November 12, 2013
The Honorable Dave Camp
Chairman
Committee on Ways and Means
U.S. House of Representatives
Washington, DC 20515
The Honorable Sander Levin
Ranking Member
Committee on Ways and Means
U.S. House of Representatives
Washington, DC 20515
Dear Chairman Camp and Ranking Levin:
On behalf of the American College of Radiation Oncology (ACRO), we appreciate the
opportunity to comment on the recently released bipartisan, bicameral proposal to permanently
repeal and replace the Sustainable Growth Rate (SGR) formula (“SGR Reform Framework”).
We are appreciative of the Committee’s dedication to repeal the SGR and look forward to
working with you to advance the legislation and finally do away with the non-functional
payment system that threatens care to millions of our seniors. ACRO represents radiation
oncologists in the socioeconomic and political arenas. With a current membership of
approximately 1,000, ACRO is dedicated to fostering radiation oncology education and science;
improving patient care services; studying the socioeconomic aspects of the practice of radiation
oncology; and encouraging education in radiation oncology.
We agree that a new system must focus on quality, value and efficiency. We look forward to
continuing to work with you and your staff on the development of this proposal and its
enactment by the Congress this year. In addition, we encourage the Committee to include in its
SGR Reform Framework the proposal put forth by the Radiation Therapy Alliance (RTA) to
establish episode-based, bundled payments for freestanding radiation therapy services.
RTA Proposal to Bundle Radiation Therapy Services Fits SGR Reform Framework
We support the Radiation Therapy Alliance (RTA) proposal to fundamentally reform payments
for radiation therapy services in the physician office setting by establishing a new, episodebased, bundled payment system for radiation therapy. We believe this proposal is consistent
with the Committee’s objectives of improving quality of care, reducing costs and moving away
from “fee-for-service” towards “fee-for-value” systems.
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Key provisions of the RTA’s proposal would:
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Establish episode-based, bundled payments for specified radiation therapy services by
2018 using the most recent medical guidelines and in consultation with stakeholders.
Reduce reimbursement by 1 percent each year during a 3-year transition (2015-2017).
New, bundled payment rates would be based off the lower, post-transition, baseline of
2017 payments – thereby securing scoreable savings that can help finance SGR reform.
This period of predictability and stability is essential to “set the table” for constructive
discussions with stakeholders regarding the establishment of appropriate episodes of care.
Include a “shared savings” component to promote and ensure additional Medicare
savings in excess of the reduced payment rates. The RTA proposal would incent
providers to produce greater efficiencies and ensure that Medicare would share in half of
any savings from the payment reform.
Create a patient registry to collect data on treatment patterns and patient outcomes.
Need for Reform of Medicare Payment System for Radiation Therapy Services
Freestanding radiation therapy centers, more akin to a “facility” than a physician office, do not
fit well within the current Physician Fee Schedule. For example, freestanding radiation therapy
center capital costs are in the millions of dollars, while most physician office costs are in the
hundreds of thousands. Also, their narrower set of service makes freestanding radiation therapy
centers significantly more vulnerable to volatile changes in a few codes relative to other
specialties. In addition, the high-technology nature of radiation therapy services often makes it
difficult for the current fee-for-service system to properly value such services.
These points are evidenced by the consistent payment errors for radiation therapy services
contained in the last several Physician Fee Schedule regulations, including:
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2010 Physician Fee Schedule
o Confusion of “radiation therapy” services with “diagnostic imaging” which
resulted in inappropriate proposed cuts of up to 19 percent to the specialty.
 This was fixed in the 2010 Final Rule.
2011 Physician Fee Schedule
o Incorrect calculations for radiation treatment management code resulted in
additional 15% reduction for work RVUs.
 This was fixed with a technical correction.
2012 Physician Fee Schedule
o Missing page of direct cost inputs for key radiation therapy delivery code resulted
in an inappropriate 3 percent reduction to practice expense RVUs.
 This was fixed in the 2013 Final Rule.
2013 Physician Fee Schedule
o Missing and outmoded direct cost inputs for key radiation therapy delivery code
resulted in cuts of 15 percent to the specialty in the Proposed Rule.
 Cuts were mitigated by half with corrected data in the 2013 Final Rule.
2014 Physician Fee Schedule
o This rule proposes to cap certain radiation therapy services in the physician office
setting through the use of 2013 APCs in the Hospital Outpatient PPS (HOPPS), an
entirely different payment system.
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This policy would cut freestanding radiation therapy centers by 8 percent.
At the same time, ACRO is helping to educate CMS that the radiation treatment vault – which
ensures that other patients, staff and pedestrians are not irradiated during a patient’s radiation
therapy treatment – is integral to the linear accelerator itself and should be included as a direct
cost. The inappropriate removal of the radiation treatment vault as a direct cost (which CMS
began to contemplate in the 2013 Physician Fee Schedule) would result in yet another significant
reduction for radiation therapy services
Compounding the extreme volatility in payments over the last several years, freestanding
radiation therapy services have suffered under real cuts of almost 20 percent over the last
decade. Given the aforementioned concerns, we believe radiation therapy centers would be more
appropriately reimbursed under a separate, bundled payment methodology. ACRO notes that
Congress mandated as part of the “Middle Class Tax Relief and Job Creation Act of 2012,” CMS
submit a study not later than January 1, 2013 to examine “options for bundled or episode-based
payments, to cover physicians’ services currently paid under the physician fee schedule” for
chronic conditions such as cancer. Although this report still is forthcoming, private sector
initiatives already exist in the private sector today. Last year, a leading radiation therapy
provider and private insurer that also services the Medicare Advantage market announced a
national agreement to create bundled radiation therapy payments. Under this agreement,
radiation therapy cases for 13 specified diseases (representing most of a typical practice’s case
mix) now are paid on an episode-of-care basis.
Conclusion
ACRO strongly supports the Committee’s SGR Reform Framework and efforts to establish a
new system for physician reimbursement in Medicare focused on quality, value and efficiency.
We look forward to actively working with Members on a bipartisan basis in support of the SGR
Reform Framework and the inclusion of the RTA’s proposal to create a separate, bundled
payment methodology for radiation therapy services in the physician office setting.
If you have additional questions regarding these matters and the views of the ACRO, please
contact Jason McKitrick at (202) 442-3710.
Sincerely,
Sincerely,
Arno J. Mundt, M.D., FACRO
President
American College of Radiation Oncology
5272 River Road, Suite 630
Bethesda, Maryland 20816
Sheila Rege, M.D., FACRO
Chair, Economics Committee
American College of Radiation Oncology
5272 River Road, Suite 630
Bethesda, Maryland 20816
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