Patients across rural and small-town America are driving longer distances for radiation therapy as local clinics shut their doors. Between 2014 and 2022, 382 rural hospitals stopped providing cancer treatment services, and nearly 90% of radiation oncologists now work in urban areas. A new bill moving through Congress proposes changing how these cancer treatments are paid for through Medicare – but could this actually halt the closures?
The Payment Crisis Driving Clinic Closures
Medicare payments for radiation oncology services have fallen 23% from 2013 to 2024 – one of the steepest declines among medical specialties. These cuts hit rural clinics particularly hard because they typically operate on thinner margins and serve fewer patients than their urban counterparts.
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‘I have seen patients left bewildered and searching for a new provider because their practice closed due to ever-declining payments,’ said Aaron Ambrad, MD, a radiation oncologist at Ironwood Cancer & Research Centers in Scottsdale and board member of the Community Oncology Alliance.
The combination of falling payments and rising costs creates an impossible equation for many community practices. Rural areas face additional challenges with lower patient volumes and limited resources , making it harder to absorb these financial pressures compared to larger urban systems.
How the Proposed Fix Would Work
The Radiation Oncology Case Rate programme would replace the current fee-for-service system with episode-based payments covering 15 common cancer types over 90-day treatment periods. Instead of being paid per radiation session, clinics would receive a bundled payment for the entire course of treatment.
The model includes several features designed to support rural access: site-neutral payments that equalise reimbursement regardless of location, annual inflation adjustments to protect against future cuts, bonus payments for practices that achieve accreditation standards, and additional payments to cover patient transportation costs in rural and underserved areas.
‘Under ROCR, I suspect we will see major growth in the accessibility of radiation services for patients,’ said Mark Thompson, MD, medical director of public policy at the Community Oncology Alliance.
Evidence and Remaining Concerns
The American Society for Radiation Oncology developed this payment model after analysing data from Medicare samples and large treatment centres . Their research suggests the programme could generate modest Medicare savings of approximately 3% while stabilising practice finances.
However, bundled payment models in oncology carry inherent risks. Studies of similar programmes raise concerns about potential under-treatment when providers bear financial risk for expensive cancer therapies. As digital platforms reshape how patients access treatment, rural providers face particular challenges with these models due to lower patient volumes and fewer resources for managing complex payment arrangements.
‘More than half of cancer patients will receive radiation therapy at some point in their treatment plan. It is a critical – but endangered – tool in our oncology toolbox,’ said Casey Chollet-Lipscomb, MD, chief medical officer at Tennessee Oncology and chair of the ASTRO Government Relations Council.
Political Support and Next Steps
The Radiation Oncology Case Rate Value Based Payment Program Act has drawn bipartisan support in both chambers of Congress. Representatives Brian Fitzpatrick (R-PA), John Joyce (R-PA), Jimmy Panetta (D-CA) and Paul Tonko (D-NY) introduced the House version, while Senators Thom Tillis (R-NC) and Gary Peters (D-MI) sponsored the Senate bill.
The legislation now awaits Congressional passage, though no timeline has been established for floor votes. Healthcare policy experts note that payment reform bills typically face lengthy review processes, particularly when they involve significant changes to Medicare reimbursement structures.
Stakes for Rural Cancer Care
The closure of rural oncology services creates ripple effects beyond inconvenience. Patients who must travel long distances for treatment face higher costs, disrupted work schedules and separation from family support systems during already challenging periods. This mirrors concerns about accessing alternative treatments that might help patients manage side effects during cancer care.
The proposed payment reform represents a test of whether policy changes can reverse the geographic concentration of speciality medical services. For the millions of Americans living outside major metropolitan areas, the outcome could determine whether cancer treatment remains accessible in their communities or becomes another service requiring long-distance travel.
Watch for Congressional action on H.R. 2120 and S. 1031 as lawmakers weigh the trade-offs between Medicare cost control and maintaining rural healthcare access.
