The radiation oncology landscape is on the brink of its most significant transformation in decades. The bipartisan Radiation Oncology Case Rate (ROCR) Value Based Payment Program Act of 2025, reintroduced in March by a coalition of senators and representatives, promises to revolutionize how Medicare reimburses radiation therapy services. For practices struggling with more than a decade of declining payments, this legislation represents both an opportunity and a challenge that demands immediate attention.
The Payment Crisis Driving Change
The numbers tell a stark story. Radiation oncology has suffered a devastating 23% reduction in Medicare payments over the past decade—one of the steepest cuts among all medical specialties. This decline has created a perfect storm of financial pressures that threaten the sustainability of radiation oncology practices across the country.
Recent studies reveal that these financial pressures have contributed to significant practice consolidation, with a 51% increase in large practices and 27% decrease in solo practices between 2015 and 2023. The current fee-for-service system has created perverse incentives that actually penalize practices for following evidence-based guidelines.
Consider the paradox: ASTRO analysis indicates that the use of guideline-supported shorter treatment regimens has already reduced hospital technical payments by about $1,500 per patient, with further drops forecasted as more practices adopt these clinical best practices. In essence, doing what’s best for patients—delivering more efficient, targeted treatments—has become financially punitive under the current system.
Understanding the ROCR Act: A Legislative Solution
The ROCR Act, sponsored by Senators Thom Tillis (R-NC) and Gary Peters (D-MI), along with Representatives Brian Fitzpatrick (R-PA), Jimmy Panetta (D-CA), John Joyce, MD (R-PA), and Paul Tonko (D-NY), would protect access to high quality cancer care and improve outcomes for patients nationwide, while generating savings for Medicare.
The legislation addresses the fundamental flaw in the current payment system. By shifting away from the current quantity-based, per-treatment system to patient-focused, episode-based payments, ROCR prioritizes the quality and value of care provided rather than the number of treatment visits.
Learning from Past Failures
ROCR builds on lessons learned from the indefinitely delayed Medicare Radiation Oncology Alternative Payment Model (RO Model), which offered changes but failed to adequately address stakeholders’ concerns. The new legislation takes a more pragmatic approach, incorporating the strengths of episode-based payments while eliminating the problematic elements that doomed the RO Model.
The bipartisan ROCR bill incorporates the RO Model’s strengths, namely the use of episode-based payments to support patient-centric care, while addressing shortcomings such as mandated cuts and burdensome reporting requirements.
Episode-Based Payments: A Fundamental Shift
The transition from fee-for-service to episode-based payments represents more than just an accounting change—it’s a complete reimagining of how radiation oncology care is valued and delivered.
How Episode-Based Payments Work
Under the episode-based model, providers are paid prospectively with a fixed lump sum for each 90-day episode of care and are at 100% financial risk for any additional expenditures. This stands in sharp contrast to the current system where practices are paid incrementally for each service provided.
The ROCR model covers the 15 most common cancer types treated with external beam or stereotactic radiation therapy. Professional services and technical services are paid separately under ROCR, with both PC and TC payments based on M Code rates that CMS established in the 2022 Medicare Physician Fee Schedule.
Payment Structure and Geographic Adjustments
The PC and TC base rates are based on radiation oncology payment data under the Hospital Outpatient Prospective Payment System (HOPPS) between 2017-2019 and trended forward to 2024. Importantly, ROCR case rate payments would be geographically adjusted depending on the location of the radiation oncology clinic, based on the Medicare Geographic Practice Cost Index and Wage Index.
What’s Excluded
Proton therapy treatment delivery codes are currently not valued under the Medicare Physician Fee Schedule, and payments for proton therapy services are determined regionally by each Medicare contractor and vary significantly. For this reason, along with brachytherapy and radiopharmaceuticals, these services remain outside the ROCR model and continue under fee-for-service arrangements.
Quality and Accreditation: The New Requirements
ROCR doesn’t just change payment—it elevates quality standards across the specialty. The legislation includes specific accreditation requirements designed to ensure that episode-based payments correlate with high-quality care delivery.
Accreditation Incentives and Penalties
ROCR provides a 1% update to the Technical Component payment for practices that either have accreditation or are actively working toward accreditation in the first three years. The qualifying programs include the ASTRO APEx Program, the ACR Radiation Oncology Accreditation Program, and ACRO Accreditation Program.
However, there’s also a stick alongside the carrot. After the first two years, the ROCR methodology applies a -2.5% reduction to the technical component payment for practices that are not accredited by one of the three accrediting bodies.
Support for Limited-Resource Practices
Recognizing that not all practices have the same resources, ROCR includes provisions for smaller or under-resourced facilities. Practices with limited resources, as defined by the Secretary, will receive a 0.25% increase to their technical payments if they complete an audit that demonstrates attainment of quality standards, and these same practices will not be penalized if they do not pursue an audit.
Addressing Health Equity Through ROCR
One of the most innovative aspects of ROCR is its focus on health equity. To address disparities, ROCR provides an evidence-based approach through the Health Equity Achievement in Radiation Therapy (HEART) initiative, providing transportation assistance payment for the underserved.
This provision recognizes that access to radiation therapy often depends on factors beyond clinical decision-making. Transportation barriers, particularly in rural and underserved communities, can significantly impact treatment completion rates and outcomes. The HEART initiative provides a mechanism to address these social determinants of health within the payment structure itself.
Implementation Timeline: What to Expect
Understanding the timeline is crucial for practice planning. With the March 2025 reintroduction, it is ASTRO’s goal to secure passage of the ROCR Act before the end of the year.
If successful, the implementation would follow this schedule:
- 2025: Congressional consideration and potential passage
- 2026: One-year planning period in which CMS will promulgate regulations related to implementation, during which time the radiation oncology code set will be frozen to ensure a smooth transition
- 2027: ROCR then will be effective one year after the enactment date, ideally in 2027
Financial Impact: What Practices Can Expect
The financial implications of ROCR vary significantly based on practice characteristics, case mix, and current efficiency levels. ASTRO has developed modeling tools to help practices assess their specific situation, but several general principles apply.
Benefits for Different Practice Types
For practices already following evidence-based guidelines and using efficient treatment protocols, ROCR should provide financial stability and potentially increased revenue. The elimination of financial penalties for hypofractionation means that practices can optimize treatment regimens based purely on clinical considerations.
Additionally, ROCR allows practices sufficient capital to maintain existing equipment and invest in new technology, increasing patient access to technological advancements allowing for more efficient, targeted, and personalized care.
Managing Financial Risk
The 100% financial risk model requires careful planning and risk management. Practices will need to develop sophisticated cost management systems and potentially consider risk-sharing arrangements or stop-loss insurance for catastrophic cases.
Technology and Innovation Under ROCR
The legislation includes forward-thinking provisions for emerging technologies. ASTRO recognizes that use of Adaptive Radiotherapy (ART) is growing, and ROCR includes language creating a transitional payment period for adaptive radiation therapy to ensure billing can continue until a new code is developed.
This approach demonstrates how ROCR attempts to balance payment predictability with innovation support—a critical consideration for a field that continues to evolve rapidly with new technologies and techniques.
Industry Support and Physician Perspectives
ROCR is broadly supported by more than 80 organizations representing a wide spectrum of radiation oncology stakeholders, including patient advocates, health professionals, small and large hospital systems, independent clinics and technology companies.
However, physician perspectives are more nuanced. A recent survey, which included more than 500 practicing radiation oncologists, found that 61% of respondents supported implementing an episode-based payment model such as that proposed in the 2025 legislation, 17.3% neither supported nor opposed it, and 21.6% opposed the model.
The concerns largely center on implementation details and the process by which the legislation was developed. Some physicians express concerns about transparency in the rollout and what they perceive as regulatory capture, where accreditation requirements essentially mandate business relationships with the sponsoring organizations.
Immediate Action Items for Practices
Given the potential 2027 implementation timeline, practices need to begin preparation immediately. Here are the critical first steps:
Accreditation Assessment
Evaluate your current accreditation status with ASTRO APEx, ACR, or ACRO programs. If not currently accredited, begin the process immediately, as it can take significant time to complete all requirements.
Financial Modeling
ASTRO provides a ROCR modeling tool for members to assess practice-specific financial impacts. Use this tool to understand how your current case mix and practice patterns would perform under the new payment model.
Quality Infrastructure Development
Assess your current quality measurement and improvement capabilities. ROCR’s success will depend on delivering high-quality, efficient care, which requires robust quality management systems.
Staff Education and Training
Begin educating your entire team about episode-based payments and what they mean for daily operations. This cultural shift requires buy-in from all staff members, from physicians to billing specialists.
Billing and Administrative Changes
As part of ROCR implementation, CMS will outline the claims submission process. It is likely that CMS will seek to monitor ROCR by requiring the submission of CPT codes, in addition to M codes, similar to what was planned under the RO Model.
This means practices will need to prepare for a hybrid billing approach during the transition and possibly beyond. Billing systems will need updates to handle M-code submissions while maintaining the granular tracking that CPT codes provide.
Risk Management Strategies
The 100% financial risk model requires sophisticated risk management approaches. Practices should consider:
- Patient Selection: Developing clear criteria for case complexity and resource requirements
- Care Coordination: Strengthening multidisciplinary coordination to prevent complications and inefficiencies
- Technology Investment: Aligning equipment purchases with efficiency and outcome improvements
- Quality Programs: Investing in programs that reduce complications, readmissions, and unnecessary resource utilization
The Broader Healthcare Context
ROCR represents part of a broader shift toward value-based care across healthcare. The lessons learned from other episode-based payment models, such as those in orthopedics and cardiology, suggest that success requires significant operational changes and cultural adaptation.
As Congressman Fitzpatrick noted, “The ROCR Act modernizes Medicare to ensure radiation therapy remains accessible, innovative, and patient-centered, especially for those in our most vulnerable communities”.
Looking Ahead: The Future of Radiation Oncology
The ROCR Act represents more than just a payment reform—it’s an opportunity to align financial incentives with clinical excellence and patient outcomes. As ASTRO Board Chair Dr. Howard Sandler stated, “The ROCR Act represents a balanced, evidence-based policy solution to safeguard access to high value cancer treatment for Americans, and it is the only viable policy solution designed to provide payment stability for the field of radiation oncology in 2026 and beyond”.
For practices willing to embrace this change, ROCR offers the potential for financial stability, clinical optimization, and improved patient outcomes. However, success will require thoughtful preparation, strategic planning, and a commitment to quality improvement.
The time to begin preparation is now. The radiation oncology community has an opportunity to shape its future through this legislation, but only if practices take proactive steps to understand, prepare for, and ultimately succeed under the new payment model.
Conclusion
The ROCR Act 2025 represents a pivotal moment for radiation oncology. After more than a decade of declining payments and increasing financial pressures, the specialty has an opportunity to establish a sustainable, value-based payment system that aligns financial incentives with clinical excellence.
Success under ROCR will require significant preparation and adaptation. Practices must begin now to assess their accreditation status, model financial impacts, develop quality infrastructure, and prepare their teams for a fundamentally different approach to care delivery and payment.
The stakes are high, but so is the potential reward. For practices that prepare well and execute effectively, ROCR offers the promise of financial stability, clinical optimization, and the ability to focus on what matters most: delivering high-quality care to cancer patients when they need it most.
The revolution in radiation oncology payment is coming. The question is not whether practices will be affected, but whether they will be prepared to thrive in this new environment. The time to start that preparation is now.
Sources
- American Society for Radiation Oncology (ASTRO). “ROCR Act 2025: Congress takes step toward patient-centered, value-based cancer care with bipartisan plan.” March 14, 2025. https://www.astro.org/news-and-publications/news-and-media-center/news-releases/2025/rocr-act-2025-press-release
- American Society for Radiation Oncology (ASTRO). “Advocacy Radiation Oncology Case Rate Program.” https://www.astro.org/advocacy/key-issues-8f3e5a3b76643265ee93287d79c4fc40/rocr
- Tillis, Thom, and Gary Peters. “Tillis, Peters Introduce Bill to Safeguard Access to High Quality Cancer Care.” March 14, 2025. https://www.tillis.senate.gov/2025/3/tillis-peters-introduce-bill-to-safeguard-access-to-high-quality-cancer-care
- Medscape Medical News. “Radiation Oncology Reimbursement: New Bill Rocks the Boat.” April 14, 2025. https://www.medscape.com/viewarticle/radiation-oncology-reimbursement-new-bill-rocks-boat-2025a10008va
- American Bar Association Health Law Section. “The ROCR Act Continues to Gain Steam.” May 2025. https://www.americanbar.org/groups/health_law/news/2025/5/rocr-act-continues-gain-steam/
- Fitzpatrick, Brian, et al. “Fitzpatrick, Panetta, Joyce, Tonko Lead Bipartisan Effort to Protect Patient Access to High Quality Cancer Treatments.” March 28, 2025. https://fitzpatrick.house.gov/2025/3/fitzpatrick-panetta-joyce-tonko-lead-bipartisan-effort-to-protect-patient-access-to-high-quality-cancer-treatments
- Centers for Medicare & Medicaid Services. “Radiation Oncology (RO) Model Fact Sheet.” https://www.cms.gov/newsroom/fact-sheets/radiation-oncology-ro-model-fact-sheet
- American Society for Radiation Oncology (ASTRO). “Advocacy Radiation Oncology Case Rate Program FAQs.” https://www.astro.org/advocacy/key-issues-8f3e5a3b76643265ee93287d79c4fc40/rocr/rocr-faqs
- American Society for Radiation Oncology (ASTRO). “Radiation Oncology Reimbursement Could Face Major Changes in 2026.” ASTROblog, February 25, 2025. https://www.astro.org/blog/february-2025/radiation-oncology-reimbursement-could-face-major-changes-in-2026
- Yashar, Catheryn M., et al. “ROCR: Modernizing Radiation Oncology Payment to Embrace Innovation and Better Care.” Seminars in Radiation Oncology, September 11, 2024. https://www.sciencedirect.com/science/article/abs/pii/S1053429624000535
- Cureus Journal of Medical Science. “General Consensus on Implementing an Episode-Based Payment Model: Results From the American College of Radiation Oncology (ACRO) Payment Reform Survey.” April 1, 2025. https://www.cureus.com/articles/335390-general-consensus-on-implementing-an-episode-based-payment-model-results-from-the-american-college-of-radiation-oncology-acro-payment-reform-survey
- Congress.gov. “S.1031 – 119th Congress (2025-2026): ROCR Value Based Program Act.” https://www.congress.gov/bill/119th-congress/senate-bill/1031