Caught Between a Radiation Oncology Case Rate (ROCR) and a Hard Place: Improving Proposed Radiation Oncology...

Area of Science:

• Oncology
• Health Economics
• Health Policy

Background:

• The current fee-for-service (FFS) model for radiation oncology reimbursement in the US may not align with value-based care principles.
• The proposed Radiation Oncology Case Rate (ROCR) payment model aims to shift towards bundled payments, decoupling treatment fractionation from reimbursement.
• Understanding the financial impact of ROCR on different cancer types and patient populations is crucial for successful implementation.

Purpose of the Study:

• To compare historical reimbursement rates with proposed ROCR base rates across various cancer types.
• To assess the impact of treatment and disease characteristics on reimbursement under the ROCR model.
• To identify potential inequities in reimbursement that may arise from the ROCR methodology.

Main Methods:

• Utilized electronic medical record data from Mayo Clinic and Medicare 5% research identifiable files (2017-2020).
• Calculated 90-day episodic historical reimbursement rates for 15 cancer types using the ROCR methodology.
• Performed multivariate regression analysis to evaluate the association of treatment intent and cancer stage with historical reimbursement rates.

Main Results:

• ROCR base rates resulted in an average decrease of 2.4% (Mayo Clinic) and 2.9% (Medicare) compared to historical FFS reimbursement.
• Treatment intent (curative vs. palliative) significantly impacted historical reimbursement, with curative intent associated with higher rates.
• Cancer stage (III-IV vs. I-II) also influenced historical reimbursement, with advanced stages generally receiving higher payments.

Conclusions:

• ROCR base rates may lead to an average decrease in reimbursement, potentially generating Medicare savings.
• Consideration of factors like hypofractionation, FFS rate cuts, and inflation is necessary for accurate future projections.
• Distinct ROCR rates and shorter episode durations for palliative care, along with stage-based modifiers, may mitigate reimbursement inequities.