United States: CMS Proposes New Payment Models For Radiation Oncology And End Stage Renal Disease (ESRD)

On July 10, the Centers for Medicare & Medicaid Services (CMS) issued a proposed rule that would implement and test two new mandatory payment models under its Center for Medicare & Medicaid Innovation (CMMI): the Radiation Oncology Model (RO Model) and the End-Stage Renal Disease (ESRD) Treatment Choices (ETC Model).

The proposed RO Model would make prospective payments to hospital outpatient departments, freestanding radiation therapy centers and physician group practices for radiation therapy (RT) episodes of care.

The proposed ETC Model would make payment adjustments to ESRD facilities and some clinicians caring for beneficiaries with ESRD, to encourage greater use of home dialysis and kidney transplants.

Both models would be mandatory, operating in selected geographic areas. CMS announced the proposed mandatory ETC Model, in addition to four new optional payment models following the July 10 Executive Order on Advancing American Kidney Health.1

For quick reference, the table below summarizes key features of each proposed model. A more detailed description follows the table below.

Proposed Radiation Oncology (RO) Model Proposed End-Stage Renal Disease Treatment Choices (ETC) Model
Payment Prospective payment for RT services for 17 cancer types furnished in 90-day episode with split for professional and technical components; site-neutral payments (common payment amount regardless of where services are furnished)

(1) Increased payment for some home dialysis and related claims during initial 3 years of model

(2) Positive or negative payment adjustments for in-center and home dialysis and related claims based on facilities' and clinicians' rates of kidney and kidney-pancreas transplants, and home dialysis

Timeline 1/1/2020 or 4/1/2020 – 12/31/2024 (performance period) 1/1/2020 – 6/30/2026 (period in which payment adjustments are applied)
Geographic Area To be announced To be announced (will include Maryland)
Participation Mandatory participation for RT providers in geographic areas selected by CMS Mandatory participation for ESRD facilities and clinicians in geographic areas selected by CMS
Quality Measures 4 MIPS-approved measures and patient satisfaction and experience survey Standardized Mortality Ratio and Standardized Hospitality Ratio
Program Waivers Yes (for some Medicare payment adjustment requirements) Yes (for some Medicare payment adjustment requirements and use of the Kidney Disease Education (KDE) benefit)
Quality Payment Program Status Qualifies as MIPS APM and Advanced APM Does not qualify as a MIPS APM or Advanced APM2

Radiation Oncology Model

The proposed RO Model would focus on prospective episode-based payments for RT services furnished during a 90-day episode to Medicare beneficiaries diagnosed with one or more of 17 specified types of cancer.3

  • Payment Amount: The RO Model would make separate payment amounts for the professional and technical components of each episode of RT.4 The professional component payment would apply to RT services that may be furnished only by a physician, and a technical component payment would apply to RT services that are not furnished by a physician, including provision of equipment, supplies, and non-physician personnel related to RT services.5 The professional and technical component payments for RT services included in the RO Model would be the same for services provided at a hospital outpatient department or a freestanding radiation center,6 and would be determined based on proposed national base rates, trend factors and adjustments for each participant's case-mix, historical experience and geographic location.7
  • Adjustments to the Payment: Payment amounts would be subject to adjustment for withholds for incomplete episodes, quality and, starting in performance year 3, beneficiary experience.8 For withholds due to quality and beneficiary experience, RO Model participants would have the ability to earn back a portion of the withheld amount based on the reporting of clinical data, quality measure performance and reporting, and beneficiary-reported surveys.9
  • Mandatory Participation for Providers: CMS proposes that participation in the RO Model would be mandatory for all RT providers and suppliers within Core Based Statistical Areas (CBSAs) randomly selected by CMS10 (with some proposed exclusions).11 This proposed requirement has drawn concerns from key industry leaders given the model's significant departure from the status quo.12
  • Forms of Participation: An RO Model participant would be able to participate as a Professional participant, Technical participant, or Dual participant.13 Two separate participants could furnish the technical and professional components of the same episode (e.g., a physician group practice could furnish the professional component as a Professional participant and a hospital outpatient department could furnish the technical component as a Technical participant).14 A participant like a freestanding radiation therapy center also could elect to furnish both the professional component and technical component as a Dual participant through a single entity.15
  • Covered Cancer Types: The covered cancer types are anal cancer, bladder cancer, bone metastases, brain metastases, breast cancer, cervical cancer, CNS tumors, colorectal cancer, head and neck cancer, kidney cancer, liver cancer, lung cancer, lymphoma, pancreatic cancer, prostate cancer, upper GI cancer, and uterine cancer.16
  • Beneficiary Participation: Medicare beneficiaries eligible for Medicare and enrolled in Medicare Part B who have a diagnosis of at least one of the covered cancer types and who receive RT services from a provider participating in the RO Model would automatically be a beneficiary of the model.17 Only beneficiaries who have traditional Medicare Fee-for-Service as their primary payer are included—Medicare Advantage enrollees are excluded.18 Professional and Dual participants must notify beneficiaries of their inclusion in the RO Model through a standardized written notice during their initial treatment planning session.19 Beneficiaries may not opt out of the RO Model's payment methodology, but may exercise their freedom to choose a provider that is not subject to mandatory participation in the RO Model (i.e., a provider in a different CBSA).20 A beneficiary may also opt out of sharing his or her data under the RO Model.21
  • Quality Measure and Reporting Requirements: CMS proposes to adopt four quality measures focused on the effectiveness of the RO Model.22 The measures relate to (1) plan of care for pain; (2) preventive care, screening, and follow-up planning for depression; (3) advanced care planning; and (4) treatment summary communications for radiation oncology.23 RO Model participants would be required to report data for all applicable patients, not just beneficiaries participating in the RO Model.24 CMS also proposes to administer a patient satisfaction and experience survey to RO Model beneficiaries through a CMS-approved contractor beginning April 1, 2020. These measures would be scored to calculate an Aggregate Quality Score (AQS) that would be applied against any withheld payment amounts.25 CMS believes that adoption of these proposed quality measures will meet the quality measure-related requirements that would qualify the RO Model as an Advanced Alternative Payment Model (APM) and as a Merit-Based Incentive Payment System (MIPS) APM.26
  • Data Sharing: CMS proposes to offer RO Model participants the opportunity to request a claims data file that contains patient identifiable data on the participant's patient population, which can be used for treatment, care management and quality improvement activities.27 CMS will also permit RO Model participants to reuse the data for provider incentive design and implementation.28
  • Beneficiary Waivers: CMS will waive some Medicare payment-related requirements for carrying out testing of the RO Model, such as the payment reduction for Hospital Outpatient Quality Reporting (OQR) and the requirement to apply the additional MIPS payment adjustment factor for services billed under the RO Model.29
  • Performance Period: The proposed RO Model would have a performance period of five calendar years, beginning in 2020 (either January 1, 2020 or April 1, 2020), and ending on December 31, 2024.30 However, the model would capture all episodes that finish within the performance period, meaning that data collection, episode payments, and reconciliation would continue into calendar year 2025.31

ESRD Treatment Choices (ETC) Model

The proposed ETC Model is a mandatory payment model for ESRD facilities and clinicians caring for beneficiaries with ESRD (Managing Clinicians) located in selected geographic areas. Its stated goal is to test whether adjusting Medicare payments to ESRD and Managing Clinicians would increase rates of home dialysis and kidney and kidney-pancreas transplants.32

  • Payment Amounts: The Model would include two types of payment adjustments:
    1. The Home Dialysis Payment Adjustment (HDPA) would increase payments for some Medicare home dialysis and home dialysis-related claims during the initial three years of the Model, for participating ESRD facilities and Managing Clinicians.33
    2. The Performance Payment Adjustment (PPA) would increase or reduce payments (in increasing amounts over time), for both home and in-center dialysis and related claims (from the ESRD Prospective Payment System for ESRD facilities and monthly capitation payments (MCPs) to Managing Clinicians as an ESRD patient management fee).34 The adjustment would tie to ESRD facilities' and Managing Clinicians' rates of kidney and kidney-pancreas transplants and home dialysis among attributed beneficiaries during the Measurement Year.35 The PPA would be applied during a six-month period after the Measurement Year. Rates would be measured using Medicare claims data, Medicare administrative data including enrollment data, and the Scientific Registry of Transplant Recipients (SRTR) data.36
  • Mandatory Participation: CMS would select ESRD facilities and Managing Clinicians to participate in the model according to their location in randomly selected geographic areas (Hospital Referral Regions or HRRs). CMS intends the selection to account for approximately 50% of ESRD facilities and Managing Clinicians in all 50 states and in the District of Columbia. However, ESRD facilities and Managing Clinicians in Maryland must generally be included in the model (to be consistent with the Total Cost of Care Model currently being tested in that state). Some facilities and clinicians would be excluded from certain parts of the model, if they serve low volumes of adult ESRD beneficiaries.37
  • Beneficiary Participation and Attribution: Beneficiaries participating in the ESRD Model would include Medicare beneficiaries receiving dialysis or other services for ESRD, and beneficiaries who received kidney or kidney-pancreas treatments prior to receiving dialysis. CMS proposes that beneficiaries would be unable to opt out of the payment methodology, although some beneficiaries would be excluded from participation, including those under age 18, in hospice, diagnosed with dementia, or receiving dialysis for acute kidney injury.38 ETC Participants would be required to notify beneficiaries of the ETC Participant's participation in the ETC Model by prominently displaying informational materials in the ESRD facilities and Managing Clinician offices or facilities where beneficiaries receive care.39 Participating beneficiaries would be attributed on a month-by-month basis to the ESRD facility accounting for the most dialysis claims during the month for that beneficiary, and to the Managing Clinician billing the monthly capitation payment claim for the month for services to the beneficiary.40
  • Medicare Payment Waivers: CMS proposes to waive certain Medicare program requirements for the ESRD PPS, ESRD Quality Incentive Program, and the Medicare Physician Fee Schedule to make payment adjustments to ETC Participants.41 Some requirements regarding the use of the Medicare Kidney Disease Education (KDE) benefit (including who must furnish such KDE services, to whom they must be furnished, and certain curriculum restrictions) would also be waived.42
  • Quality Measures: CMS proposes to use two quality measures for the ETC Model: the Standardized Mortality Ratio, and the Standardized Hospitalization Ratio.43 ESRD facilities already are required to calculate these measures in connection with other CMS initiatives (Dialysis Facility Reports and the ESRD Quality Incentive Program (QIP)), and thus require no additional reporting for Model participants.44 The proposed ETC Model quality measures would not be tied to payment adjustments under the Model. The Model would overlap with a number of other CMS dialysis-focused programs, including MIPS, the ESRD QIP, and the Kidney Care First (KCF) and Comprehensive Kidney Care Contracting (CKCC) Models.45
  • Performance Period: The payment adjustments for the selected ESRD facilities and Managing Clinicians would apply to Medicare claims from January 1, 2020 through June 30, 2026.46 ss


1. Centers for Medicare and Medicaid Services, " HHS To Transform Care Delivery for Patients with Chronic Kidney Disease", Press Release (Jul. 10, 2019).

2 .Centers for Medicare and Medicaid Services, Medicare Program; Specialty Care Models to Improve Quality of Care and Reduce Expenditures, CMS-5527-P (Unpublished in Federal Register), pgs. 300-302.

3. Supra note 2 at 8.

4. Id. at 9.

5. Id. at 63.

6. Id at 49.

7. Id. at 11.

8. Id.

9. Id.

10. Id. at 10.

11. Id at 65. Specifically, CMS proposes to exclude from RO Model participation any physician group practice, freestanding radiation therapy center or hospital outpatient department that furnishes RT only in Maryland, Vermont or the U.S. Territories; is classified as an ambulatory surgery center, critical access hospital, or Prospective Payment System-exempt cancer hospital; or participates in or is identified as eligible to participate in the Pennsylvania Rural Health Model.

12. See American Society for Radiation Oncology, Statement in Response to HHS Secretary Azar's comments on radiation oncology alternative payment model, Nov. 8, 2018; Gregory Twachtman, " First take on radiation oncology APM mixed," MDedge, Jul. 12, 2019.

13. Supra note 2 at 9.

14. Id.

15. Id.

16. Id. at 78.

17. Id. at 73.

18. Id.

19. Id. at 13.

20. Id. at 74.

21. Id. at 185.

22. Id. at 133.

23. Id. at 122.

24. Id. at 134.

25. Id. at 121.

26. Id. at 123.

27. Id. at 12-13.

28. Id. at 13.

29. Id. at 14, 153-163.

30. Id. at 5.

31. Id. at 8.

32. Id. at 14.

33. Id. at 16-17.

34. Centers for Medicare and Medicaid Services, " Proposed End-Stage Renal Disease Treatment Choices (ETC) Mandatory Model," Fact Sheet (Jul. 10, 2019).

35. Supra note 2 at 16-17.

36. Id.

37. Centers for Medicare & Medicaid Services, Innovation Center, ESRD Treatment Choices (ETC) Model.

38. Id. at 244-245.

39. Id.

40. Id; Supra note 2 at 246.

41. Id. at 18.

42. Id. at 289.

43. Id. at 20.

44. Id. at 19.

45. Id. at 283.

46. Supra note 30; Id. at 5-6.

The content of this article is intended to provide a general guide to the subject matter. Specialist advice should be sought about your specific circumstances.

To print this article, all you need is to be registered on Mondaq.com.

Click to Login as an existing user or Register so you can print this article.

Similar Articles
Relevancy Powered by MondaqAI
Akin Gump Strauss Hauer & Feld LLP
In association with
Related Topics
Similar Articles
Relevancy Powered by MondaqAI
Akin Gump Strauss Hauer & Feld LLP
Related Articles
Related Video
Up-coming Events Search
Font Size:
Mondaq on Twitter
Mondaq Free Registration
Gain access to Mondaq global archive of over 375,000 articles covering 200 countries with a personalised News Alert and automatic login on this device.
Mondaq News Alert (some suggested topics and region)
Select Topics
Registration (please scroll down to set your data preferences)

Mondaq Ltd requires you to register and provide information that personally identifies you, including your content preferences, for three primary purposes (full details of Mondaq’s use of your personal data can be found in our Privacy and Cookies Notice):

  • To allow you to personalize the Mondaq websites you are visiting to show content ("Content") relevant to your interests.
  • To enable features such as password reminder, news alerts, email a colleague, and linking from Mondaq (and its affiliate sites) to your website.
  • To produce demographic feedback for our content providers ("Contributors") who contribute Content for free for your use.

Mondaq hopes that our registered users will support us in maintaining our free to view business model by consenting to our use of your personal data as described below.

Mondaq has a "free to view" business model. Our services are paid for by Contributors in exchange for Mondaq providing them with access to information about who accesses their content. Once personal data is transferred to our Contributors they become a data controller of this personal data. They use it to measure the response that their articles are receiving, as a form of market research. They may also use it to provide Mondaq users with information about their products and services.

Details of each Contributor to which your personal data will be transferred is clearly stated within the Content that you access. For full details of how this Contributor will use your personal data, you should review the Contributor’s own Privacy Notice.

Please indicate your preference below:

Yes, I am happy to support Mondaq in maintaining its free to view business model by agreeing to allow Mondaq to share my personal data with Contributors whose Content I access
No, I do not want Mondaq to share my personal data with Contributors

Also please let us know whether you are happy to receive communications promoting products and services offered by Mondaq:

Yes, I am happy to received promotional communications from Mondaq
No, please do not send me promotional communications from Mondaq
Terms & Conditions

Mondaq.com (the Website) is owned and managed by Mondaq Ltd (Mondaq). Mondaq grants you a non-exclusive, revocable licence to access the Website and associated services, such as the Mondaq News Alerts (Services), subject to and in consideration of your compliance with the following terms and conditions of use (Terms). Your use of the Website and/or Services constitutes your agreement to the Terms. Mondaq may terminate your use of the Website and Services if you are in breach of these Terms or if Mondaq decides to terminate the licence granted hereunder for any reason whatsoever.

Use of www.mondaq.com

To Use Mondaq.com you must be: eighteen (18) years old or over; legally capable of entering into binding contracts; and not in any way prohibited by the applicable law to enter into these Terms in the jurisdiction which you are currently located.

You may use the Website as an unregistered user, however, you are required to register as a user if you wish to read the full text of the Content or to receive the Services.

You may not modify, publish, transmit, transfer or sell, reproduce, create derivative works from, distribute, perform, link, display, or in any way exploit any of the Content, in whole or in part, except as expressly permitted in these Terms or with the prior written consent of Mondaq. You may not use electronic or other means to extract details or information from the Content. Nor shall you extract information about users or Contributors in order to offer them any services or products.

In your use of the Website and/or Services you shall: comply with all applicable laws, regulations, directives and legislations which apply to your Use of the Website and/or Services in whatever country you are physically located including without limitation any and all consumer law, export control laws and regulations; provide to us true, correct and accurate information and promptly inform us in the event that any information that you have provided to us changes or becomes inaccurate; notify Mondaq immediately of any circumstances where you have reason to believe that any Intellectual Property Rights or any other rights of any third party may have been infringed; co-operate with reasonable security or other checks or requests for information made by Mondaq from time to time; and at all times be fully liable for the breach of any of these Terms by a third party using your login details to access the Website and/or Services

however, you shall not: do anything likely to impair, interfere with or damage or cause harm or distress to any persons, or the network; do anything that will infringe any Intellectual Property Rights or other rights of Mondaq or any third party; or use the Website, Services and/or Content otherwise than in accordance with these Terms; use any trade marks or service marks of Mondaq or the Contributors, or do anything which may be seen to take unfair advantage of the reputation and goodwill of Mondaq or the Contributors, or the Website, Services and/or Content.

Mondaq reserves the right, in its sole discretion, to take any action that it deems necessary and appropriate in the event it considers that there is a breach or threatened breach of the Terms.

Mondaq’s Rights and Obligations

Unless otherwise expressly set out to the contrary, nothing in these Terms shall serve to transfer from Mondaq to you, any Intellectual Property Rights owned by and/or licensed to Mondaq and all rights, title and interest in and to such Intellectual Property Rights will remain exclusively with Mondaq and/or its licensors.

Mondaq shall use its reasonable endeavours to make the Website and Services available to you at all times, but we cannot guarantee an uninterrupted and fault free service.

Mondaq reserves the right to make changes to the services and/or the Website or part thereof, from time to time, and we may add, remove, modify and/or vary any elements of features and functionalities of the Website or the services.

Mondaq also reserves the right from time to time to monitor your Use of the Website and/or services.


The Content is general information only. It is not intended to constitute legal advice or seek to be the complete and comprehensive statement of the law, nor is it intended to address your specific requirements or provide advice on which reliance should be placed. Mondaq and/or its Contributors and other suppliers make no representations about the suitability of the information contained in the Content for any purpose. All Content provided "as is" without warranty of any kind. Mondaq and/or its Contributors and other suppliers hereby exclude and disclaim all representations, warranties or guarantees with regard to the Content, including all implied warranties and conditions of merchantability, fitness for a particular purpose, title and non-infringement. To the maximum extent permitted by law, Mondaq expressly excludes all representations, warranties, obligations, and liabilities arising out of or in connection with all Content. In no event shall Mondaq and/or its respective suppliers be liable for any special, indirect or consequential damages or any damages whatsoever resulting from loss of use, data or profits, whether in an action of contract, negligence or other tortious action, arising out of or in connection with the use of the Content or performance of Mondaq’s Services.


Mondaq may alter or amend these Terms by amending them on the Website. By continuing to Use the Services and/or the Website after such amendment, you will be deemed to have accepted any amendment to these Terms.

These Terms shall be governed by and construed in accordance with the laws of England and Wales and you irrevocably submit to the exclusive jurisdiction of the courts of England and Wales to settle any dispute which may arise out of or in connection with these Terms. If you live outside the United Kingdom, English law shall apply only to the extent that English law shall not deprive you of any legal protection accorded in accordance with the law of the place where you are habitually resident ("Local Law"). In the event English law deprives you of any legal protection which is accorded to you under Local Law, then these terms shall be governed by Local Law and any dispute or claim arising out of or in connection with these Terms shall be subject to the non-exclusive jurisdiction of the courts where you are habitually resident.

You may print and keep a copy of these Terms, which form the entire agreement between you and Mondaq and supersede any other communications or advertising in respect of the Service and/or the Website.

No delay in exercising or non-exercise by you and/or Mondaq of any of its rights under or in connection with these Terms shall operate as a waiver or release of each of your or Mondaq’s right. Rather, any such waiver or release must be specifically granted in writing signed by the party granting it.

If any part of these Terms is held unenforceable, that part shall be enforced to the maximum extent permissible so as to give effect to the intent of the parties, and the Terms shall continue in full force and effect.

Mondaq shall not incur any liability to you on account of any loss or damage resulting from any delay or failure to perform all or any part of these Terms if such delay or failure is caused, in whole or in part, by events, occurrences, or causes beyond the control of Mondaq. Such events, occurrences or causes will include, without limitation, acts of God, strikes, lockouts, server and network failure, riots, acts of war, earthquakes, fire and explosions.

By clicking Register you state you have read and agree to our Terms and Conditions