General Consensus on Implementing an Episode-Based Payment Model: Results From the American College of Radiation Oncology (ACRO) Payment Reform Survey.

Introduction Medicare payments for radiation oncology (RO) services adhere to a fee-for-service model. However, a growing number of stakeholders, including both payers and physicians, are increasingly supportive of transitioning to an episode-based payment (EBP) model. Multiple novel models have been proposed, including the Centers for Medicare and Medicaid Services/Center for Medicare & Medicaid Innovation Radiation Oncology Model and the American Society for Radiation Oncology Radiation Oncology Case Rate (ROCR) program. Data regarding the level of RO physician support for implementing an EBP model, and RO physician opinions on key elements of the proposed models, have not been published. The American College of Radiation Oncology (ACRO) Government Relations and Economics Committee conducted a robust survey to gain insight into physician sentiment, enhance transparency, promote dialogue, and assess consensus on payment reform. Methods A 29-item questionnaire was created and distributed electronically via email to practicing RO attending and resident physicians, identified using American Medical Association Physician Professional Data and ACRO membership rolls. The survey commenced on October 2, 2023, and concluded on February 1, 2024. Hypothesis testing was conducted using the null hypothesis that there is no consensus amongst physicians on a given item (i.e., the proportion of physicians agreeing or disagreeing with a statement defined as equal to 50%). One-sample tests of proportions, specifying the null hypothesis as 0.5, were run using R 4.3.3 (R Core Team, Vienna, Austria), a statistical computing software. Results A total of 528 responses were collected, of which 500 were from practicing RO physicians in the United States (U.S.) and were included for analysis. Respondents included attending physicians from all 50 U.S. states, the District of Columbia, and Puerto Rico. It was found that 61.0% (n = 285 of 467; p < 0.001; 95% CI: 56.4%-65.4%) of respondents support implementing an EBP model for RO services, in which payment is primarily based on the site of disease being treated, rather than the X-ray beam modality or fraction number; 17.3% (n = 81 of 467) neither support nor oppose it, and 21.6% (n = 101 of 467) oppose such a model. Support for EBP exceeds 50.0% across all experience levels, practice types (academic, community or private practice, and Veteran's Health Administration), practice sites (hospital and freestanding), practice settings (rural, suburban, and urban), and U.S. geographic regions. It was found that 63.8% (n = 298 of 467) of respondents agree that such a model would better align financial incentives with clinical guidelines. Additionally, 78.6% (n = 367 of 467) support site-neutral payments that equalize pay for RO services, regardless of whether treatments are delivered at a freestanding radiation therapy center or hospital outpatient department. Although not directly tied to EBP models, 68.7% (n = 321 of 467) support site-neutral direct supervision requirements, with specified limited exceptions. Conclusion A clear majority of RO physicians currently practicing in the U.S. either support or are neutral towards the implementation of an EBP model for their specialty. This survey represents the first comprehensive assessment of practicing RO physicians' views on implementing an EBP model. The findings provide critical insight for RO stakeholders, including members of Congress, considering the ROCR program.