S. 1031 — ROCR Value Based Program Act

This section states congressional findings on radiation therapy (used by nearly 60% of cancer patients), Medicare spending on radiation oncology services ($4.2 billion in 2021), challenges in physician fee schedule payments for external beam radiation therapy (i.e., fluctuating rates due to capital equipment costs and inadequate recognition of professional expertise), the superiority of bundled payments for promoting efficient care, issues with the prior Radiation Oncology Model (including payment reductions and reporting burdens that delayed implementation), 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 to issue regulations within one year of enactment using notice-and-comment rulemaking (including an advance notice of proposed rulemaking and proposed rulemaking, each with at least 60 days for comment). It prohibits reductions in payment rates for radiation therapy services under the physician fee schedule or hospital outpatient prospective payment system from enactment until the regulations take effect. The ROCR Program provides site-neutral per-episode payments (i.e., same amount regardless of whether furnished in a hospital outpatient department or physician office) to radiation therapy providers and suppliers for covered treatment of included cancer types furnished to Medicare beneficiaries, equal to 80% of a per-episode payment amount that covers all professional and technical services during an episode of care. Payments are issued in two halves—first half within 30 days of the initial treatment delivery, and second half at the scheduled end of treatment or the 90th day of the episode (or 30th day for bone or brain metastases episodes), with full payment due within 30 days of a beneficiary's death during treatment; per-episode amounts are based on national base rates (updated annually), subject to geographic and other adjustments, plus a health equity add-on payment. (As background, the program replaces traditional fee-for-service payments for radiation oncology with bundled episode payments to promote stable unified payments, reduce care disparities and spending, enhance quality through accreditation and shorter treatments, and encourage advanced technology.)

This section adds an exception to civil monetary penalties under SSA section 1128A(i)(6) for 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 engaged in supplying health care items) that meets specified conditions. Those conditions require, among other safeguards against inducements, (1) a uniform, consistently applied policy for availability unrelated to federal health care program business volume or value; (2) no public marketing or advertising of the services; (3) drivers or arrangers not marketing health care items or services or paid on a per-beneficiary basis; (4) services limited to patients residing within a 75-mile radius of the radiation therapy provider or supplier or in a rural area (i.e., outside specified metropolitan or designated county areas) who need transport for medically necessary radiation therapy; and (5) the entity bearing all costs without shifting them to federal programs, other payers, or individuals. The section also adds subsection (t) defining relevant terms, including "established patient" (i.e., one who has selected/scheduled or attended an appointment with a radiation therapy provider or supplier). (Thus, this safe harbor facilitates beneficiary access to radiation therapy without penalty risk for compliant entities.)

This section exempts reduced expenditures attributable to the Radiation Oncology Case Rate Value Based Payment Program (i.e., the RO Model under section 1899C, which pays Medicare providers a single bundled case rate per radiation therapy treatment course instead of fee-for-service amounts) from budget neutrality adjustments under the outpatient prospective payment system (OPPS). Specifically, it (1) directs the Secretary not to account for such reduced expenditures in making OPPS budget neutrality adjustments under SSA section 1833(t); and (2) excludes the program from physician fee schedule (PFS) calculations of target spending intensity and separately lists its reduced expenditures for fee schedules established after the program's enactment under SSA section 1848(c)(2)(B). (Thus, RO Model savings are preserved and not used to offset payment rate increases elsewhere in OPPS or PFS.)