Radiation Oncology Perspective on Health Reform & Value-Based Initiatives Najeeb Mohideen , M.D.

2. Radiation Oncology Perspective on Health Reform & Value-Based Initiatives NajeebMohideen, M.D.

3. Disclosure Information NajeebMohideen, M.D. Employment or Leadership Position: None Consultant or Advisory Role: None Stock Ownership: None Honoraria: None Research Funding: None Expert Testimony: None Other Remuneration: None Please note, all disclosures are reported as submitted to the Cancer Center Business Summit and are available at cancerbusinesssummit.com.

4. Reimbursement Trends and Risks in Radiation Oncology

5. The Sources of the SGR “Hole” Increasing use of IMRT and IGRT Alhassani, New England Journal of Medicine, January 2012

6. What happened to Medicare IMRT utilization (office setting) 2002-2012?

7. What happened to Medicare IGRT utilization (office setting) 2007-2012?

8. Where Are We Now? • Unstable Medicare Fee Schedule payment rates for Radiation Oncology • 2012 = -10% cut • 2013 = -7% cut • 23 RO codes flagged by CMS for review by the RUC • Specialty at risk for arbitrary cuts • Gamma Knife Radiosurgery cuts were used to help offset cost of fiscal cliff deal (January 2013) • 2014 = - 5% cut (Proposed)

9. MPFS Proposed Rule 2014: • Revising the Medicare Economic Index • Radiation Oncology: -2%. • OPPS Cap • Radiation Oncology: -3%.

10. Medicare Allowable Charges 2003-2012Freestanding vs Hospital Based

11. Medicare Reimbursement Rates 2013-2014 (prop)IMRT (0073T & 77418)Freestanding vs Hospital Based

12. Payment Risks • Concerns about radiation therapy use, cost and other factors have contributed to fluctuations in Medicare reimbursement, including severe cuts to reimbursement for commonly used treatments • Unending threat of negative updates • Unpredictability and instability in RVUs

13. Looking Forward – ASTRO’s Efforts in Value Based Initiatives and Payment Reform .

14. Payment Reform Models in Radiation Oncology • Fee Schedule Adjustment • Oncology Specific ACO’s • Clinical pathways • Bundles or Episode payment

15. A direct message to Radiation Oncology from Medicare “…If we were to engage in a bundling project for radiation therapy, we would want to do more than provide a single episode payment for the normal course of radiation therapy that aggregates the sum of the individual treatments.” Final Rule, 2013 Medicare Physician Fee Schedule

16. Payment Reform Models Payment for service Payment for event or condition Payment for care of a population Fee-for-service Augmented fee-for-service (e.g., P4P) Bundled Payment (single provider) Bundled Payment (multiple providers) Partial Capitation Full Capitation Increasing aggregation of services into a unit of payment Increased focus on value ? Increased financial risk based on chosen model

17. Payment Reform Opportunities in Radiation Oncology: Improve Quality and Safety Show Value Patient Centered Care Complexity of Care Care Coordination Evidence Based Care Decrease Cost …. where is the largest impact? Things within the control of the specialty Opportunities that are related to better coordination of care with other specialties

18. Targets for Reduced Spending For Cancer Care Fractionation Use of Technology Treatment Alternatives Better Care Coordination Accurate Cost inputs Health Care Outcomes Prove Value Coverage with Evidence Development

19. ASTRO’s 3 Phase Payment Reform Plan 1. Redesign Key Radiation Therapy Codes • Considerable external pressure to update • Look for ASTRO webinars, etc, once finalized 2. Implement Quality-Based Incentive Payments • Re-energized Accreditation program • Anticipating value-based payments 3. Incentivize Cost‐Effective Cancer Care • First challenge is understanding what the costs of care are and where they go • Next challenge would be proposing non-FFS payment models that would improve quality and decrease cost

20. Phase 1 – Redesign Key Radiation Therapy Codes • ASTRO is recommending that numerous radiation therapy codes be revised to better reflect clinical practice, including the use of new technology • Proposed codes designations based on complexity • Revised radiation oncology codes to more accurately reflect clinical practice and package together services typically billed at the same time

21. Phase 2 – Implement Quality-Based Incentive Payments • ASTRO/ROI is launching a data registry, beginning with a prostate cancer pilot • It will begin receiving patient data this fall • Improve the care of patients with cancer by capturing data on treatment and outcomes • A standardized set of data elements for the prostate pilot • An IT infrastructure to support the efficient collection, aggregation, and analysis of clinical data • Establishment of a standardized set of radiation practice

22. Phase 2 – Implement Quality-Based Incentive Payments • ASTRO is launching a new practice accreditation program • Integrated with ASTRO’s other safety and quality improvement initiatives, the robust program will accredit practices that represent the highest standard of radiation oncology care • ASTRO’s accreditation program is organized around five pillars: • Patient-centered care, • The process of care, • The radiation oncology team, • Safety, and • Quality management and assurance.

23. Patient Safety Organization (PSO) Radiation Oncology- Incident Learning System (RO-ILS) • A secure and confidential reporting system for medical errors and near misses specifically related to radiation oncology. • The Patient Safety and Quality Improvement Act authorized the PSOs to improve quality and safety through the collection and analysis of data on patient events. • PSOs create a secure, non-punitive environment where health care providers can collect, aggregate, and analyze data in order to identify and reduce the risks and hazards associated with patient care.

24. Clinical Affairs and Quality Council • Guidelines • Evidence-based clinical practice guidelines • Best Practices • Optimal patient care based on available literature and expert opinion and will complement ASTRO’s clinical practice guidelines and safety white papers • White Papers • Develop modern risk-based and process-focused quality assurance methods for radiotherapy treatment.

25. Outpatient Radiation for BoneMetastases from Prostate Cancer Bekelman et al: JAMA Oct 9: 2013

26. EBRT for Bone Metastases From Clinical Practice Guideline to Measure

27. EBRT for Bone Metastases Measure Specifications Measure Numerator: All patients, regardless of age, with painful bone metastases, and no previous radiation to the same anatomic site who receive EBRT with any of the following recommended fractionation schemes: 30Gy/10fxns, 24Gy/6fxns, 20Gy/5fxns, 8Gy/1fxn. Measure Denominator: All patients with painful bone metastases and no previous radiation to the same anatomic site who receive EBRT Denominator Exclusions: The medical reasons for denominator exclusions are: 1) Previous radiation treatment to the same anatomic site; 2) Patients with femoral axis cortical involvement greater than 3 cm in length; 3) Patients who have undergone a surgical stabilization procedure; and 4) Patients with spinal cord compression, cauda equina compression or radicular pain 16

28. UHC data – prepared by CareCore National Permission for use granted by UHC 10/24/2013 CCBS • Breast IMRT utilization

29. ASTRO’s Choosing Wisely list is: • Don’t initiate whole breast radiotherapy as a part of breast conservation therapy in women age ≥50 with early stage invasive breast cancer without considering shorter treatment schedules • Don’t initiate management of low risk prostate cancer without discussing active surveillance • Don’t routinely use extended fractionation schemes (>10 fractions) for palliation of bone metastases • Don’t routinely recommend proton beam therapy for prostate cancer outside a prospective clinical trial or registry • Don't routinely use intensity modulated radiotherapy (IMRT) to deliver whole breast radiotherapy as part of breast conservation therapy

30. Phase 3 – Incentivize Cost Effective Care • ASTRO has launched a comprehensive payment reform effort to identify alternatives to the traditional fee-for-service model: The Payment Reform Task Force: • Identify areas where better coordinated care or alternative delivery models would improve quality and decrease cost • RFP for relevant Medicare data: • For episodes of care defined as the 1st year of treatment, 2nd year of treatment, and final 6 mos of life, we want to know all costs for selected groups of cancer patients: • Chemo, RT, surgery, radiology, hospitalizations, etc

31. ASTRO’s Commitment • Invest • Significant resources into the development of clinical guidelines, best practices, quality measures, and comparative effectiveness research • Support • A robust practice accreditation program, national patient safety database and clinical data registry • Lead • The development of new payment methodologies in oncology with the goal of incentivizing better quality, efficiency, coordination of care and optimal patient outcomes… the Value Proposition

32. Thanks for your attention!