Section 3(b) of the Patient Access and Medicare Protection Act (“PAMPA”) (P.L. REPORTING PROTON BEAM THERAPY ICRU 78 RAJESH THIYAGARAJAN Senior Medical Physicist & RSO MedantaThe Medicity. Proton beam therapy is a form of radiation treatment that the Medicare Payment Advisory Commission (“MedPAC”), in its “June 2018 Report to the Congress: Medicare and the Health Care Delivery System,” (the “MedPac Report”) once referred to as a “potentially low value” treatment modality and an example of why CMS should consider the development and implementation of new RT payment models to create, “incentives for organizations to reduce low-value services.”. In this article, we will focus on the concerns of such detractors, including those voiced by proton therapy providers who consider the RO Model’s payment reductions – which apply to all RT providers regardless of the treatment modality at issue – as a CMS-intended financial hit against proton beam therapy. Mayo Clinic doctors and other specialists consult with their colleagues about each patient's condition and recommend treatment options based on their experience and evidence-based medicine. … People who must undergo radiation therapy early in life are less likely to have long-term side effects and complications, such as secondary cancers, with proton beam therapy than with conventional radiation therapy. Shortly after my treatment, I was asked to provide my story to The Alliance for Proton Beam Therapy Access Association. Ensure that appropriate payments are made for patients treated with multiple RT modalities or with multiple cancer types. The AHA believes that the RO Model as described in the NPR would place too much risk and burden on providers with little opportunity for shared savings as a reward. This alert is provided for information purposes only and does not constitute legal advice and is not intended to form an attorney client relationship. This may include but is not limited to: Please let us know if you have any metal hardware in your body, including pacemakers and hip replacements. Dhara Waghela is an associate in the Corporate Practice Group in the firm’s Century City office and is a member of the firm’s Healthcare team. But proton therapy is relatively new and costly for providers to administer. That means that there is no national rule, so the decision is … Proton beam therapy … The COA maintains that the RO Model should be voluntary because, “not all RT providers have the infrastructure, commitment, and organizational buy-in to succeed in new payment arrangements.” Moreover, the COA notes that if RT providers are required to participate, they may not have adequate support to achieve the RO Model’s goals – the provision of high quality RT services at lower rates – while ensuring that they continue to meet the needs of their patients; and. The RT community will be watching and so will we. In doing so, the COA argues that the RO Model payments, even before the adjustment factors are applied, will be more sensitive to the diversity of RT providers and patients who are going to be impacted by the RO Model. Although the proposed RO Model is consistent with broader trends in the healthcare industry to cut healthcare costs and increase quality through the use of bundled and other alternative (i.e., not fee-for-service) payment methodologies, the RO Model has garnered its fair share of detractors within the RT community. The RO Model and its Potential Impact on Innovation and New Technology: The Case for Proton Beam Therapy. CMS invites comment on its proposal to include proton beam therapy in the RO Model. This means highly specialized radiation oncologists work in a multidisciplinary environment that considers all your needs. They should not be required to participate in such a complicated program, which includes 17 different types of cancer, if they do not believe it will benefit the patients they serve.” This concern about the mandatory nature of the RO Model is a common one that is shared by many providers and provider organizations. In order to address these concerns the AHA Letter calls for the following revisions to RO Model: In addition to the foregoing, the AHA, like the COA, is concerned that by making the RT Model mandatory for those RT providers located in the selected geographic area creates an unfair and unnecessary burden on the providers who have no choice but to participate in the RT Model program. The APTA’s comment letter sums up many of the RO Model concerns that seem to be commonly accepted within the proton beam therapy provider and trade association communities. … Also Known As: Proton beam radiation therapy, Proton radiotherapy PRIOR AUTHORIZATION: Required. Finally, RO Model payments do not differentiate between the type of RT provider, the RT modality, or the RT modality’s cost. Proton Therapy Basics. This experience means your doctors are equipped with the knowledge and resources to provide you with exactly the care you need. This site complies with the HONcode standard for trustworthy health information: verify here. Pediatric tumors are among the most beneficial to treat with proton beam therapy, as it imparts less damage to a child's still-developing organs. Proton beam therapy … Sadly, only about 5% of folks wanting/needing radiation that helps protect vital organs in and around the head and neck with limited long term side affects, are able to get Proton beam … Make the model retrospective rather than prospective, to allow CMS to reconcile providers’ historical and actual case mix and avoid under or over payments; Replace the RO Model’s historical experience and efficiency adjustments with an adjustment that blends participants’ historical performance and national and regional average performance, as has been done in other models; Lower the discount amount, especially for the technical component (TC) payment, to 2.5% – 2.75%; Incorporate a stop-loss provision into the RO Model; Develop approaches to ensure that appropriate payments are made when providers introduce new service lines or technologies that were not included in their historical data; and. You do not need a referral from a doctor. 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