ASTRO panel session on US rad onc labor market

[Krukenberg]

Just wanted to give a heads up to anyone at ASTRO this week. Tomorrow (Monday) at 10:45-12:15pm Dr. Zietman will be moderating a panel session on the rad onc labor market. More details here:
Future of the US Radiation Oncology Labor Market.

---

Members don't see this ad.

 

[Gfunk6]

I am very glad to hear that this is being presented in a public forum. However, after reading the description, I am afraid that they will essentially be "rubber stamping" unbridled residency expansion.

If anyone is attending and could provide a brief summary here, that would be great.

 

[xrthopeful]

very interesting.

 

[thesauce]

I am very glad to hear that this is being presented in a public forum. However, after reading the description, I am afraid that they will essentially be "rubber stamping" unbridled residency expansion.

If anyone is attending and could provide a brief summary here, that would be great.

What makes you say that? I don't get that impression based on the descriptions. One talk specifically speaks about the rapid expansion of programs. Another is comparing it to DR which is probably going to conclude "we need to be careful."

Anyone who goes: please report back

 

[medgator]

What makes you say that? I don't get that impression based on the descriptions. One talk specifically speaks about the rapid expansion of programs. Another is comparing it to DR which is probably going to conclude "we need to be careful."

Anyone who goes: please report back

Agreed. I'm glad this is finally getting some session time at astro. There must be enough waves being made to warrant this

 

[xrthopeful]

'Dr. Benjamin Smith will then present information on the current state of the labor market, including data on the geographic distribution of radiation oncologists, unemployment and untapped capacity. Dr. Smith will also discuss his 2010 JCO paper, which projected a massive under-supply of radiation oncologists, and ideally include some updates and/or a preliminary analysis of whether those projections are coming to fruition'

There's that

 

[Krukenberg]

Agreed. I'm glad this is finally getting some session time at astro. There must be enough waves being made to warrant this

Are the waves primarily coming from this forum, or are residents vocally stating their concerns to senior leaders in their departments?

 

[medgator]

Are the waves primarily coming from this forum, or are residents vocally stating their concerns to senior leaders in their departments?

There was that red journal op-ed... http://forums.studentdoctor.net/threads/bloodbath-in-red-journal.1014614/

 

[BobbyHeenan]

I commend ASTRO for finally presenting a panel like this. It is a step forward.

Would love to see this as a yearly thing. I think it would also be beneficial to have someone from the private sector (like a rep from a large private practice group or something) give some input, because I would think he/she has a finger on the pulse in a way that may be different (or possibly more accurate) than that of these academic leaders.

Please someone that attends let us know how it goes, it will be interesting to hear.

 

[Krukenberg]

This was a fantastic panel session and the room was standing room only. Overall, the conclusion of each panel member's talks supported the fears that people on this forum have had.

The first speaker focused on workforce demand and supply, and how payment reform would affect them. He said that if there is a growth in demand for radiation services, it could be met by improvements in workflow and that would be a better solution than just increasing the supply of rad oncs. His greatest fear was actually of the new payment models that Medicare is about to start. Med oncs will receive financial incentives to reduce GLOBAL onc spending, which he thinks could significantly reduce the demand for radiation treatment (as well as imaging and any other services requiring referral). He said that rad oncs need to get a seat at that table to protect autonomy and business.

The second speaker talked about projections for radiation supply and demand. He published a paper back in 2010ish that projected an increase in demand. His updated projection of the increase in demand is about 10% less than what he projected in 2010. If I recall correctly his demand projections are primarily based on population changes and do not take into account any possible reimbursement changes.

The next speaker talked about what organizations, if any, are controlling the "spigot" of rad oncs. The answer is none.

The last speaker was a diagnostic radiologist in charge of workforce projections for ACR. He said that the result of the tight radiology job market is a drastic decrease in quality medical students entering the field. 28% of programs had unfolded spots, and of students who matched in radiology, only about 50% were US grads. He said the job market is now beginning to improve, but the damage to the quality of applicants has been done.

There were many questions, and it seems that all of them had big concerns. Two private practice docs from the Midwest stated that there is too much emphasis on training academic doctors because they can't fill their openings.

I think the only positive outlook was Dr. Zietman's, as he thought that one thing going for the field is the possibility that the current wave of exceptional quality medical students will innovate new business for the specialty.

 

[BobbyHeenan]

This was a fantastic panel session and the room was standing room only. Overall, the conclusion of each panel member's talks supported the fears that people on this forum have had.

The first speaker focused on workforce demand and supply, and how payment reform would affect them. He said that if there is a growth in demand for radiation services, it could be met by improvements in workflow and that would be a better solution than just increasing the supply of rad oncs. His greatest fear was actually of the new payment models that Medicare is about to start. Med oncs will receive financial incentives to reduce GLOBAL onc spending, which he thinks could significantly reduce the demand for radiation treatment (as well as imaging and any other services requiring referral). He said that rad oncs need to get a seat at that table to protect autonomy and business.

The second speaker talked about projections for radiation supply and demand. He published a paper back in 2010ish that projected an increase in demand. His updated projection of the increase in demand is about 10% less than what he projected in 2010. If I recall correctly his demand projections are primarily based on population changes and do not take into account any possible reimbursement changes.

The next speaker talked about what organizations, if any, are controlling the "spigot" of rad oncs. The answer is nonr

Thanks for the update.

Many on this forum (including myself) were very skeptical of the projections from that JCO article. Things like breast hypofractionation, usage of mid level providers to help with clinic work flow, and pressures about reimbursement changes were not taken into account and this was cited as a major flaw.

I think that Chirag Shah, the original author of the red journal article that started (or at least propelled) this concern, deserves a big thank you. Kudos to ASTRO/Red Journal for publishing and moving this forward and at least getting the ball rolling on something.

I would love to see a 24 month freeze on expansion of residency spots to allow ASTRO to put a task force together with administrators, rad oncs (BOTH private and academic), and residency directors to study this before we continue expanding.

 

[Gfunk6]

The next speaker talked about what organizations, if any, are controlling the "spigot" of rad oncs. The answer is none.

This is really the bottom line. We can mentally masturbate and pontificate all day on this subject but residency programs will continue to expand unchecked. ASTRO members will then be invited to another specialty's national conference to do a post-mortem on how they can avoid what happened to Rad Onc.

I think the only positive outlook was Dr. Zietman's, as he thought that one thing going for the field is the possibility that the current wave of exceptional quality medical students will innovate new business for the specialty.

Dangerous thinking. People are only looking out for themselves - it's natural. Look at what happened in anesthesiology - corporate owned mega groups are taking over which reduces physician pay and autonomy.

 

[Krukenberg]

One thing I forgot. One of the panel members, as his last comment, said that he believed some programs were expanding/opening for the wrong reasons, mainly just prestige.

 

[thesauce]

The next speaker talked about what organizations, if any, are controlling the "spigot" of rad oncs. The answer is none.

This is really the bottom line. We can mentally masturbate and pontificate all day on this subject but residency programs will continue to expand unchecked. ASTRO members will then be invited to another specialty's national conference to do a post-mortem on how they can avoid what happened to Rad Onc.

Agreed, Gfunk. Was there any discussion about how to proceed with CREATING an organization to control this "spigot?"

 

[RadOncDoc21]

GLOBAL onc spending decided by the Med Onc... sounds legit...

 

[medgator]

GLOBAL onc spending decided by the Med Onc... sounds legit...

What happens to those of us who see patients first?

The elephant in the room is that rad onc isn't the driver of onc spending, it's inpatient hospitalizations and targeted chemo/immunotherapy. $ for $, photons are as cost-efficient of a cancer curer/palliator as you can get.

 

[BobbyHeenan]

GLOBAL onc spending decided by the Med Onc... sounds legit...

The way that it has been described to me as well by a few high ups in oncology administration is that the "ultimate plan" for onc spending to even impact PCP or the beginning of the referral chain. Somehow there are plans to tie reimbursement cuts (potentially up to like 4-6%) back to punish referring docs for referring to groups that consistently spend more to treat X type of cancer than others in the area.

I'm sure this was biased, but my hospital administrator stated that on average, private practice med onc groups spend more (and use more chemo) than those of employed (or academic) med onc groups, so one way medicare is further pinching their bottom line is to start cutting reimbursement all the way back to the provider that referred the patients into that particular med onc group.

Take this all with a grain of salt. I have not personally verified this narrative, however.

 

[BobbyHeenan]

One thing I forgot. One of the panel members, as his last comment, said that he believed some programs were expanding/opening for the wrong reasons, mainly just prestige.

This was beaten to death on this board before, but like Gfunk says until something is done it's absolutely laughable that the metric of supply/demand is NOT EVEN ACCOUNTED FOR in determining who can expand.

If your department is busy and you have the numbers and the training is good, then you pretty much can expand. With academic hospitals buying up all kinds of local/regional centers of course their volume is going up.

 

[BobbyHeenan]

Was there discussion about rural openings? They love to cite that there are tons of jobs in the middle of nowhere with "no one to fill them."

My experience with these rural positions is that unless they're paying really well, it's going to be hard to fill them. Especially when you consider everyone coming down on using a med onc or NP to cover the linac...it's very hard to recruit a full time rad onc to cover a 15 patient/day linac in rural whereever unless you're paying well above the professional billing.

 

[RadOncDoc21]

The way that it has been described to me as well by a few high ups in oncology administration is that the "ultimate plan" for onc spending to even impact PCP or the beginning of the referral chain. Somehow there are plans to tie reimbursement cuts (potentially up to like 4-6%) back to punish referring docs for referring to groups that consistently spend more to treat X type of cancer than others in the area.

I'm sure this was biased, but my hospital administrator stated that on average, private practice med onc groups spend more (and use more chemo) than those of employed (or academic) med onc groups, so one way medicare is further pinching their bottom line is to start cutting reimbursement all the way back to the provider that referred the patients into that particular med onc group.

Take this all with a grain of salt. I have not personally verified this narrative, however.

Man, how did it all get to this level?

I work in a private group and we don't do anything differently then the academic department I was recently at, except we cut through all the BS like this. I'm not yet that experienced in the field, but to me it seems that hospitals are trying to gain on the competition and this is their angle. If there is going to be a "bundle or Global onc package" or whatever they want to call it, its just going to mean more go to the sharks upstream.

 

[BobbyHeenan]

Man, how did it all get to this level?

I work in a private group and we don't do anything differently then the academic department I was recently at, except we cut through all the BS like this. I'm not yet that experienced in the field, but to me it seems that hospitals are trying to gain on the competition and this is their angle. If there is going to be a "bundle or Global onc package" or whatever they want to call it, its just going to mean more go to the sharks upstream.

Again, I'm no expert on this but since I've been out in practice for a couple of years I've tried to self educate and keep a finger on the pulse of these things...

The way it was described to me (again, from a hospital administrator surely very biased against private groups) was that medicare was paying out much more for med onc/chemo services - things like amount of chemo used, admissions, etc were higher for the private groups in our area (though he did say this was a trend nationally). He said he wasn't as educated about radiation costs, so he didn't comment on that - just that chemo and med onc billing was lower for non-private groups.

 

[napoleondynamite]

One problem is that cheaper is not always better in radiation oncology. I have worked in a market where linacs that were >20 years old were being utilized. True, they do the job. But lack the conformality, imaging etc of a modern linac. At the end of the day, if we believe that our technological changes in the last 20 years have been important, than likely these deficiencies with older technologies are clinically relevant.

Conversely, we all know that more expensive is not necessarily better either..see protons for prostate cancer.

Finding balance in there is difficult when it comes to the paper pushers making health policy decisions. But it is often not physicians making these decisions. Just last week I did a doc-to-doc to appeal an SBRT approval with an insurance company - the doc on the other end of the phone was an emergency room physician with no idea what SBRT even is..that is the kind of world we are headed into - one where decisions are made on paper based purely on the numbers and by people who are not adequately trained to make health care decisions.

 

[RadOncDoc21]

Again, I'm no expert on this but since I've been out in practice for a couple of years I've tried to self educate and keep a finger on the pulse of these things...

The way it was described to me (again, from a hospital administrator surely very biased against private groups) was that medicare was paying out much more for med onc/chemo services - things like amount of chemo used, admissions, etc were higher for the private groups in our area (though he did say this was a trend nationally). He said he wasn't as educated about radiation costs, so he didn't comment on that - just that chemo and med onc billing was lower for non-private groups.

I understand and definitely appreciate the feedback. As you can probably tell, I'm not a fan of bean counters and bureaucracy and the limitations placed on physicians as a whole.

Thanks again for reporting back and keeping me up to date!

 

[hockyfan]

Was there discussion about rural openings? They love to cite that there are tons of jobs in the middle of nowhere with "no one to fill them."

My experience with these rural positions is that unless they're paying really well, it's going to be hard to fill them. Especially when you consider everyone coming down on using a med onc or NP to cover the linac...it's very hard to recruit a full time rad onc to cover a 15 patient/day linac in rural whereever unless you're paying well above the professional billing.

Yes - one physician practicing in a "rural area" mentioned tremendous difficulty filling open positions for years - with the caveat that despite conventional thinking, the pay in that area is not all that high - or certainly not high enough - and may potentially influence the lack of interest. In response, one of the panelists added that filling rural spots would help the current job situation, but there would be high costs - literally - to acquire greater interest in these positions. Also mentioned was increased academia and residency spots in the rural areas rather than on the coasts, but of course, the problem is that the coastal areas have the largest amount of funding...

 

[BobbyHeenan]

Yes - one physician practicing in a "rural area" mentioned tremendous difficulty filling open positions for years - with the caveat that despite conventional thinking, the pay in that area is not all that high - or certainly not high enough - and may potentially influence the lack of interest. In response, one of the panelists added that filling rural spots would help the current job situation, but there would be high costs - literally - to acquire greater interest in these positions. Also mentioned was increased academia and residency spots in the rural areas rather than on the coasts, but of course, the problem is that the coastal areas have the largest amount of funding...

The issue for a few rural positions in different parts of the country had a similar "feel" to them, but not true of all. The story often goes something like this...

Single linac treating ~16-20 patients per day in the middle of no where. At 16 patients a day an efficient rad onc is going to have a lot of down time and the professional fees will not pay a salary that is at MGMA average. Hospitals aren't enthusiastic about paying well above professional billing to employ a rad onc, because margins are already a little tight treating that number of patients. Plus, there is some pressure from the bean counters about hospitals paying well above "fair market value" for physician coverage. We can argue about what is fair market value for say somewhere like Rhinelander, Wisconsin, but suffice it to say that hospitals and doctors find that number different.

One solution some have done many years ago was to only staff the clinic with an in house rad onc ~3 days/week and use a mid level or med onc on the other days. However, with new rules this is really frowned upon, some say even illegal (see prior threads on this)....

So - good luck staffing your single linac center with a rad onc that potentially will make less than MGMA average in a rural location. As Dr. Shah mentioned in his red journal article/response, to fix this access to care/maldistribution issue in rad onc you're going to have to provide financial incentives to fill these positions. The solution is not simply graduate more residents and saturate the whole job market so badly that someone will jump at the chance for ANY job.

 

[medgator]

The really "rural" CAHs (critical access hospitals) can get an exemption from Medicare for the physician supervision requirement.

I'm not sure how CAHs are defined though

 

[BobbyHeenan]

The really "rural" CAHs (critical access hospitals) can get an exemption from Medicare for the physician supervision requirement.

I'm not sure how CAHs are defined though

The clinics I've looked into never met the CAH requirement. When I found the list of hospitals/clinics that met it, they were indeed REALLY rural...as I recall only one or two out of dozens was large enough to even have a linac. I too don't know how they're defined, but the hospitals I was familiar with that met CAH designation were VERY rural, had very few hospital beds, no ICU, etc and certainly no cancer center/linac.

Plus, my administrator says the CAH exemption for radiation oncology is going away in 2016. I haven't verified that, but that's what we were told.

 

[napoleondynamite]

Anyone have a link for the actual Medicare Supervision Requirement guideline? I was not aware that there is now a requirement..I had read ASTRO's guideline, but not aware of anything official from CMS?

The only guidelines I am aware of state that a physician must be in the clinic, but it does not specifically state a radiation oncologist..

Just wondering if that has changed since 2011 and if so if someone can point me to the actual source for that? I'm not finding anything on the old Google.

 

[BobbyHeenan]

Anyone have a link for the actual Medicare Supervision Requirement guideline? I was not aware that there is now a requirement..I had read ASTRO's guideline, but not aware of anything official from CMS?

There is nothing much new with CMS requirement - they still require a radiation oncologist or "non-physician" practitioner.

CMS defers to hospital credentialing bodies to determine what is appropriately trained non-physician practitioner. The CMS language is below. However, do note that there has been a HUGE increase in the number of whistleblower cases brought up in the last 24 months where rad onc groups had to pay back millions for lack of supervision. In addition, I was told by my biller that an ASTRO rep at a recent billing conferences heavily implied some sort of statement regarding supervision will be issued by ASTRO soon, helping to clarify the issue; off-the-record discussion is leaning toward eliminating any gray area - ie ASTRO is likely supporting a clear cut solution that a rad onc must be physically present for all treatments.



=====CMS=====

"In the CY 2010 OPPS/ASC final rule with comment period, we finalized our proposal to allow, in addition to clinical psychologists, certain other nonphysician practitioners to directly supervise services that they may perform themselves under their State license and scope of practice and hospital-granted or CAH-granted privileges. The nonphysician practitioners that were permitted to provide direct supervision of therapeutic services under the CY 2010 OPPS/ASC final rule with comment period are physician assistants, nurse practitioners, clinical nurse specialists, certified nursemidwives, and licensed clinical social workers. These nonphysician practitioners may directly supervise outpatient therapeutic services that they may personally furnish in accordance with State law and all additional requirements, including the Medicare coverage rules relating to their services specified in our regulations at 42 CFR 410.71, 410.73, 410.74, 410.75, 410.76, and 410.77 (for example, requirements for collaboration with, or GENERAL supervision by, a physician)."

"In the CY 2010 OPPS/ASC final rule with comment period, we also finalized our proposal to add paragraph (a)(1)(iv)(B) to §410.27. This paragraph updated our previous regulation at §410.27(f) to reflect that, for off-campus PBDs of hospitals, the physician or nonphysician practitioner must be present in the off-campus PBD, as defined in §413.65, and immediately available to furnish assistance and direction throughout the performance of the procedure. It does not mean that the physician or nonphysician practitioner must be in the room when the procedure is performed. In addition, we finalized the proposed technical change to clarify the language in §410.27(f) by removing the phrase “present and on the premises of the location” and replacing it with the phrase “present in the off-campus provider-based department.”

http://www.wsha.org/files/83/Physician_Supervision_Proposed_Rule.pdf
Page 407-409

========

Here is also an excellent journal article about recent whistleblower/supervision cases and issues.

http://www.appliedradiationoncology...act-allegations-against-radiation-oncologists

 

[medgator]

Anyone have a link for the actual Medicare Supervision Requirement guideline? I was not aware that there is now a requirement..I had read ASTRO's guideline, but not aware of anything official from CMS?

The only guidelines I am aware of state that a physician must be in the clinic, but it does not specifically state a radiation oncologist..

Just wondering if that has changed since 2011 and if so if someone can point me to the actual source for that? I'm not finding anything on the old Google.

I think the ASTRO white paper cites the medicare guidelines which indicates the said physician must be available to "furnish assistance" with the procedure. Only rad oncs have IGRT training.

 

[RadOncDoc21]

I'm still confused. I understand that some docs took advantage by never being present at a specific site and billing for everything but what if I have to go to a Tumor Board that's across the street or at another facility? Can I have one of my Med Oncs "cover" the linacs, no special procedures?

 

[BobbyHeenan]

I'm still confused. I understand that some docs took advantage by never being present at a specific site and billing for everything but what if I have to go to a Tumor Board that's across the street or at another facility? Can I have one of my Med Oncs "cover" the linacs, no special procedures?

This is a bit of a grey area.

I think across the street is fine. For IGRT you could leave the conference, walk, and assist with IGRT if need be. You need to be able to "immediately assist" with the procedure - and in our world that procedure is really image guidance.

Off campus at another facility is a different ball game:

Safest answer: no, machines need to stop.

Alternative answer: no image guidance during time you're gone; otherwise, machines can run with med onc coverage.

Riskiest answer: beam on with med onc coverage. There is a written policy that the hospital has signed outlining that this is an appropriate thing to do. It's discussed in that link above from the journal article, but it's clear that CMS wants some sort of hospital credentialing process for these grey areas if you're going to risk it.

 

[RadOncDoc21]

This is a bit of a grey area.

I think across the street is fine. For IGRT you could leave the conference, walk, and assist with IGRT if need be. You need to be able to "immediately assist" with the procedure - and in our world that procedure is really image guidance.

Off campus at another facility is a different ball game:

Safest answer: no, machines need to stop.

Alternative answer: no image guidance during time you're gone; otherwise, machines can run with med onc coverage.

Riskiest answer: beam on with med onc coverage. There is a written policy that the hospital has signed outlining that this is an appropriate thing to do. It's discussed in that link above from the journal article, but it's clear that CMS wants some sort of hospital credentialing process for these grey areas if you're going to risk it.

To be honest, I trust my team (dosimetrists, therapists) over my Med Oncs in regards to verifying films and patient set up. I thought it was an issue in regards to patient safety (health issues) that occur if I wasn't available at that time. I understand how the use of SBRT and even cone beam CT can be an issue but I'm talking about bread and butter daily treatments, with port films I can review later.

I understand you don't know all the details and that this is still a work in progress. Just trying to understand so I can avoid future conflicts.

 

[napoleondynamite]

yeah - I agree it's a grey area. some of the chatter above made it seem that it's not a grey area..that's it's actually illegal or violating clear CMS policy, like some new policy had been issued which has changed practice. At least, that was my interpretation of what was being said, I could be wrong.

The white paper cited above has pretty egregious cases that were whistleblown and all were appropriate. Clearly, you shouldn't be on vacation with no physician whatosoever in the building and checking CBCT's using GoToMyPC software while you're sipping maitais on the beach. Clearly a radonc should be present and directly involved with SBRT, brachy procedures and simulations.

But I do not know of a policy which stipulates against physician supervision of bread and butter treatments. Most of us check IGRT films at the end of the day if we're being honest. It is the rare radonc that is going to the machine before every single treatment. We train our therapists and adjust when needed. So if you're working at freestanding center and you want to attend tumor board - even if it is all the way across town - I don't see that you are doing anything egregious or wrong if you have another physician who is on-site (med onc or whatever).

 

[BobbyHeenan]

yeah - I agree it's a grey area. some of the chatter above made it seem that it's not a grey area..that's it's actually illegal or violating clear CMS policy, like some new policy had been issued which has changed practice. At least, that was my interpretation of what was being said, I could be wrong.

The white paper cited above has pretty egregious cases that were whistleblown and all were appropriate. Clearly, you shouldn't be on vacation with no physician whatosoever in the building and checking CBCT's using GoToMyPC software while you're sipping maitais on the beach. Clearly a radonc should be present and directly involved with SBRT, brachy procedures and simulations.

But I do not know of a policy which stipulates against physician supervision of bread and butter treatments. Most of us check IGRT films at the end of the day if we're being honest. It is the rare radonc that is going to the machine before every single treatment. We train our therapists and adjust when needed. So if you're working at freestanding center and you want to attend tumor board - even if it is all the way across town - I don't see that you are doing anything egregious or wrong if you have another physician who is on-site (med onc or whatever).

I think that is a very reasonable approach. The language for CBCT is "immediate supervision," however CMS does not define what that means. In the rad onc world it's not unreasonable to think "immediate" means prior to the next fraction.

Our group has presented such an approach to our hospital administrators for when we go across the street for a conference, etc. But our administrators felt this new run of whistleblowers was scary enough to institute a policy of no rad onc, no treat. Like was mentioned on another thread...somewhere in your department someone is disgruntled enough to blow the whistle - especially with new financial incentives for collections going back to whistleblowers. Even if you "win" your case, no one wins when that happens.

I still think it's overkill and if I had enough say I would do the option of no CBCT during my absence, med/onc or NP to cover emergencies of patient care in clinic, and treat simple bread/butter patients during my absence.

=====

Back to this original thread and the rural recruitment problem....leaving the linac to go to tumor board for an hour IMO is different than some potential "gray area" solutions for covering a clinic with a mid level or med onc for days at a time. I do foresee a clarification on this gray area in the next year or so, and if it's going to be cut-and-dry that a rad onc must be physically present in the building 100% of the time, then I think these rural clinics are going to shut down unless hospitals figure out a way to pay a rad onc a big salary for living in the middle of nowhere staffing a clinic with low/moderate volume.

 

[RadOncDoc21]

This is a very interesting discussion. I know of surgical centers that had PA's, Nurses, etc. performing low-level procedures while the surgeon was either at another hospital or attending multiple cases. I feel like this would require more supervision versus a standard daily fraction that has been QA'd and verified.

 

[BobbyHeenan]

This is a very interesting discussion. I know of surgical centers that had PA's, Nurses, etc. performing low-level procedures while the surgeon was either at another hospital or attending multiple cases. I feel like this would require more supervision versus a standard daily fraction that has been QA'd and verified.

Completely agree.

Not to mention the leeway they give mid levels for inpatient management.

In my opinion it's all about money and billing. Our administrators have admitted as much when they think it's OK for hospital policy that an NP adjusting an ICU patient's vent settings is fine, but a NP babysitting a linac while the doc goes across the road to tumor board is not.

They percieve the financial/legal risks of a whistle blower to be so scary that the latter is not an option. Part of the disconnect is that administrators and even doctors have ZERO CLUE what a rad onc does. They perceive daily radiation as essentially a surgery, so it's hard for them to image some therapist "doing a procedure" while we're not in the building.

 

[medgator]

There are recent "whistleblower" qui tam cases where lack of rad onc physician presence was cited while treating Medicare/Medicaid/tricare patients with imrt/igrt.

If you're in a freestanding center, the requirement is more stringent than in a hospital and I'd be less likely to give myself the benefit of a doubt

 

[napoleondynamite]

There are recent "whistleblower" qui tam cases where lack of rad onc physician presence was cited while treating Medicare/Medicaid/tricare patients with imrt/igrt.

If you're in a freestanding center, the requirement is more stringent than in a hospital and I'd be less likely to give myself the benefit of a doubt

yikes, really? I haven't heard of any cases that didn't involve gross negligence and clear shisterism in terms of radoncs leaving clinics completely unsupervised with no physician coverage or leaving for days at a time.

Where are these requirements listed that are more stringent for freestanding centers? I just haven't seen them or been able to find anything specific.

 

[medgator]

yikes, really? I haven't heard of any cases that didn't involve gross negligence and clear shisterism in terms of radoncs leaving clinics completely unsupervised with no physician coverage or leaving for days at a time.

Where are these requirements listed that are more stringent for freestanding centers? I just haven't seen them or been able to find anything specific.

https://www.astro.org/Practice-Management/Reimbursement/Medicare/Supervision.aspx

"Direct personal supervision" required in freestanding centers

 

[napoleondynamite]

Yes, ASTRO feels that way..mostly because ASTRO is run by academics who work for large hospital systems.

I'm not trying to be nitpicky here, but rather to clarify what the CMS policy is, not ASTRO's view.

The CMS policy from 2011 stated that to meet direct supervision that "a physician" or even "a nonphysician practitioner" must be present on the same hospital campus and immediately available to furnish assistance and direction throughout treatment.

ASTRO's interpretation of that, as you point out:

"It is ASTRO’s view that the Radiation Oncologist is always considered a clinically
appropriate physician but there may be others who meet these requirements."

 

[medgator]

Yes, ASTRO feels that way..mostly because ASTRO is run by academics who work for large hospital systems.

I'm not trying to be nitpicky here, but rather to clarify what the CMS policy is, not ASTRO's view.

The CMS policy from 2011 stated that to meet direct supervision that "a physician" or even "a nonphysician practitioner" must be present on the same hospital campus and immediately available to furnish assistance and direction throughout treatment.

ASTRO's interpretation of that, as you point out:

"It is ASTRO’s view that the Radiation Oncologist is always considered a clinically
appropriate physician but there may be others who meet these requirements."

As a pp in a freestanding center, I'm going to interpret rules very conservatively. You might have more leeway in a hospital-based setting, but then again....

http://www.rightinginjustice.com/ne...ospital-network-recovers-5-4-million-for-u-s/

http://www.businessinsurance.com/article/20130916/NEWS07/130919865

http://www.dallasnews.com/news/comm...over-allegations-of-false-medicare-claims.ece

As Warren Buffett once said, "It takes 20 years to build a reputation and 5 mins to destroy it. When you realize that, you'll start acting differently"

 

[napoleondynamite]

Again, all 3 of those cases had much more egregious fraud. In the Baylor case, SRS was being performed without any physician present and then Texas Oncology was double billing for the treatments - I think we can all agree that this is a completely different set of circumstances than what we are talking about. The other two cases involved either outright fraudulent billing or zero physician oversight..that is also quite different than stating that a radonc must be physically present for each and every treatment.

On a personal level, I agree that staying as far away from the line and acting conservatively is always prudent.

But on a political level, we shouldn't embrace and propogate this policy in the field. It's pretty stupid. With the provider shortage in rural areas, we need to stand up for the solo radonc who practices in these places. If they have to miss a few treatments to attend tumor board or see an emergent patient in the hospital, that is reasonable IMO and should be allowable. We have to allow these things to be somewhat regulated at the local level.

 

[DukeNukem]

I was there and I came away with this analysis.

1. Supply of radiation oncologists has grown rapidly, outpacing predictions by Dr. Smith's JCO paper.

2. Demand for radiation oncology services has been flat. Despite an aging population and more cancer, there is decreasing rad onc services utilization that balances that out.

3. Ben Smith had predicted a rise in demand starting in 2010 with his paper. It never happened. He projects that demand will start to rise in 2015. It looked to me like the demand growth on his chart was just shifted on the x-axis to the right 5 years.

4. If there was an undersupply, we could improve efficiency with improvements in EHR, mid level support, etc.

5. There is nobody that regulates residency position numbers. It wasn't explicitly stated to my recollection, but was clear from the red journal fiasco that the RRC and ACGME don't view this as part of their functions. In addition, Dr. Zeitman's talk took a very neutral stance, essentially that data is imperfect and applicants can self regulate as they did in radiology.

6. There are significant threats to radiation oncology demand, especially the reimbursement issues discussed in this thread.

The radiologist on the panel discussed their job market with data from the 2010s. But this happened in the 2000s, and what was analyzed was the reaction to the decline in their job market. The reaction from medical students was 5-10 years after their job market collapsed. This means 5-10 years of radiology residents got screwed.

I took away from this:

1. Supply has outpaced demand for at least the past 5 years.

2. Future demand is very uncertain with very significant threats to our field. Demand has been flat over the past 5 hears.

3. Thus, I would propose a moratorium on growth of residency positions for at least the next 5 years to reassess whether demand has begun to grow again. This would avoid the job market disasters as in Canada and in radiology.

4. Given the current likely oversupply based on surveys and increasing number of fellowships, and the ability to improve productivity for mild undersupply, there would be minimal risk in slowing growth at this time. There seems to be no willpower to make that happen.

 

[BobbyHeenan]

If any part of our solution, as Zeitman suggests, is "we'll just do what radiology did" then we're in trouble.

I'm willing to pitch in however to help ASTRO take some sort of stance and get the willpower to do something. The issue is that the people making these decisions (ie academic rad oncs in high administrative positions) are probably effected the least by all of this. Not a good combo.

 

[OTN]

Again, all 3 of those cases had much more egregious fraud. In the Baylor case, SRS was being performed without any physician present and then Texas Oncology was double billing for the treatments - I think we can all agree that this is a completely different set of circumstances than what we are talking about. The other two cases involved either outright fraudulent billing or zero physician oversight..that is also quite different than stating that a radonc must be physically present for each and every treatment.

On a personal level, I agree that staying as far away from the line and acting conservatively is always prudent.

But on a political level, we shouldn't embrace and propogate this policy in the field. It's pretty stupid. With the provider shortage in rural areas, we need to stand up for the solo radonc who practices in these places. If they have to miss a few treatments to attend tumor board or see an emergent patient in the hospital, that is reasonable IMO and should be allowable. We have to allow these things to be somewhat regulated at the local level.

FYI the lawsuit was dismissed and Texas Oncology did not have to pay anything in settlements. The three organizations found at fault were Baylor University Medical Center, Baylor Health Care System, and HealthTexas Provider Network. While, yes, the suit said TxO double-billed the government, the lawsuit was dismissed and TxO paid no penalites.

 

[Gfunk6]

Fantastic post DukeNukem, that was an excellent summary and analysis. The sad reality is that the people who would be most helped by a moratorium on increased residency slots are also the most politically disenfranchised (e.g. residents and med students).

Attending Rad Oncs like me will not be affected by this and may marginally benefit because we can get cheap labor. My suggestion would be for ARRO to grow a pair and advocate internally.

I know we have users from ARRO posting here so I would be happy to hear their view.

 

[napoleondynamite]

Agree 100% with the moratorium. I don't see it happening though. I rarely really see anything happen with ASTRO. The 1-year presidency seems more like an honor bestowed on the radonc elite rather than a position of true activism. How is anyone supposed to get anything accomplished in just 1 year? They are probably just learning the ropes by the time they pass the baton to the next president.

ARRO certainly would be a good avenue to try to get something done. Unfortunately, we saw how poor Shah took a beating in the Red Journal - likely the same outcome would happen with ARRO as ASTRO has the bully pulpit of their future jobs and funding for other projects, etc.

It might make a simple research project to publish a survey among residents and recently graduated residents about their thoughts on the subject. Maybe that's already been done and I missed it..

 

[medgator]

It might make a simple research project to publish a survey among residents and recently graduated residents about their thoughts on the subject. Maybe that's already been done and I missed it..

http://www.redjournal.org/article/S0360-3016(15)00337-5/abstract

 

[RSAOaky]

Fantastic post DukeNukem, that was an excellent summary and analysis. The sad reality is that the people who would be most helped by a moratorium on increased residency slots are also the most politically disenfranchised (e.g. residents and med students).

Attending Rad Oncs like me will not be affected by this and may marginally benefit because we can get cheap labor. My suggestion would be for ARRO to grow a pair and advocate internally.

I know we have users from ARRO posting here so I would be happy to hear their view.

This is an excellent point. The people most affected really have the least say in things. The way that things are going, with large corporations buying up radonc practices, the oversupply of radoncs is only going to drive salaries down overall. It was a very somber mood in that room.