Centers for Medicare & Medicaid Services (CMS) is launching a radiation oncology bundle in January 2022. This bundle covers 16 types of cancer, about 30% of radiotherapy episodes, is a prospective payment model, and will be mandatory for most providers. The selection of providers was chosen by random selection of providers in specific Core-Based Statistical Areas (CBSAs) throughout the United States. This bundle has had some pushback from providers, including a response from the American Society for Radiation Oncology, who were concerned about the financial cuts portion of this design, especially while providers were trying to recover from the Covid-19 shutdowns. CMS originally had the effective date of January 1st, 2021 but has pushed to January 2022 to accommodate. That said, the focus now shifts to implementation.
The bundle design is clean and understandable with clear starts and finishes – part of the payment is paid when the bundle starts. The bundle is 90 days long but can be ended early by billing an appropriate modifier on the patient’s bill, allowing for the remainder of the payment (minus a reserve) to be paid prior to the 90 days. This is beneficial for two reasons. First, withholding a portion of the prospective payment allows for quick adaptability of the payer to address any issues that might bust the bundle. Second, it incentivizes the providers to focus on communication and quality since aspects that might lead to a payer needing to hold back money, such as care being duplicated, can be addressed through those mechanisms.
Aver has built the Radiation Oncology bundle logic and is working with our current clients to start implementing it in their geographic areas. This bundle design, though prospective for CMS, easily lends itself to a retrospective payment model, and with the Aver tools, can quickly take different approaches depending on the needs of the client. Since the design is so straightforward, providers are quick to engage with payers, focusing more on the payer providing the data for them to manage the bundle than other areas such as tweaking the model.
With the Aver, payers are able to provide providers with timely monitoring reports, so they can track their members throughout the process and see areas of opportunity to improve their care. This gives the providers the right information to manage their patients within the bundle and gives confidence that they will not only succeed with the bundle but also improve their patient’s care in the process. Aver often gets requests to sit in on payer and provider discussions to review the clinical and financial data that the provider will receive through these tools. We have used these opportunities to create provider-facing tools that fit the needs of the provider community. Because of this, the Aver toolset makes this bundle arrangement an easy win for both the provider and the payer.
Radiation Oncology Model