Radiation therapy fights back against proposed Medicare cuts

Few radiation oncology practices were prepared when the federal government proposed double-digit cuts in Medicare reimbursement in July. But the specialty's defenders are mobilizing to fight back with a major line of attack on the methodology used to justify the payment changes.

The U.S. Centers for Medicare and Medicaid Services (CMS) has proposed cutting payments to radiation oncologists by 15% and reducing payments to radiation therapy centers by 19%. The cuts are part of the proposed Medicare Physician Fee Schedule (MPFS) for 2013.

Letters opposing the proposed reductions are focusing on reimbursement for two types of radiotherapy for cancer patients, and they are circulating in both the U.S. Senate and the House of Representatives. Even though both legislative bodies are in recess, signatures are being obtained, and a surge of support is expected in mid-September after legislators have returned to Capitol Hill.

Radiation therapy proponents say that CMS used a faulty methodology in developing the new reimbursement levels, relying on information in patient literature to calculate treatment times rather than more rigorous statistical data used in the past to set payment rates. Ironically, much of the patient literature used by CMS was produced by academic societies themselves.

Cuts to IMRT and SBRT

Drawing the greatest ire are recommendations in the proposed MPFS that would dramatically reduce reimbursement for two CPT codes covering commonly used radiation therapy procedures, one for intensity-modulated radiation therapy (IMRT, CPT code 77418) and the other for stereotactic body radiation therapy (SBRT, CPT code 77373).

AuntMinnie.com spoke with Dr. Michael Steinberg, president of the board of directors of the American Society for Radiation Oncology (ASTRO), and professor and chairman of radiation oncology at the David Geffen School of Medicine at the University of California, Los Angeles.

What has bemused Steinberg and fellow radiation oncologists is that CMS appears to have based its decision on information that ASTRO, the American College of Radiology (ACR), and RSNA provide on websites and in brochures sent to educate patients -- but that information doesn't include all of the work required to provide radiation treatments.

"When I read this in the CMS document, my initial reaction was, "What did we say?' " Steinberg added. "When I read the referenced information, I was surprised that CMS did not realize that this information is not all inclusive, nor is it meant to be."

Patients who undergo radiation therapy often want to know details such as how long the radiation beam is on, Steinberg explained, but they don't usually care about preparation time prior to the treatment or the time to complete the care process. Therefore, this information wasn't included in patient literature published by the societies.

But CMS opted to use the patient literature rather than a more methodologically sound approach, such as the American Medical Association (AMA) Relative Value Scale Update Committee's practice expense evaluation process, which has been used in the past to set rates.

Take IMRT, for example. While IMRT treatment times vary, treatment duration can range from 30 to 90 minutes. This time incorporates positioning and immobilizing the patient, adjusting patient alignment, running safety checks, and setting up and sequencing the radiation beam and its many subsegments. These are time-consuming activities that occur even before the actual treatment begins, he pointed out.

The current CPT code 77418 represents an average treatment time of 60 minutes for reimbursement. But CMS now wants to halve the treatment time, from 60 minutes to 30 minutes, and reduce payment accordingly.

CMS said that it's basing its decision on the 30-minute treatment period mentioned in the patient literature. There are "wide discrepancies" between technical facts known to clinicians and "the procedure times made widely available to Medicare beneficiaries and the general public," according to the agency.

SBRT

Similarly, CMS emphasized patient literature rather than clinical process-based information in stating that SBRT should be limited to a 60-minute window. The proposed rule references the joint ACR/RSNA website RadiologyInfo.org as stating that "SBRT treatment can take up to one hour"; therefore, it should reimburse for no more time than this. The AMA committee analysis, however, determined that average treatment time is 90 minutes.

It appears that CMS overlooked another statement in the same section of the website stating that patients should "be prepared to spend up to a half day or more at the facility." While the website discusses patient positioning issues in more detail, it does not include estimates of the time required. This is typically 90 minutes, Steinberg said, noting that spending 90 minutes to perform a spine treatment is not at all unusual.

ASTRO would like CMS to review its proposed payment schedules using a more scientifically rigorous valuation tool, on par with that used by the AMA committee. Although the AMA committee is criticized for some of its decisions regarding relative value units and CPT codes, its process for review is based on an analysis of all clinical elements relating to a procedure.

The committee regularly reviews CPT codes that are based on rapidly changing technology, and when a procedure becomes faster or easier to perform as a result of technological innovation, the time allocated for the procedure is reduced.

What is onerous to ASTRO is that both the IMRT CPT code 77418 and the SBRT CPT code 77373 were recently reviewed by the AMA committee, and the current times represent what the committee feels are fair and accurate averages for these treatments. Now, without doing a similar review, CMS is saying that the committee has overestimated the time for IMRT by 100% and for SBRT by 33%.

ASTRO's position is that CMS has the right to review IMRT reimbursement, but it should use a responsible clinical methodology to do so. ASTRO said it considers CMS' reliance on simplified patient-education information to be "ludicrous."

In the proposed rule, CMS states the following: "While we generally have not used publicly available resources to establish procedure time assumptions, we believe that the procedure time assumptions used in setting payment rates for the Medicare PFS should be derived from the most accurate information available."

ACR and ASTRO representatives said they agree with that philosophy, but they were perplexed that CMS did not contact either organization to ascertain if the information presented to the public was comprehensive.

Fighting back

As soon as CMS published its proposed rule in the Federal Register, ASTRO conducted a survey of its U.S. members to determine how the reimbursement cuts would affect private practices offering IMRT and SBRT. Nearly 600 members responded, stating that if the cost reductions are implemented, the pinch will be felt by patients who go to freestanding cancer treatment centers and the practices that operate them.

ASTRO is leading an initiative to make Health and Human Services (HHS) Secretary Kathleen Sebelius aware of the potentially devastating effects of the cuts on community radiation oncology centers. The effort was started by Rep. Joe Pitts (R-PA), chairman of the subcommittee on health of the House Energy and Commerce Committee, and Frank Pallone Jr., its ranking member. About a week later, Senate Finance Committee members Debbie Stabenow (D-MI) and Richard Burr (R-NC) circulated a similar letter in the Senate.

The senators are requesting that if CMS re-evaluates practice expense inputs, it should examine all components of the expenses to propose reimbursement rates that more accurately reflect the costs associated with IMRT and SBRT.

"Congressman Pallone and I are very concerned that a flawed CMS process has yielded cuts that would hurt our constituents currently receiving cancer care," Pitts told AuntMinnie.com. "The last thing cancer patients should have to worry about is whether or not their doctor will be able to perform the proper tests to advance their treatment."

Support has been steady and stronger than expected during a Congressional recess, according to a representative from Pitts' staff. They expect a surge of support in September, and the House letter is expected to be delivered to HHS after September 15.

ACR comments

Because the ACR represents radiation oncologists as well as radiologists, AuntMinnie.com asked Assistant Executive Director Cynthia Moran about the organization's actions. While ASTRO led the lobbying effort on Capitol Hill, ACR has also been active, she said. ACR members have been asked to submit formal comments to the proposed rule.

"There are so many things wrong with this proposed rule," Moran said. "ACR is preparing a detailed response to CMS. We will comment in depth and great detail not only about the radiation oncology cuts but also about the diagnostic radiology cuts."

"Many of these proposed changes are ridiculous," she added. "I'm tremendously concerned about the thought processes behind them. It seems as if something has been published on the Web, CMS will use it, versus relying upon a scientific-based process that has been used for the past 20 years."

Moran expressed concern that CMS is taking over the role of healthcare fee setter for physicians in the U.S., yet no legislation has given the agency this authority. This encroachment by CMS is very troubling, and members of Congress should be extremely concerned about it, she said.

CMS is accepting formal comments about the proposed rule through September 4, 2012. ACR, ASTRO, and the letters' sponsors all encourage responders to also contact their congressperson.

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