Medicare plans to cut RO reimbursement by 14%

[Gfunk6]

Something to think about this weekend.

http://www.magnetmail.net/actions/e...&user_id=ASTRO&group_id=862815&jobid=10726903

Looks like a good time to donate to the ASTRO PAC. Spend a little money now to prevent a lot of pain later.

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Members don't see this ad.

 

[DrAwsome]

Something to think about this weekend.

http://www.magnetmail.net/actions/e...&user_id=ASTRO&group_id=862815&jobid=10726903

Looks like a good time to donate to the ASTRO PAC. Spend a little money now to prevent a lot of pain later.

I guess I personally don't understand where these cuts come from and why they keep occurring. Isn't this something that radiation oncologists should agree with the gov on? Is this something that will keep occurring or will there ever be an actual rate taht is established that stays frozen?

 

[Gfunk6]

Health care costs are unsustainable. To control them you have to either raise taxes or drop reimbursements. For many years Rad Onc was "under the radar" because our contribution to Medicare expenses was negligible compared to other specialties.

However with the ubiquity of IMRT, protons and urorads our costs are now a significant part of Medicare expenditures, hence we are taking a hit. Note that we have more than a year to advocate against these cuts so they need not be inevitable. However we have to donate our time and money to convince CMS that cuts are a bad idea. Then, they'll move on to other targets.

 

[DrAwsome]

Health care costs are unsustainable. To control them you have to either raise taxes or drop reimbursements. For many years Rad Onc was "under the radar" because our contribution to Medicare expenses was negligible compared to other specialties.

However with the ubiquity of IMRT, protons and urorads our costs are now a significant part of Medicare expenditures, hence we are taking a hit. Note that we have more than a year to advocate against these cuts so they need not be inevitable. However we have to donate our time and money to convince CMS that cuts are a bad idea. Then, they'll move on to other targets.

Sure, I can understand that. But my point is -these potential cuts are here this year. And next year more cuts? And then the year after that and so forth? How long will the cutting take? Is it something that will happen every year for the rest of our practicing years?

 

[Gfunk6]

Sure, I can understand that. But my point is -these potential cuts are here this year. And next year more cuts? And then the year after that and so forth? How long will the cutting take? Is it something that will happen every year for the rest of our practicing years?

There is a clear distinction to be made between proposed cuts (which these are) and actual cuts. Each recent year Medicare funding was scheduled to be cut but Congress ended up passing a one year delay each time. They do this because of medical specialty PACS, the AARP, and their constituents. However cuts HAVE to come eventually. Once they do, it's anybody guess how deep or frequent they will be.

These cuts will have a trickle down effect on ancillary hospital staff as well because hospitals won't be generating as much revenue from their physicians. All in all a sub-optimal and decidedly uncertain future for all physicians.

 

[Radonc11]

"Also, under our potentially misvalued codes initiative, , we propose to adjust the payment rates for two common radiation oncology treatment delivery methods, intensity-modulated radiation treatment (IMRT), and stereotactic body radiation therapy (SBRT) to reflect more realistic time projections based
upon publicly available data. The combined effect of the PPIS transition and the latter two
proposals would be a reduction in payments to radiation therapy centers and radiation oncology."

Just perused the report. Cardiology, Optho also getting cut. Interesting;y, CRNA's will now be paid for performing pain related procedures? WTF?

 

[BraggPeak]

I hate to say it, but it is true that the amount time/work required at least from a physics/dosimetry point of view for IMRT and SBRT has gone down. It doesn't take days to come up with a suitable plan for prostate IMRT (as compared to head and neck). Similarly, our dosimetrists can come up with an SBRT plan for a peripheral lung nodule fairly quickly.

All this combined with the lack of evidence for much of the stuff that we do, coupled with high billing for these services, makes it hard for us to complain to CMS. Everyone knows about lack of evidence re: protons + prostate. We all use IMRT for prostate and prostatic fossa. Based on the presentation at ASTRO last year by Dr. Michalski,, there is only 1-2% decrease in late GI/GU toxicity for patients treated to 79 Gy. Coupled with that, patient reported outcomes from that study (presented at RTOG) showing NO difference in PROs for acute or late-onset side effects. And then for all those centers billing for daily cone beam for prostate, again no real evidence of a clinically-meaningful benefit.

Having said all this, I think that dramatic pay cuts are unwarranted and will have a long lasting detriment to our field, that will only limit the development of new and improved technologies that could offer benefit to cancer patients across the country. If the government wants to cut costs, address Urorads first!

 

[Radonc11]

For the most part, CMS is complaining about IMRT and SBRT being "overvalued" based on procedure time. The current schedule assumes that each IMRT treatment takes 60 minutes and that each SBRT treatment takes 90minutes. They go on to cite the "ASTRO" website suggesting IMRT is no longer than 15 minutes per treatment and SBRT no more than 30 minutes.

As such they are reducing IMRT procedure time to 30 minutes from 60 and SBRT to 60minutes from 90.

They also mention the Wapo article and the WSJ articles complaining about Urorads, over-treatment and financial incentives related to over-treatment. I'm not clear exactly what they plan on doing about this. There's also quite a bit of ranting about Stark laws and billing for "ongoing radiation physics consult- HCPCS code 77370"

In any case, there is little doubt that radonc was deliberately targeted and cut.

 

[DrAwsome]

"Also, under our potentially misvalued codes initiative, , we propose to adjust the payment rates for two common radiation oncology treatment delivery methods, intensity-modulated radiation treatment (IMRT), and stereotactic body radiation therapy (SBRT) to reflect more realistic time projections based
upon publicly available data. The combined effect of the PPIS transition and the latter two
proposals would be a reduction in payments to radiation therapy centers and radiation oncology."

Just perused the report. Cardiology, Optho also getting cut. Interesting;y, CRNA's will now be paid for performing pain related procedures? WTF?

And this is why I am like a dog with a bone when it comes to being more proactive and saying that we must demand what we get payment wise. CRNA's are making the same/more than many of our colleagues. Not only does that NOT cut any costs, but it also makes the quality of service lower.

It makes more sense to be a CRNA/PA than a pediatrician, FM, IM, rheum, ID doc at this point. And they make 150k+, which is not that far off from anesthesia salaries. So again-how is this cost cutting? I would LOVE someone to actually address this. All I hear is how we as docs are getting cut right and left, yet nursing goes up in salaries and nurses get to do more and more, yet we need more training for less/same money and sometimes less than CRNA's/nursing. so someone please tell me why no one is addressing this issue because I am kind of appalled honestly.

 

[Gfunk6]

1. CRNA = MD for routine anesthesia
2. CRNA is cheaper to employ than MD
3. CRNA do not need to carry the same level of malpractice insurance as MDs; when people sue they go after those with deep pockets (eg. Hospitals and MDs).
4. If a single MD is supervising multiple CRNAs then reimbursement is maxed, costs of malpractice insurance is minimized, and the cost to the hospital for salaries is optimized.

 

[DrAwsome]

1. CRNA = MD for routine anesthesia
2. CRNA is cheaper to employ than MD
3. CRNA do not need to carry the same level of malpractice insurance as MDs; when people sue they go after those with deep pockets (eg. Hospitals and MDs).
4. If a single MD is supervising multiple CRNAs then reimbursement is maxed, costs of malpractice insurance is minimized, and the cost to the hospital for salaries is optimized.

Well but do you really think that paying a CRNA 150k+ a pop is really all that cost efficient? Who came up with those salaries for CRNA? When they are nurses that get paid the same/more than PCPs, what's the point? I'm talking about how it's crazy to pay nurses these salaries and for docs to get cut in reimbursement. Are we really saying that paying CRNAs 150k when we could pay them far less than that does not make financial sense in a struggling healthcare scenario? Also CRNAs are much more likely to have poor outcomes, so it's much more likely patients would sue under CRNAs vs. MDs.

 

[Gfunk6]

If a nursing "professional" can do almost everything an MD can at less then 50% of the cost with a fraction of the medical liability, how does that not make financial sense for a hospital?

From the hospital's perspective, why would they care what PCPs make? Their job is to turn a profit, not to enforce social justice.

Also, the jury's out on whether CRNAs are "much more likely to have poor outcomes" much to the chagrin of the MDs. Data in this area is sparse.

 

[deleted4401]

There is almost no evidence at this point to say that outcomes are poorer with CRNAs as much as we want to believe they are. Funny that poster appeared so sure of it, but obviously unable to provide a link or abstract.

S

 

[DrAwsome]

There is almost no evidence at this point to say that outcomes are poorer with CRNAs as much as we want to believe they are. Funny that poster appeared so sure of it, but obviously unable to provide a link or abstract.

S

This is what I read. I cannot link specific articles at this point, no. However, if we are saying that CRNAs can do what MDs can do, then why not make anesthesia a CRNA/nursing field, and pay them much less period? Why would we need MD anesthesiologists if we are saying they are the same/have the same knowledge/competence that MD anesthesiologists do? I don't think that they do, and I would be terrified to have a nurse CRNA do my anesthesia during surgery. But if the premise is that they are the same, I also think that it would make sense to eliminate the anesthesia MD field no? It bothers me that we have this double layered type of medical system more and more. It doesn't make sense in my opinion to have both MD and mid level providers perform the same job. Same with NP/PA type people and PCPs. If we are saying that you don't need an MD to do a PCP job, then why not have the PCP role just be taken over by midlevels, pay them half what PCPs get paid, and save all the rest? I cant quite grasp why we have both I guess. And as far as Gfunk's point that they are less costly than anesthesiologists, sure to some extent, but still quite expensive. Who set the wage for these providers?
Why not pay them 100k or something like that, which is far more reasonable?

 

[deleted4401]

You raise very good questions and these will be raised when our system goes toward collapse. Are they better? Are they worse? Are they the same? Shouldn't we answer rather than assume? Shouldn't we sort these things out? If you are terrified about a CRNA performing anesthesia, quit your residency, because a large proportion of surgeries are being (safely) performed by them.

As far as PCPs... Sure - there are a lot of things they can do that can be done by extenders. Does that mean PCPs should be eliminated? No. Does it mean we should have the brightest and best do 3 year residencies to do well baby checks and treat URIs and be paid high incomes? I'm not sure and I don't claim to know the answer, but I know many countries have great outcomes for many non-acute issues without utilizing MDs. I don't know, but what scares me is that people think they do. Without data. Ignoring data. Acting reactionary and protectionist before looking at outcomes. That scares me 100x more than a CRNA giving anesthesia.

 

[Gfunk6]

However, if we are saying that CRNAs can do what MDs can do, then why not make anesthesia a CRNA/nursing field, and pay them much less period?

This is an extreme, inaccurate position. Probably ~95% of the time, when anesthesia administration has no complications a CRNA = MD. However, when the **** hits the fan I don't think any reasonable person would say an MD is not superior to a CRNA. Also, there are more specialized areas of anesthesiology (pediatrics, OB, Cards) that are better done by MDs. Finally, VIPs will always use MDs (can you imagine the President of the United States using a CRNA for elective surgery??).

It bothers me that we have this double layered type of medical system more and more.

You can blame the MD anesthesiologists. They are the ones who pioneered the CRNA concept and it has now become their Frankenstein's monster.

If we are saying that you don't need an MD to do a PCP job, then why not have the PCP role just be taken over by midlevels, pay them half what PCPs get paid, and save all the rest?

As mentioned above a midlevel cannot totally replace a PCP in all cases. You still need a PCP for complex cases, VIPs, and (unfortunately) to be medically liable in case of a screw-up.

Who set the wage for these providers?
Why not pay them 100k or something like that, which is far more reasonable?

They are unionized. If their wages fall below what they consider reasonable, they can simply strike. However, with the over-proliferation of CRNA programs their salaries are likely to fall as the market is saturated with mid-levels.

 

[DrAwsome]

You raise very good questions and these will be raised when our system goes toward collapse. Are they better? Are they worse? Are they the same? Shouldn't we answer rather than assume? Shouldn't we sort these things out? If you are terrified about a CRNA performing anesthesia, quit your residency, because a large proportion of surgeries are being (safely) performed by them.

As far as PCPs... Sure - there are a lot of things they can do that can be done by extenders. Does that mean PCPs should be eliminated? No. Does it mean we should have the brightest and best do 3 year residencies to do well baby checks and treat URIs and be paid high incomes? I'm not sure and I don't claim to know the answer, but I know many countries have great outcomes for many non-acute issues without utilizing MDs. I don't know, but what scares me is that people think they do. Without data. Ignoring data. Acting reactionary and protectionist before looking at outcomes. That scares me 100x more than a CRNA giving anesthesia.

I'm not saying that we should eliminate PCPs or anesthesiologists altogether. It's just a thought, given so many changes and the continuous introduction of midlevels. I think we need to have a more concise and clear cut system. Do i know or have the answers, nope. I find it troublesome that we have this double tiered system of docs and midlevels, where in some places one group of them does this and in other places the other group does something else, and so forth. I do agree with you that we need to look at data and say hey, which group has the better outcome and who can do what for the lowest cost.

 

[DrAwsome]

This is an extreme, inaccurate position. Probably ~95% of the time, when anesthesia administration has no complications a CRNA = MD. However, when the **** hits the fan I don't think any reasonable person would say an MD is not superior to a CRNA. Also, there are more specialized areas of anesthesiology (pediatrics, OB, Cards) that are better done by MDs. Finally, VIPs will always use MDs (can you imagine the President of the United States using a CRNA for elective surgery??).



You can blame the MD anesthesiologists. They are the ones who pioneered the CRNA concept and it has now become their Frankenstein's monster.



As mentioned above a midlevel cannot totally replace a PCP in all cases. You still need a PCP for complex cases, VIPs, and (unfortunately) to be medically liable in case of a screw-up.



They are unionized. If their wages fall below what they consider reasonable, they can simply strike. However, with the over-proliferation of CRNA programs their salaries are likely to fall as the market is saturated with mid-levels.

Gfunk, as always, I think you bring up an excellent point re: VIPs using MDs vs. midlevels. But doesn't that also bring up issues in and out of itself? If the president says hey I want Dr. Gas vs. CRNA, but everyone else can use a CRNA, they are basically saying that CRNAs are really not *that* great. I think many people would have an issue with that. Second the whole notion that nurses can be unionized and demand whatever they want salary wise is appalling. The fact that we are told what we will get pay while nurses demand what they want and strike otherwise makes it a system where once again we are saying nurses are more important and doctors are expendable, that's why no one listens to us anymore. Shouldn't it be the other way around? Shouldn't we be able to demand the salaries we think are fair?

 

[medgator]

Gfunk, as always, I think you bring up an excellent point re: VIPs using MDs vs. midlevels. But doesn't that also bring up issues in and out of itself? If the president says hey I want Dr. Gas vs. CRNA, but everyone else can use a CRNA, they are basically saying that CRNAs are really not *that* great. ?

Didn't Congress and the president exempt themselves from the Aca? I know it was discussed before the bills passage but I'm not sure if it actually made it in

 

[Palex80]

The problem with Radiation Oncology expenses is that the technology we use is being introduced into clinical practice and considered "standard treatment" a lot faster, than evidence care medicine can keep track of it and actually prove, that these techniques are necessary.

We have performed hundreds of trials looking into radiochemotherapy (or radiotherapy & hormonal treatment for prostate cancer) and have only invested very little effort into proving the point, why IMRT, SBRT, gating, etc are important in daily practice.

There are only a few studies looking into whay IMRT is better than 3D for prostate cancer, no randomized trial has ever been performed (as far as I know).
The same goes out for other techniques, which are being pushed into clinical practice way too fast, without anyone thinking of conducting trials, which can help us persuade our colleagues, the insurance companies and the law makers, why these techniques are better.
Look at SBRT:
1. Why haven't we conducted a cost-effectiveness analysis, trying to show that SBRT is safer and cheaper than sublobar resection for NSCLC?
2. Why haben't we conducted trials demonstrating, that SBRT delivers superior local control and less need for retreatment (and those less costs) for bone metastasis in good prognosis patients?
3. Why hasn't anyone looked into what clinical benefits gating brings to the patient? I have seen tons of fancy videos and DVH-analyses showing that gating is great for sparing the lung, but noone has come up with data, which actually shows less pneumonitis through gating.

Two special aspects of the US Radiation Oncology landscape, which we do not see in other parts of the developed world and which are probably responsible for rising costs and concerns of the insurance companies & law-makers are:
1. Proton treatment.
When one looks at how many proton centers are being built in the US, you can only ask yourself if there are actually that many patients, which have a clear clinical indication for protons in the US, or why then are so many proton centers being built?
It's clear that prostate cancer is the "problem" here, a cancer, whose treatment with protons does not have any clinical benefits for the patient, than with a good planned conformal photon therapy in my opinion. The late Mr. Kennedy getting protons for his glioblastoma is also a good example in my opinion of how resources can be misused in radiation oncology.
If you look at Europe, you'll see, that most European nations try to get 1 or 2 proton centers online or already have them online. There is a very strict list, of what is going to be treated in these centers and most of them are gonna be treating children, chondrosarcomas, chordomas, complex meningeomas. The rest are gonna be study patients, being treated in strict protocols. There are a couple of private centers running or getting ready to run. On the other hand, you see that proton business plans are quite difficult to run: In Germany alone 4 proton therapy projects had to be terminated, in two cases the buildings were ready and the equipment installed. The numbers just didn't work out. Too many costs, too little reimbursement. But hey, this is Europe. In Germany, you get a complete prostate IMRT for less than $5.000!

2. Urologists running linacs.
This is something, which is unheard of in Europe. It certainly hurt the US radiation oncology society and probably led to a lot of overtreatment taking place. Thank God, that regulations prohibit this from happening here.

 

[Radonc11]

Palex raises some good points. I've heard MD Anderson's Protons for Prostate ad running on Mike and Mike ESPN radio. It is pure blatant pandering! It suggests to a lay cancer patient that Proton therapy will "save your life" compared to the other crap all those other guys are doing. Its not right, but in an arms race, anything goes.

However conducting a trial SBRT vs sublobar resection (Invasive vs Non-invasive treatment) will be very difficult.I assume everyone will prefer to be on the non-invansive arm. Some of the other suggestions are feasible but I don't know if anyone in the real world really wants those answers.

I would really like to hear from our private practice folks. How does this "code revaluation" affect your billing practices?

 

[radiaterMike]

There in fact is an ongoing RTOG/ACOSOG study of SBRT versus sublobar resection (+/- brachy which is not randomized).

Palex raises some good points. I've heard MD Anderson's Protons for Prostate ad running on Mike and Mike ESPN radio. It is pure blatant pandering! It suggests to a lay cancer patient that Proton therapy will "save your life" compared to the other crap all those other guys are doing. Its not right, but in an arms race, anything goes.

However conducting a trial SBRT vs sublobar resection (Invasive vs Non-invasive treatment) will be very difficult.I assume everyone will prefer to be on the non-invansive arm. Some of the other suggestions are feasible but I don't know if anyone in the real world really wants those answers.

I would really like to hear from our private practice folks. How does this "code revaluation" affect your billing practices?

 

[napoleondynamite]

Palex raises some good points. I've heard MD Anderson's Protons for Prostate ad running on Mike and Mike ESPN radio. It is pure blatant pandering! It suggests to a lay cancer patient that Proton therapy will "save your life" compared to the other crap all those other guys are doing. Its not right, but in an arms race, anything goes.

This is the biggest, and most appalling problem IMO. We expect that some private groups will abuse the system and put profit over patient and ethics at times. However, when corruption infiltrates our "sacred temples" of academia and you see our top cancer centers contributing to, if not fueling the problem, well, we deserve as a field to see the guillotenes chopping our reimbursements.

My residency hospital serviced the underprivileged children of Philadelphia. I had an 18 month old with bilateral Rb and could not get Penn to give up a little gantry space to treat her and potentially spare orbital hypoplasia (actually something we have data for with protons). I literally called every proton center in the country, but due to the patients lack of insurance, no one would see this little girl in consult. Well, she got treatment with photons at our facility with our inferior technology meanwhile some "VIP" was getting his T1c zapped across town on a gantry that would have better served her. Appalling. Shameful. Disgusting. I let the touters of protons know as much during their spending extravaganza in San Diego on the aircraft carrier. I'm sure anyone who was there probably remembers the silence in the room after I told my story to the presenter from MDACC. (*Queue subsequent denial and condescending tone from said presenter. However, every word of what I spoke was 100% fact).

I got no problem with us advancing technology quickly when it makes sense to do so. I'm not convinced we need a randomized trial to show the benefits of all technologic advances. However, if we as a specialty put the stamp of approval on "progress" which really just measn "$$" well then, sadly, we do need watch dogs to monitor us and prohibit abuse. The one way to do that effectively is to go after the problem - make the carrot smaller. If that ends up improving the ethical disbursement of cancer care, then I guess it needs to happen.

 

[medgator]

Palex raises some good points. I've heard MD Anderson's Protons for Prostate ad running on Mike and Mike ESPN radio. It is pure blatant pandering! It suggests to a lay cancer patient that Proton therapy will "save your life" compared to the other crap all those other guys are doing. Its not right, but in an arms race, anything goes.

This is the biggest, and most appalling problem IMO. We expect that some private groups will abuse the system and put profit over patient and ethics at times. However, when corruption infiltrates our "sacred temples" of academia and you see our top cancer centers contributing to, if not fueling the problem, well, we deserve as a field to see the guillotenes chopping our reimbursements.

My residency hospital serviced the underprivileged children of Philadelphia. I had an 18 month old with bilateral Rb and could not get Penn to give up a little gantry space to treat her and potentially spare orbital hypoplasia (actually something we have data for with protons). I literally called every proton center in the country, but due to the patients lack of insurance, no one would see this little girl in consult. Well, she got treatment with photons at our facility with our inferior technology meanwhile some "VIP" was getting his T1c zapped across town on a gantry that would have better served her. Appalling. Shameful. Disgusting. I let the touters of protons know as much during their spending extravaganza in San Diego on the aircraft carrier. I'm sure anyone who was there probably remembers the silence in the room after I told my story to the presenter from MDACC. (*Queue subsequent denial and condescending tone from said presenter. However, every word of what I spoke was 100% fact).

I got no problem with us advancing technology quickly when it makes sense to do so. I'm not convinced we need a randomized trial to show the benefits of all technologic advances. However, if we as a specialty put the stamp of approval on "progress" which really just measn "$$" well then, sadly, we do need watch dogs to monitor us and prohibit abuse. The one way to do that effectively is to go after the problem - make the carrot smaller. If that ends up improving the ethical disbursement of cancer care, then I guess it needs to happen.

Yup. It's sad. The UF Proton therapy center has been in full force with ads across FL and the southeast touting the virtues of protons for prostate CA therapy. These facilities were commissioned with the idea of offering treatments that would be meaningfully better for certain populations of patients, but the economic reality they are facing is that they need to keep those centers filled to the brim with every possible patient they can find (and a big chunk of that ends up being prostate CA).

The recent SEER analysis comparing 3DCRT, IMRT and protons in prostate CA seems to be providing lots of egg on their (and every proton facility) face I'm sure. We don't have ideal data on it but what we do have with that SEER data certainly doesn't put protons in the best light. And patients ask about any data they can get when they hear about the "virtues" of proton therapy for prostate CA

http://jama.jamanetwork.com/article.aspx?articleid=1148148

 

[napoleondynamite]

I would imagine (or at least hope) that it's not the radiation oncologists in these academic practices that are initiating these marketing claims. However, that does not absolve them of any responsibility when you see their smiling faces in the ads on TV. I will soon be joining a group with plans for protons and can promise I won't be a passive voice (usually my problem in life..)

As someone said above, we just have to take responsibility and police ourselves. We have to say no to the Urorad job that pays 750k. We have to say no to IMRT palliation of 40/20. Bottom line we have to stand up and do the right thing for our patients and also make ethical financial decisions. Most of the problems we have are created by US.

Easy for me to stand on my pulpit and pound it hard when I haven't been in the real world yet. However, if we want to have the high ground in the urorad argument or in negotiating CMS cuts, we must first actually be on the high ground. I seriously just find it disturbing that our best centers in the country are so obviously working the system, and to me, decieving patients in their marketing of protons.

 

[Reaganite]

This is the biggest, and most appalling problem IMO. We expect that some private groups will abuse the system and put profit over patient and ethics at times. However, when corruption infiltrates our "sacred temples" of academia and you see our top cancer centers contributing to, if not fueling the problem, well, we deserve as a field to see the guillotenes chopping our reimbursements.

My residency hospital serviced the underprivileged children of Philadelphia. I had an 18 month old with bilateral Rb and could not get Penn to give up a little gantry space to treat her and potentially spare orbital hypoplasia (actually something we have data for with protons). I literally called every proton center in the country, but due to the patients lack of insurance, no one would see this little girl in consult. Well, she got treatment with photons at our facility with our inferior technology meanwhile some "VIP" was getting his T1c zapped across town on a gantry that would have better served her. Appalling. Shameful. Disgusting. I let the touters of protons know as much during their spending extravaganza in San Diego on the aircraft carrier. I'm sure anyone who was there probably remembers the silence in the room after I told my story to the presenter from MDACC. (*Queue subsequent denial and condescending tone from said presenter. However, every word of what I spoke was 100% fact).

I got no problem with us advancing technology quickly when it makes sense to do so. I'm not convinced we need a randomized trial to show the benefits of all technologic advances. However, if we as a specialty put the stamp of approval on "progress" which really just measn "$$" well then, sadly, we do need watch dogs to monitor us and prohibit abuse. The one way to do that effectively is to go after the problem - make the carrot smaller. If that ends up improving the ethical disbursement of cancer care, then I guess it needs to happen.

I can definitely corroborate your story on the peds patients. I saw it first hand...

 

[Brim]

This is the biggest, and most appalling problem IMO. We expect that some private groups will abuse the system and put profit over patient and ethics at times. However, when corruption infiltrates our "sacred temples" of academia and you see our top cancer centers contributing to, if not fueling the problem, well, we deserve as a field to see the guillotenes chopping our reimbursements.

My residency hospital serviced the underprivileged children of Philadelphia. I had an 18 month old with bilateral Rb and could not get Penn to give up a little gantry space to treat her and potentially spare orbital hypoplasia (actually something we have data for with protons). I literally called every proton center in the country, but due to the patients lack of insurance, no one would see this little girl in consult. Well, she got treatment with photons at our facility with our inferior technology meanwhile some "VIP" was getting his T1c zapped across town on a gantry that would have better served her. Appalling. Shameful. Disgusting. I let the touters of protons know as much during their spending extravaganza in San Diego on the aircraft carrier. I'm sure anyone who was there probably remembers the silence in the room after I told my story to the presenter from MDACC. (*Queue subsequent denial and condescending tone from said presenter. However, every word of what I spoke was 100% fact).

I got no problem with us advancing technology quickly when it makes sense to do so. I'm not convinced we need a randomized trial to show the benefits of all technologic advances. However, if we as a specialty put the stamp of approval on "progress" which really just measn "$$" well then, sadly, we do need watch dogs to monitor us and prohibit abuse. The one way to do that effectively is to go after the problem - make the carrot smaller. If that ends up improving the ethical disbursement of cancer care, then I guess it needs to happen.

That's awful.

Shame on you, U. Penn. Shame on you.

 

[jcradonc]

If a nursing "professional" can do almost everything an MD can at less then 50% of the cost with a fraction of the medical liability, how does that not make financial sense for a hospital?

From the hospital's perspective, why would they care what PCPs make? Their job is to turn a profit, not to enforce social justice.

Also, the jury's out on whether CRNAs are "much more likely to have poor outcomes" much to the chagrin of the MDs. Data in this area is sparse.

Is there any threat of another health professional taking the place or supplementing the role of a rad onc physician?

 

[Gfunk6]

Is there any threat of another health professional taking the place or supplementing the role of a rad onc physician?

No. Rad Onc has formed a kind of synergistic and complementary relationship between physicists, therapists and dosimetrists. We all need and rely on each other but here is no doubt (especially where medical liability is involved) that the MD is the captain of the ship.

 

[jimbobb23]

Health care costs are unsustainable. To control them you have to either raise taxes or drop reimbursements. For many years Rad Onc was "under the radar" because our contribution to Medicare expenses was negligible compared to other specialties.

I think collectively we lack imagination for the many ways health care costs can be altered. The two options you propose are two of many, but Obamacare contains many many more, and there are ways we will never know because the incentives are not there.

That aside, I am once again disappointed that with the wave of a hand we are getting screwed. But, that is the way of things when turning over your life to the capricious nature of uncle sam.

As for other things posted - I am a little unclear on the fervor for clinical trials of IMRT or 3D conformal. Protons might be useful but probably not. So, if we do a trial and IMRT is not as good at some metric, are you going back to 3D conformal. I never would. For one, I cannot do a head and neck that way, but the dosimetrical differences alone are compelling enough to use better technology. Why are we obsessed with trials for which the answer is so uninteresting? Trials for Tomo vs IMRT, VMAT vs this or that? Why not test whether EPIDs result in better patient outcomes vs film? Who cares? We use better technology because we can and see a benefit to pts or implementation. I am pretty sure surgeons don't do trials to test different scapels out...it sounds silly (ok I know someone can find such a trial on pubmed in 3..2..1). But that is what a trial of 3D conformal vs IMRT would be for us. Trials are a limited resource so I would use them on questions that are interesting and likely to result in significant benefits to patients. We are always going to use the technology that is best within a cost effective framework.

I am a resident so am pretty financially naive, but what's with all the hate on Urorads? Isn't that all about the money we think they get from us? Some radoncs are employed by hospitals - is that ok but being employed by a bunch of guys who are trained as urologists isn't? Plenty of RadOncs work for MedOncs. Who cares? The problem with those set-ups are if you stop doing what is guideline driven and do things for billing alone that is a problem. If you do what is best for the patient, why should we care what happens in one set-up vs the next. I would love to get the technical fees as much as the next radonc, but for most of us that simply does not happen for a long time.

 

[medgator]

I am a resident so am pretty financially naive, but what's with all the hate on Urorads? Isn't that all about the money we think they get from us? Some radoncs are employed by hospitals - is that ok but being employed by a bunch of guys who are trained as urologists isn't? Plenty of RadOncs work for MedOncs. Who cares? The problem with those set-ups are if you stop doing what is guideline driven and do things for billing alone that is a problem.

It's obvious that you're a little green and naive to this.

What do you think happens in the real world when a urologist sees a patient who might be best-served by surgery (younger guy, large prostate, low-volume disease) but financially does better by referring to a center with which he has an ownership interest? Do you think the rad onc will likely be able to talk either him, or the patient he has already consulted, counseled and referred out of getting XRT?

Do you think such a model serves either patients or the healthcare system well?

 

[Gfunk6]

I think collectively we lack imagination for the many ways health care costs can be altered. The two options you propose are two of many, but Obamacare contains many many more, and there are ways we will never know because the incentives are not there.

That aside, I am once again disappointed that with the wave of a hand we are getting screwed. But, that is the way of things when turning over your life to the capricious nature of uncle sam.

To use a highway and destination analogy . . .

The destination is clear. The writing is on the wall and we cannot change it. However, we can change the route and the length of time it takes to get there by influencing policy. Some may view this as fatalistic but I view it as pragmatic.

As for other things posted - I am a little unclear on the fervor for clinical trials of IMRT or 3D conformal. Protons might be useful but probably not. So, if we do a trial and IMRT is not as good at some metric, are you going back to 3D conformal. I never would. For one, I cannot do a head and neck that way, but the dosimetrical differences alone are compelling enough to use better technology. Why are we obsessed with trials for which the answer is so uninteresting? Trials for Tomo vs IMRT, VMAT vs this or that? Why not test whether EPIDs result in better patient outcomes vs film? Who cares? We use better technology because we can and see a benefit to pts or implementation. I am pretty sure surgeons don't do trials to test different scapels out...it sounds silly (ok I know someone can find such a trial on pubmed in 3..2..1). But that is what a trial of 3D conformal vs IMRT would be for us. Trials are a limited resource so I would use them on questions that are interesting and likely to result in significant benefits to patients. We are always going to use the technology that is best within a cost effective framework.

This is argument is like the "protons and parachutes" editorial a few years ago. There are no randomized trials showing that there is benefit to parachutes when jumping out of a plane. Obviously, no sane person would recommend against parachutes in this scenario. Therefore, the benefit of parachutes from anecdotal data is so overwhelming that it is unethical to even do a randomized trial.

However, this argument cannot be successfully used to wave away the need for Category I evidence in all cases. In the example you cited, we do have Category 2a evidence that IMRT > 3DCRT in H&N cancer based on studies from the US, Southeast Asia and Canada.

However, for prostate cancer it is a much murkier subject. As alluded to in earlier posts in this thread, there is limited data to support the use of IMRT over 3DCRT even for dose-escalation. There is even less for protons (see the SEER study quoted above). Also, "dosimetric superiority" should in no way substitute as a metric for "clinical superiority." If daily IGRT and IMRT lets me reduce the V70 to my rectum from 18% to 14% that's good. But what does it mean clinically? And do the massive costs of IMRT and daily IGRT really justify the minuscule clinical benefit?

These are uncomfortable questions but will be eventually asked.

I am a resident so am pretty financially naive, but what's with all the hate on Urorads? Isn't that all about the money we think they get from us? Some radoncs are employed by hospitals - is that ok but being employed by a bunch of guys who are trained as urologists isn't? Plenty of RadOncs work for MedOncs. Who cares? The problem with those set-ups are if you stop doing what is guideline driven and do things for billing alone that is a problem. If you do what is best for the patient, why should we care what happens in one set-up vs the next. I would love to get the technical fees as much as the next radonc, but for most of us that simply does not happen for a long time.

Urorads is a financial model to funnel all early-stage prostate cancer patients into the maximally reimbursed form of cancer treatment, that is daily IMRT with 1.8 Gy per fraction with daily IGRT. Lip service is given to surgery and LDR/HDR both of which have equivalent outcomes and are markedly cheaper. This means that (a) patients are getting over-treated, (b) there is no thought put into evidence-based treatment, and (c) payers are getting fleeced (most notably Medicare).

In a true multi-disciplinary environment patients see all relevant specialists and/or their cases are discussed in tumor board. If I see an early stage prostate or lung cancer patient, you'd better believe I would send him to a surgeon if he has not already seen one. Also, I strongly recommend brachytherapy for early stage patients.

 

[Pointless]

Just so that I understand... if this cut were to pass as stated, this would reduce the professional component of IMRT delivery by 14%. From my understanding, a group that is practicing evidence-based care would have an IMRT utilization rate somewhere between 20-30%, meaning a reduction in the total professional component of about ~5%. Furthermore, the technical reimbursement, which remains the true lifeblood of our field, would be unchanged. I understand the need to advocate for the field and to avoid the slippery slope for as long as possible, but this doesn't sound like the end of the world. Am I misunderstanding the issues here?

 

[napoleondynamite]

No, certainly not the end of the world. However, when was the last time we got a raise in reimbursements? A cost-of-living adjustment? Etc. I think it's the overall trend from year to year that has some people worried.

 

[medgator]

Furthermore, the technical reimbursement, which remains the true lifeblood of our field, would be unchanged. I understand the need to advocate for the field and to avoid the slippery slope for as long as possible, but this doesn't sound like the end of the world. Am I misunderstanding the issues here?

Many groups are professional only. If anything, that's the true lifeblood of the specialty.

 

[Pointless]

No, certainly not the end of the world. However, when was the last time we got a raise in reimbursements? A cost-of-living adjustment? Etc. I think it's the overall trend from year to year that has some people worried.

Isn't the whole issue with the annual SGR song-and-dance that we ARE getting incremental increases in compensation every year? Looking at the compensation for our field, it does appear to be steadily creeping upward every year, at least according to Flynn's annual presentation at ASTRO.

I guess I'm just trying to convince myself that I won't be graduating into a complete financial disaster.... maybe I'm naive.

 

[Pointless]

Many groups are professional only. If anything, that's the true lifeblood of the specialty.

But the hospitals that employ them and front all of the practice costs are still reaping the technical. As long as someone is profiting heavily from our existence, it stands to reason that we will continue to be appropriately compensated.

 

[Gfunk6]

The professional:technical fee breakdown percentage is something like 18%:82%. That's pretty lopsided and has increased with time. If reimbursements are going to be cut anyway, we should try to argue to re-arrange the pro:tech fees to a more equitable distribution.

 

[radiadouken]

1. Why haven't we conducted a cost-effectiveness analysis, trying to show that SBRT is safer and cheaper than sublobar resection for NSCLC?

http://www.ncbi.nlm.nih.gov/pubmed/20932688

This study didn't actually include cost but it's a decent start.

 

[Pointless]

The professional:technical fee breakdown percentage is something like 18%:82%. That's pretty lopsided and has increased with time. If reimbursements are going to be cut anyway, we should try to argue to re-arrange the pro:tech fees to a more equitable distribution.

From my understanding, more and more practices are moving toward hospital employee contracts with straight salaries, as opposed to partnerships sharing in the professional. As long as the salary is acceptable, it would no longer matter which piece of the pie it came from. Again, hospitals salivate over those technical fees and somebody has to work the frigging machines.... (two thumbs pointing at this guy).

 

[Radonc11]

No, certainly not the end of the world. However, when was the last time we got a raise in reimbursements? A cost-of-living adjustment? Etc. I think it's the overall trend from year to year that has some people worried.

Just thought I'd infuriate you further napoleon!

"The 2012 Hospital Outpatient Prospective Payment System final rule with comment period, released Tuesday, provides a nearly 15 percent increase in reimbursements for proton therapy over last year, and even a slight increase on payments floated by the CMS in an earlier 2012 proposal.


The final rule payments for the "simpler" or Level I proton therapy (Ambulatory Payment Classification 0664), which includes most prostate treatments, is about $1,184, up from 2011 rates of $1,032 and from proposed 2012 rates of $1,028.

For Level II, intermediate or complex, proton treatments (APC 0667), reimbursement for hospitals is set at around $1,549, up from the 2011 rates of $1,350 and from proposed rates of $1,345." Nov, 2011

Want a raise? Get yourself a cyclotron STAT!

 

[medgator]

Just thought I'd infuriate you further napoleon!

"The 2012 Hospital Outpatient Prospective Payment System final rule with comment period, released Tuesday, provides a nearly 15 percent increase in reimbursements for proton therapy over last year, and even a slight increase on payments floated by the CMS in an earlier 2012 proposal.


The final rule payments for the "simpler" or Level I proton therapy (Ambulatory Payment Classification 0664), which includes most prostate treatments, is about $1,184, up from 2011 rates of $1,032 and from proposed 2012 rates of $1,028.

For Level II, intermediate or complex, proton treatments (APC 0667), reimbursement for hospitals is set at around $1,549, up from the 2011 rates of $1,350 and from proposed rates of $1,345." Nov, 2011

Want a raise? Get yourself a cyclotron STAT!

SimulD nailed it. People should be standing outside of CMS offices protesting this crap

 

[napoleondynamite]

Just thought I'd infuriate you further napoleon!

"The 2012 Hospital Outpatient Prospective Payment System final rule with comment period, released Tuesday, provides a nearly 15 percent increase in reimbursements for proton therapy over last year, and even a slight increase on payments floated by the CMS in an earlier 2012 proposal.


The final rule payments for the "simpler" or Level I proton therapy (Ambulatory Payment Classification 0664), which includes most prostate treatments, is about $1,184, up from 2011 rates of $1,032 and from proposed 2012 rates of $1,028.

For Level II, intermediate or complex, proton treatments (APC 0667), reimbursement for hospitals is set at around $1,549, up from the 2011 rates of $1,350 and from proposed rates of $1,345." Nov, 2011

Want a raise? Get yourself a cyclotron STAT!

Hopefully they're taking those funds out of the pot reserved for multidisciplinary management of head and neck coffers for patients with Medicaid. Good heavens - stop the insanity bus, I want off!!

 

[napoleondynamite]

SimulD nailed it. People should be standing outside of CMS offices protesting this crap

or maybe we at, protest next to the IBA booth at the next ASTRO..

 

[deleted4401]

So, talking to the head of the local physics company, he said it was a reduction in the technical reimbursement. He said one of the leading drivers was the high-speed of the treatment with VMAT/TruBeam. Basically, a procedure that was 30 minutes is now 10 minutes and a procedure that was an hour is now 25 minutes. So that's what they meant about the "time" component of certain IMRT and SBRT codes. I can't say I fully disagree with that. I mean, if you get 50% faster and can treat a greater volume of patients, but still get 85% reimbursement, I don't think that is so unfair. But who know - I still can't find the actual language of the cuts, but would like to be sent a link if somebody has access.

-S

 

[radninja]

So, talking to the head of the local physics company, he said it was a reduction in the technical reimbursement. He said one of the leading drivers was the high-speed of the treatment with VMAT/TruBeam. Basically, a procedure that was 30 minutes is now 10 minutes and a procedure that was an hour is now 25 minutes. So that's what they meant about the "time" component of certain IMRT and SBRT codes. I can't say I fully disagree with that. I mean, if you get 50% faster and can treat a greater volume of patients, but still get 85% reimbursement, I don't think that is so unfair. But who know - I still can't find the actual language of the cuts, but would like to be sent a link if somebody has access.

-S

Here's the link: https://www.cms.gov/Medicare/Qualit...FS-Proposed-Rule-CMS-1590-P_2012-16814_PI.pdf

 

[OTN]

Just so that I understand... if this cut were to pass as stated, this would reduce the professional component of IMRT delivery by 14%. From my understanding, a group that is practicing evidence-based care would have an IMRT utilization rate somewhere between 20-30%, meaning a reduction in the total professional component of about ~5%. Furthermore, the technical reimbursement, which remains the true lifeblood of our field, would be unchanged. I understand the need to advocate for the field and to avoid the slippery slope for as long as possible, but this doesn't sound like the end of the world. Am I misunderstanding the issues here?

Decrease in professional reimbursement --> less money directly in our pocket.

Decrease in technical reimbursement --> fewer cancer centers, fewer radonc jobs, more competition for those jobs that do exist --> less money in our pocket.

Either way, cuts to our specialty aren't going to be a good thing.

 

[Tedebear]

Not interested in Primary Care but want to refute some false notions.

Actually PCPs are nearing $220,000 a year. This notion of PCPs not being paid is a false one.

http://www.forbes.com/sites/bruceja...00k-as-obamacare-market-push-new-pay-methods/

Also how many specialties in medicine offer loan forgiveness out of residency up to $200,000?

Answer Primary Care.

http://www.healthecareers.com/hec/job/family-practice-outpatient-only-100-loan/1326919
http://www.healthecareers.com/physi...oan/1326844?type=partner&source=indeedorganic

Well but do you really think that paying a CRNA 150k+ a pop is really all that cost efficient? Who came up with those salaries for CRNA? When they are nurses that get paid the same/more than PCPs, what's the point? I'm talking about how it's crazy to pay nurses these salaries and for docs to get cut in reimbursement. Are we really saying that paying CRNAs 150k when we could pay them far less than that does not make financial sense in a struggling healthcare scenario? Also CRNAs are much more likely to have poor outcomes, so it's much more likely patients would sue under CRNAs vs. MDs.

 

[Sheldor]

Not interested in Primary Care but want to refute some false notions.

Actually PCPs are nearing $220,000 a year. This notion of PCPs not being paid is a false one.

http://www.forbes.com/sites/bruceja...00k-as-obamacare-market-push-new-pay-methods/

Also how many specialties in medicine offer loan forgiveness out of residency up to $200,000?

Answer Primary Care.

http://www.healthecareers.com/hec/job/family-practice-outpatient-only-100-loan/1326919
http://www.healthecareers.com/physi...oan/1326844?type=partner&source=indeedorganic

On my family medicine rotation the upper level residents laughed out loud when the notion of low pay was brought up by a fellow student. They all had offers in the low 200's for a 5 day work week with complete loan forgiveness.

 

[DrAwsome]

Not interested in Primary Care but want to refute some false notions.

Actually PCPs are nearing $220,000 a year. This notion of PCPs not being paid is a false one.

http://www.forbes.com/sites/bruceja...00k-as-obamacare-market-push-new-pay-methods/

Also how many specialties in medicine offer loan forgiveness out of residency up to $200,000?

Answer Primary Care.

http://www.healthecareers.com/hec/job/family-practice-outpatient-only-100-loan/1326919
http://www.healthecareers.com/physi...oan/1326844?type=partner&source=indeedorganic

I think the salaries have always been around 200k for one. For two, I think they have risen about 10% + recently due to the dire need of PCPs that is out there. Nevertheless, they are still not starting in the 300's + for the most part, like many other specialties and while the PCP/hospitalist thing may be hot right now, I think this is a trend that will likely go back to what it was before. Like everything, it's cyclical. Why are their salaries still in the 200's vs what theya re for other specialties? Also there isn't anywhere to go for the most part salary wise with these positions, so you won't see the higher salaries you'll see for other specialties mid career.