[Congressional Bills 118th Congress]
[From the U.S. Government Publishing Office]
[S. 4330 Introduced in Senate (IS)]
<DOC>
118th CONGRESS
2d Session
S. 4330
To amend title XVIII of the Social Security Act to create a Radiation
Oncology Case Rate Value Based Payment Program exempt from budget
neutrality adjustment requirements, and to amend section 1128A of title
XI of the Social Security Act to create a new statutory exception for
the provision of free or discounted transportation for radiation
oncology patients to receive radiation therapy services.
_______________________________________________________________________
IN THE SENATE OF THE UNITED STATES
May 14, 2024
Mr. Tillis introduced the following bill; which was read twice and
referred to the Committee on Finance
_______________________________________________________________________
A BILL
To amend title XVIII of the Social Security Act to create a Radiation
Oncology Case Rate Value Based Payment Program exempt from budget
neutrality adjustment requirements, and to amend section 1128A of title
XI of the Social Security Act to create a new statutory exception for
the provision of free or discounted transportation for radiation
oncology patients to receive radiation therapy services.
Be it enacted by the Senate and House of Representatives of the
United States of America in Congress assembled,
SECTION 1. SHORT TITLE.
This Act may be cited as the ``Radiation Oncology Case Rate Value
Based Program Act of 2024'' or the ``ROCR Value Based Program Act of
2024''.
SEC. 2. FINDINGS.
(a) Findings.--Congress finds the following:
(1) Radiation therapy is the careful use of various forms
of radiation, such as external beam radiation therapy, to treat
cancer and other diseases safely and effectively. Radiation
oncologists develop radiation treatment plans and coordinate
with highly specialized care teams to deliver radiation
therapy. Nearly 60 percent of cancer patients will receive
radiation therapy during their treatment.
(2) In 2021, the Centers for Medicare & Medicaid Services
reported approximately $4,200,000,000 in total spending for
radiation oncology services between the Medicare physician fee
schedule and hospital outpatient departments.
(3) The Centers for Medicare & Medicaid Services has
historically faced challenges in determining accurate pricing
for services that involve costly capital equipment, resulting
in fluctuating payment rates under the Medicare physician fee
schedules for services involving external beam radiation
therapy. Additionally, the Medicare physician fee schedule has
inadequately recognized the professional expertise physicians
and nonphysician professionals need to deliver radiation
therapy.
(4) The current payment systems incentivize greater volumes
of care while bundled payments incentivize patient centered,
efficient, and high value care.
(5) In 2017, the Centers for Medicare & Medicaid Services
recognized that the Medicare payment systems were not
adequately addressing radiation oncology services, and the
Center for Medicare & Medicaid Innovation released a
congressionally requested report on the pursuit of an
alternative payment model for radiation oncology (referred to
in this section as the ``Radiation Oncology Model'') that
addresses the issues in the Medicare physician fee schedule and
the Medicare hospital outpatient prospective payment system
payment methods.
(6) Concerns regarding the proposed Radiation Oncology
Model included the significant payment reductions proposed in
the model that would jeopardize access to high-quality
radiation therapy services and the onerous reporting
requirements for participating providers. The Radiation
Oncology Model saw indefinite implementation delays.
(7) It is necessary, therefore, to create a payment program
for radiation oncology services that appropriately recognizes
the value of quality radiation oncology services through its
financial incentives while containing costs and providing
patient-centered care.
SEC. 3. RADIATION ONCOLOGY CASE RATE VALUE BASED PAYMENT PROGRAM.
(a) In General.--Title XVIII of the Social Security Act (42 U.S.C.
1395 et seq.) is amended by adding at the end the following:
``SEC. 1899C. RADIATION ONCOLOGY CASE RATE VALUE BASED PAYMENT PROGRAM.
``(a) Establishment.--
``(1) In general.--Not later than 1 year after the date of
enactment of the ROCR Value Based Program Act, the Secretary
shall promulgate regulations, using the procedures described in
paragraph (5), establishing a Radiation Oncology Case Rate
Value Based Payment Program (referred to in this section as the
`ROCR Program') under which per episode payments are provided
to radiation therapy providers or radiation therapy suppliers
for covered treatment furnished to a covered individual during
an episode of care (as such terms are defined in subsection
(j)) in accordance with this section.
``(2) Maintaining payment rates during period prior to
effective date of regulations.--The Secretary shall not reduce
the established payment rates for radiation therapy services
under the physician fee schedule under section 1848 or the
hospital outpatient prospective payment system under section
1833(t) during the time period beginning on the date of
enactment of the ROCR Value Based Program Act and ending on the
date that the regulations issued by the Secretary pursuant to
paragraph (1) become effective.
``(3) ROCR program goals.--The ROCR Program shall seek to--
``(A) create stable, unified payments for radiation
therapy services under this title;
``(B) reduce disparities in radiation therapy care
for Medicare beneficiaries by increasing access to
radiation therapy services close to the homes of
beneficiaries;
``(C) enhance quality of radiation therapy care
through practice accreditation and shorter courses of
treatment, when appropriate;
``(D) leverage and encourage the utilization of
state-of-the-art technology to improve care and
outcomes; and
``(E) protect Medicare resources by achieving
reasonable spending reductions in Medicare for
radiation therapy services.
``(4) Payments.--Under this section, with respect to
covered treatment furnished to covered individuals, payments
shall include--
``(A) per episode payments, as described in
subsection (b), to radiation therapy providers or
radiation therapy suppliers of radiation therapy
services which meet such requirements as the Secretary
shall establish by regulation; and
``(B) the health equity achievement in radiation
therapy add-on payment described in subsection (g).
``(5) Notice and comment rulemaking.--The Secretary shall
promulgate the regulations described in paragraph (1) in
accordance with section 553 of title 5, United States Code, and
issue an advanced notice of proposed rulemaking and notice of
proposed rulemaking with a comment period of not less than 60
days for each.
``(b) Per Episode Payments.--
``(1) In general.--
``(A) Payments.--The Secretary shall pay to a
radiation therapy provider or radiation therapy
supplier an amount equal to 80 percent of the per
episode payment amount determined under paragraph 3
(referred to in this section as `the per episode
payment amount') for each covered individual furnished
covered treatment for an included cancer type to cover
all professional and technical services furnished
during such treatment by the radiation therapy provider
or radiation therapy supplier during an episode of care
(as defined in subsection (j)).
``(B) Deductibles and coinsurance.--Subject to
subsection (e), the Secretary shall pay the per episode
payment amount (subject to any deductible and
coinsurance otherwise applicable under part B) to the
radiation therapy provider or radiation therapy
supplier for an episode of care, as described in
subsection (c).
``(2) Per episode payment requirements and timing.--
``(A) In general.--Subject to subparagraph (B), for
each episode of care furnished to a covered individual:
``(i) First-half of payment.--The Secretary
shall issue \1/2\ of the payment amount under
paragraph (1) prospectively not later than 30
days after the day of the first delivery of
covered treatment.
``(ii) Second-half of payment.--The
Secretary shall issue, with the exception of an
episode of care for treatment of bone or brain
metastases and subject to clause (iii), the
remaining half of the payment amount under
paragraph (1) on the date that is the earlier
of--
``(I) the day the course of covered
treatment is scheduled to end; or
``(II) the 90th day of the episode
of care.
``(iii) Second-half of payment for bone and
brain metastases.--The Secretary shall issue
the remaining half of the payment amount under
paragraph (1) for an episode of care for
treatment of bone or brain metastases on the
date that is the earlier of--
``(I) the day the course of covered
treatment is schedule to end; or
``(II) the 30th day of the episode
of care.
``(B) Patient death.--If a covered individual dies
during treatment, both episode of care payments under
subparagraphs (A) and (B) shall be paid to the
radiation therapy provider or radiation therapy
supplier not later than 30 days after the day of the
final delivery of radiation therapy treatment to the
covered individual.
``(C) Consistency of payment.--
``(i) In general.--The per episode payment
amount shall not change depending on the site
of service.
``(ii) Site of service defined.--For the
purposes of this subparagraph, the term `site
of service' means the hospital outpatient
department or physician office in which
radiation therapy treatment is furnished by the
radiation therapy provider or radiation therapy
supplier.
``(3) Determination of per episode payment amount.--
``(A) In general.--The Secretary shall determine a
per episode payment amount for the professional
component and technical component of treatment for each
included cancer type.
``(B) Amount.--The Secretary shall determine the
per episode payment amount based on national base
rates, as described in subsection (d)(1) and as updated
in subsection (d)(2).
``(C) Adjustments.--The per episode payment amount
shall be subject to--
``(i) the adjustments as described in
subsection (d)(2) and (d)(3);
``(ii) a geographic adjustment, as
described in subsection (d)(3)(A);
``(iii) an inflation adjustment, pursuant
to which the Secretary shall adjust the per
episode payment amount by the percentage
increase in the Medicare Economic Index (as
described in section 1842 for the professional
component payments and the applicable
percentage increase in the Hospital Inpatient
Market Basket Update (as described in section
1886(b)(3)(B)(i)) for the technical component
payments during each 12-month period, and which
varies for the professional and technical
components of the service;
``(iv) a savings adjustment, as described
in subsection (d)(3)(B);
``(v) a health equity achievement in
radiation therapy adjustment applicable only to
the technical component payments, as described
in subsection (g); and
``(vi) a practice accreditation adjustment,
as described in subsection (h), that is only
applicable to technical component payments.
``(c) Treatment of Incomplete Episodes of Care; Concurrent
Treatment.--
``(1) Incomplete episode of care.--In the case of an
incomplete episode of care, payment shall be made to the
radiation therapy provider or radiation therapy supplier for
services furnished under the physician fee schedule under
section 1848 or the hospital outpatient prospective payment
system under section 1833(t), as applicable.
``(2) Multiple episodes of care for the same covered
individual.--A radiation therapy provider or radiation therapy
supplier may initiate a new episode of care for the same
beneficiary for the same course of therapy by providing another
radiation therapy treatment planning service and billing under
an applicable radiation therapy planning trigger code (as
defined in subsection (j).
``(3) Concurrent treatments.--In the case where a treatment
modality described in subsection (j)(3)(B)(i) is furnished to a
covered individual during an episode of care for an included
cancer type, payment may be made concurrently for the treatment
modality under the applicable payment system under this title
with per episode payment under this section for covered
treatment during the episode of care.
``(d) National Base Rate.--
``(1) Determination of national base rates.--For purposes
of the Secretary determining the per episode payment amount
under subsection (b)(3), the national base rates for the
professional component and technical component of radiation
therapy services for each included cancer type are based on the
M-Code national base rates identified in table 75 (including
HCPCS Codes for radiation therapy services and supplies) of the
Federal Register on November 16, 2021, 86 Fed. Reg. 63458,
63925.
``(2) Updates to the national base rates.--
``(A) Annual updates.--
``(i) In general.--Subject to clause (ii),
the Secretary shall annually update the initial
national base rates by--
``(I) in the case of the
professional component of the covered
treatment, the percentage increase in
the Medicare Economic Index; and
``(II) in the case of the technical
component of the covered treatment, the
applicable percentage increase
described in section 1886(b)(3)(B)(i).
``(ii) Payment floor.--For each annual
update, the Secretary shall not reduce the
national base rates below the established rates
from the prior year.
``(B) Periodic updates.--
``(i) In general.--The Secretary shall,
through notice and comment rulemaking, rebase
or revise the national base rates in 5-year
intervals, beginning on the day that is 5 years
after the date the regulations issued pursuant
to subsection (a)(1) become effective.
``(ii) Rebasing limit.--The Secretary shall
not reduce the national base rates through the
process of rebasing by more than 1 percent
every 5 years.
``(iii) Input from providers and
suppliers.--In rebasing or revising the
national base rates pursuant to clause (i), the
Secretary shall seek significant input from
radiation therapy providers, radiation therapy
suppliers, and other stakeholders.
``(C) Rebase and revise defined.--In this
subsection:
``(i) Rebase.--The term `rebase' means to
move the base year for the structure of costs
of the national base rates.
``(ii) Revise.--The term `revise' means
types of changes to national base rates other
than rebasing, such as using different data
sources, cost categories, or price proxies in
the national base rates input.
``(D) New technology or services.--
``(i) In general.--For purposes of this
subparagraph, the term `new technology or
services' means any technology or services
that, after the date of enactment of this
section, receives