◽  
pp. 482-487 ◽  
Author(s):  
Dennis R. Delisle
Keyword(s):  
Health Care ◽  
Quality Care ◽  
Clinical Settings ◽  
Fee For Service ◽  
Payment Systems ◽  
High Quality ◽  
Bundled Payment ◽  
High Quality Care ◽  
Bundled Payments ◽  
Daunting Task

With passage of the Affordable Care Act, the ever-evolving landscape of health care braces for another shift in the reimbursement paradigm. As health care costs continue to rise, providers are pressed to deliver efficient, high-quality care at flat to minimally increasing rates. Inherent systemwide inefficiencies between payers and providers at various clinical settings pose a daunting task for enhancing collaboration and care coordination. A change from Medicare’s fee-for-service reimbursement model to bundled payments offers one avenue for resolution. Pilots using such payment models have realized varying degrees of success, leading to the development and upcoming implementation of a bundled payment initiative led by the Center for Medicare and Medicaid Innovation. Delivery integration is critical to ensure high-quality care at affordable costs across the system. Providers and payers able to adapt to the newly proposed models of payment will benefit from achieving cost reductions and improved patient outcomes and realize a competitive advantage.

Effect of Proposed Episode-Based Payment Models on Advanced Radiotherapy Procedures

2020 ◽  
pp. OP.20.00495
Author(s):  
Sanford L. Meeks ◽  
Amish P. Shah ◽  
Gaurav Sood ◽  
Tomas Dvorak ◽  
Omar A. Zeidan ◽  
...  
Keyword(s):  
Proton Therapy ◽  
Radiation Oncology ◽  
Fee For Service ◽  
Medicare Reimbursement ◽  
Large Hospital ◽  
Specific Patient ◽  
Payment Model ◽  
Medicare Patients ◽  
Cancer Types ◽  
Radiotherapy Treatment

PURPOSE: An episode-based payment model, the Radiation Oncology Alternative Payment Model (RO-APM), has been proposed for Medicare reimbursement of radiation services provided to oncology patients. RO-APM may have significant impact on reimbursement for specific patient populations. METHODS: This investigation compares historical fee-for-service technical reimbursement estimates at a large hospital-based system to the RO-APM for advanced radiotherapy treatment of specific cancer types. These advanced techniques, stereotactic radiosurgery (SRS), stereotactic body radiotherapy (SBRT), online-adaptive SBRT, and proton therapy, were specifically chosen because they are resource intensive and are correspondingly among the most expensive radiation oncology procedures. A total of 203 Medicare patients were analyzed. RESULTS: RO-APM base-rate reimbursements were similar for SRS and were 38%-47% higher for SBRT. The proposed rates were 1%-31% lower for online-adaptive SBRT, and 48%-71% lower for proton therapy. CONCLUSION: These data suggest that the RO-APM may have the desired effect of encouraging shorter courses of radiotherapy, such as SBRT. However, emerging technologies that require large capital and operating investments may see an overall significant reduction in proposed reimbursement.

Medicare bundles for arthroplasty

2021 ◽  
Vol 103-B (6 Supple A) ◽  
pp. 119-125
Author(s):  
Bryan D. Springer ◽  
Jordan McInerney
Keyword(s):  
Acute Care ◽  
Acute Care Hospitals ◽  
Drop Out ◽  
Retention Rates ◽  
Fee For Service ◽  
Target Price ◽  
High Performing ◽  
Bundled Payment ◽  
Bundled Payments ◽  
Care Improvement

Aims There is concern that aggressive target pricing in the new Bundled Payment for Care Improvement Advanced (BPCI-A) penalizes high-performing groups that had achieved low costs through prior experience in bundled payments. We hypothesize that this methodology incorporates unsustainable downward trends on Target Prices and will lead to groups opting out of BPCI Advanced in favour of a traditional fee for service. Methods Using the Centers for Medicare and Medicaid Services (CMS) data, we compared the Target Price factors for hospitals and physician groups that participated in both BPCI Classic and BPCI Advanced (legacy groups), with groups that only participated in BPCI Advanced (non-legacy). With rebasing of Target Prices in 2020 and opportunity for participants to drop out, we compared retention rates of hospitals and physician groups enrolled at the onset of BPCI Advanced with current enrolment in 2020. Results At its peak in July 2015, 342 acute care hospitals and physician groups participated in Lower Extremity Joint Replacement (LEJR) in BPCI Classic. At its peak in March 2019, 534 acute care hospitals and physician groups participated in LEJR in BPCI Advanced. In January 2020, only 14.5% of legacy hospitals and physician groups opted to stay in BPCI Advanced for LEJR. Analysis of Target Price factors by legacy hospitals during both programmes demonstrates that participants in BPCI Classic received larger negative adjustments on the Target Price than non-legacy hospitals. Conclusion BPCI Advanced provides little opportunity for a reduction in cost to offset a reduced Target Price for efficient providers, as made evident by the 85.5% withdrawal rate for BPCI Advanced. Efficient providers in BPCI Advanced are challenged by the programme’s application of trend and efficiency factors that presumes their cost reduction can continue to decline at the same rate as non-efficient providers. It remains to be seen if reverting back to Medicare fee for service will support the same level of care and quality achieved in historical bundled payment programmes. Cite this article: Bone Joint J 2021;103-B(6 Supple A):119–125.

Radiation Oncology's Place in Payment Reform: ASTRO Advocates for a Place at the Table

2021 ◽  
pp. OP.21.00294
Author(s):  
Anne Hubbard ◽  
Constantine Mantz ◽  
Najeeb Mohideen ◽  
William Hartsell ◽  
Nikhil G. Thaker ◽  
...  
Keyword(s):  
Radiation Oncology ◽  
Payment Reform ◽  
Patient Decision Making ◽  
Current Form ◽  
True Value ◽  
Reporting Requirements ◽  
Patient Decision ◽  
American Society ◽  
Physician Patient ◽  
Therapy Treatment

In its current form, the Radiation Oncology Model (RO Model) prioritizes payment cuts over true value-based payment transformation. With significant modifications to the payment methodology, the reporting requirements, and recognition of the unique challenges faced by disadvantaged populations, the RO Model can protect patient access to care, preserve the physician-patient decision-making process, and ensure the delivery of high-quality, efficient radiation therapy treatment. The American Society for Radiation Oncology has spent several years advocating for a meaningful alternative payment model for radiation oncology and continues to push The Center for Medicare and Medicaid Innovation for changes to the RO Model that will recognize these key outcomes.

Impact of the Radiation Oncology Alternative Payment Model on Brachytherapy Reimbursement

Brachytherapy ◽  
2021 ◽  
Author(s):  
Nikhil G. Thaker ◽  
Rehman Meghani ◽  
Cassandra Wilson ◽  
Jody Garey ◽  
Philip Nelson ◽  
...  
Keyword(s):  
Radiation Oncology ◽  
Payment Model

Practice Patterns, Work Environments, and Job Outcomes of Rural and Urban Primary Care Nurse Practitioners

2020 ◽  
pp. 107755872097453
Author(s):  
Hayley D. Germack ◽  
Jordan Harrison ◽  
Lusine Poghosyan ◽  
Grant R. Martsolf
Keyword(s):  
Primary Care ◽  
Rural Communities ◽  
Nurse Practitioners ◽  
Practice Patterns ◽  
Quality Care ◽  
Work Environments ◽  
Independent Practice ◽  
Job Outcomes ◽  
High Quality ◽  
Rural And Urban

As nurse practitioners (NPs) are increasingly relied on to deliver primary care in rural communities, it is critical to understand the contexts in which they work and whether they are characterized by work environments and infrastructures that facilitate the provision of high-quality patient care. This study compares urban and rural NPs using data from a survey of 1,244 primary care NPs in Arizona, California, New Jersey, Pennsylvania, Texas, and Washington. While rural and urban NPs have a number of similarities in terms of demographic characteristics, practice patterns, and job outcomes, they also have noteworthy differences. Rural NPs report higher levels of independent practice, fewer structural capabilities that facilitate quality care, and poorer relationships with physicians. Health care organizations in rural communities may need to invest in work environments and infrastructures that facilitate high-quality care and autonomous practice for NPs.

scholarly journals Impact on Oncology Practices of Including Drug Costs in Bundled Payments

2018 ◽  
Vol 14 (5) ◽  
pp. e259-e268 ◽  
Author(s):  
Jeffery C. Ward ◽  
Laura A. Levit ◽  
Ray D. Page ◽  
John E. Hennessy ◽  
John V. Cox ◽  
...  
Keyword(s):  
Complex Disease ◽  
Drug Costs ◽  
Fee For Service ◽  
Patient Case ◽  
Bundled Payment ◽  
Bundled Payments ◽  
Average Patient ◽  
Cancer Types ◽  
The Impact ◽  
Probabilistic Risk

Introduction: This analysis evaluates the impact of bundling drug costs into a hypothetic bundled payment. Methods: An economic model was created for patient vignettes from: advanced-stage III colon cancer and metastatic non–small-cell lung cancer. First quarter 2016 Medicare reimbursement rates were used to calculate the average fee-for-service (FFS) reimbursement for these vignettes. The probabilistic risk faced by practices was captured by the type of patients seen in practices and randomly assigned in a Monte Carlo simulation on the basis of the given distribution of patient types within each cancer. Simulations were replicated 1,000 times. The impact of bundled payments that include drug costs for various practice sizes and cancer types was quantified as the probability of incurring a loss at four magnitudes: any loss, > 10%, > 20%, or > 30%. A loss was defined as receiving revenue from the bundle that was less than what the practice would have received under FFS; the probability of loss was calculated on the basis of the number of times a practice reported a loss among the 1,000 simulations. Results: Practices that treat a substantial proportion of patients with complex disease compared with the average patient in the bundle would have revenue well below that expected from FFS. Practices that treat a disproportionate share of patients with less complex disease, as compared with the average patient in the bundle, would have revenue well above the revenue under FFS. Overall, bundled payments put practices at greater risk than FFS because their patient case mix could greatly skew financial performance. Conclusion: Including drug costs in a bundle is subject to the uncontrollable probabilistic risk of patient case mixes.

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