H.R. 2120 — ROCR Value Based Program Act

This section states congressional findings concerning radiation therapy, including its use in treating nearly 60% of cancer patients; Medicare spending of approximately $4.2 billion on such services in 2021; pricing challenges under the Medicare physician fee schedule and hospital outpatient prospective payment system for services involving costly equipment and professional expertise; the superiority of bundled payments for promoting efficient, high-value care; the 2017 Centers for Medicare & Medicaid Services report on the Radiation Oncology Model and subsequent implementation concerns over payment reductions and reporting requirements; and the need for a new payment program to incentivize quality while containing costs.

This section establishes a Radiation Oncology Case Rate Value Based Payment Program (ROCR Program) under Medicare Part B, requiring the Secretary of Health and Human Services to promulgate implementing regulations using notice-and-comment procedures (including an advance notice of proposed rulemaking and proposed rulemaking, each with at least 60 days for comment) not later than one year after enactment. The program provides site-neutral per-episode payments to radiation therapy providers and suppliers for covered radiation therapy furnished to Medicare beneficiaries (covered individuals) during episodes of care for specified cancer types, with payments issued in two halves—50% within 30 days after the first treatment delivery and the remaining 50% at the earlier of the scheduled end of treatment or the 90th day of the episode (or 30th day for bone or brain metastases treatments)—and adjusted for national base rates, geography, and other factors; it also includes a health equity add-on payment. (As background, the program replaces separate professional and technical fee-for-service payments under the physician fee schedule and hospital outpatient prospective payment system—which are held harmless until regulations take effect—with bundled episode payments to promote stable unified payments, reduce care disparities, enhance quality via accreditation and shorter treatments, leverage advanced technology, and achieve Medicare savings.) The program seeks to reduce disparities in radiation therapy access for Medicare beneficiaries, improve care quality, and protect program resources.

This section adds to the exceptions from civil monetary penalties under the Social Security Act (42 U.S.C. 1320a-7a(i)(6)) a new subparagraph (K) excluding the provision of free or discounted transportation services (i.e., car services, ride shares, or public transportation, excluding air, luxury, or ambulance-level) to established patients receiving radiation therapy services if provided by an eligible entity (i.e., an individual or entity not primarily supplying health care items) that (1) applies the services uniformly via policy without regard to federal program business volume or value; (2) does not market or advertise them; (3) ensures drivers do not market health care items or services; (4) does not pay drivers or arrangers on a per-beneficiary-transported basis; (5) limits services to patients within a 75-mile radius of the radiation therapy provider or supplier (or in a rural area) who are established patients seeking medically necessary radiation therapy services; and (6) bears costs without shifting them to federal programs, other payers, or individuals. (Thus, radiation therapy providers, suppliers, or other eligible entities may offer such transportation to their patients without facing penalties for beneficiary inducement.) It also adds a new subsection (t) defining eligible entity, established patient (i.e., one who has selected/scheduled or attended an appointment), radiation therapy provider/supplier/services (as in SSA section 1866G(j)), rural area (i.e., non-urban), transportation services, and urban area (i.e., specified metropolitan areas plus six counties).

This section exempts reduced expenditures resulting from the Radiation Oncology Case Rate Value Based Payment Program (under SSA section 1899C) from budget neutrality adjustments under the Medicare outpatient prospective payment system (OPPS). (As background, budget neutrality adjustments under OPPS ensure annual payment updates do not increase total program spending; this provision allows program savings to reduce net Medicare expenditures rather than offsetting other payments.) It makes a conforming change to exclude such reduced expenditures from budget neutrality calculations under the Medicare physician fee schedule (PFS).