S. 1031: ROCR Value Based Program Act

Today Medicare pays for radiation therapy piece by piece: each planning session, each treatment, each piece of physics work gets its own billing code. The bill's findings say that system has produced unstable rates and rewards volume over value. S. 1031 would replace it, for most cancer types, with one payment per course of treatment.

Medicare would pay the clinic a single episode amount, and it would not change based on whether you are treated in a hospital outpatient department or a physician's office. Medicare covers 80% of that amount and you owe the usual 20% coinsurance, which clinics could let you pay in installments.

Medicare's share arrives in two halves. The first comes within 30 days of your first treatment. The second comes when the course is scheduled to end or on day 90, whichever is earlier, or day 30 for bone or brain metastases, which are usually treated in shorter courses.

Participation would be required for Medicare radiation providers, with exceptions for clinics in state-based Medicare innovation models and case-by-case hardship waivers such as after a natural disaster. Proton therapy, brachytherapy and several other specialized treatments stay on the old billing for 12 years, and so do newer technologies from the date they are first coded.

The bill also includes a transportation piece. At intake, the clinic would ask whether a lack of reliable transportation has kept you from appointments, work or daily activities in the past two months. If you say yes, the clinic gets an extra $500 for your course of treatment and has to keep records showing how it spent that money on getting you there.

Separately, clinics could offer free or discounted car services, ride shares or transit fare to established patients who live within 75 miles or in a rural area. Today that kind of help can run into federal rules against giving patients anything of value that might steer their business. The bill carves out an exception as long as the clinic applies one uniform policy, doesn't advertise the rides, and doesn't pay drivers per patient.

Finally, rates are protected. Medicare could not cut radiation rates before the new program starts, could not lower base rates year over year, and could cut them by no more than 1% at each five-year rebasing. Whatever Medicare saves could not be used to offset spending elsewhere in its physician and hospital outpatient payment systems.