Premier Submits Comments on Mandatory Radiation Oncology and ESRD Treatment Choices Models

In its comments, Premier expresses concern with multiple components of the design of the Radiation Oncology Model, which would create a prospective 90-day bundled payment episode for Medicare patients receiving radiation therapy for included cancer types. Payment for participating providers and facilities in the model would be subject to a payment discount and additional payment withholds that participants may earn back dependent on scores on performance metrics.

Premier expresses concern with the mandatory nature of the second model, the ESRD Treatment Choices Model. However, Premier supports other aspects of the model design. The model creates a 1) three-year bonus payment for home dialysis services and 2) two-sided payment adjustment based on performance on home dialysis and transplantation rates.

Premier urges the Centers for Medicare & Medicaid Services (CMS) to incorporate changes to the proposed Radiation Oncology model, including but not limited to:

• Opposition to mandatory participation. Premier opposes mandatory models and believes providers should be able to decide what alternative payment models are appropriate for their organization. Further, Premier believes the payment structure proposed for the Radiation Oncology model should not be used for any mandatory models.
• Delay of model implementation until July 30, 2020 and inclusion of a performance year 0 in the model. CMS has not indicated the regions where providers will be mandated to participate and participants will need to implement significant changes to support the model, as proposed.
• Incorporating appropriate clinical risk adjustment to adjust payments for episodes for patient complexity. CMS does not indicate there will be payment adjustments when multiple modalities or sites of care are necessary. Premier encourages CMS to incorporate clinical risk adjustment or an add-on payment when multiple sites of treatment are clinically indicated.
• Changes to payment discounts and withholds. Physicians would be subject to a 4 percent payment reduction in the model and 4 percent payment withhold, with hospital outpatient departments (HOPDs) and freestanding radiation oncology centers subject to a 5 percent reduction and a 3 percent withhold. Premier recommends that CMS 1) use payment withholds to create a performance program to reward high performers; and 2) reduce the magnitude of the discount factor and reallocate the percentages to payment withhold.
• Allow for a glide path to risk. CMS designed the program to meet nominal risk requirements in the Quality Payment Program program; however, not all included providers will have previous experience with risk. Premier encourages CMS to create a glide path to gradually increase risk for participants, similar to the Medicare Shared Savings Program Pathways to Success model.

Highlights of Premier's response on the ESRD Treatment Choices model include:

• Opposition to mandatory participation. Premier opposes mandatory models and believes providers should be able to decide what alternative payment models are appropriate for their organization.
• Delay of model implementation until no earlier than April 1, 2020 and support for July 30, 2020 start date. CMS has not indicated the regions where providers will be mandated to participate; participants will then need to operationalize the model.
• Support for delayed two-sided risk. CMS begins the model with only upside-only payments and introduces downside risk later.
• Support for recognition of both high performing and improving providers. CMS will assess performance under the model through the provision of achievement and improvement scores. However, CMS will use the higher of the two scores in determining providers’ eligibility for payment bonus and penalties.
• Modify home dialysis rates to adjust for clinical appropriateness and patient preference. Home dialysis will not be clinically appropriate for all patients, while other beneficiaries may decline receiving dialysis at home. CMS should adjust performance formulas to exclude these beneficiaries.
• Remove transplant rate from payment calculations. Providers have limited influence over transplant rate. Premier recommends that CMS consider alternative measures to capture efforts to increase renal transplantation rates.