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They are essentially arguing things after the fact which is a pretty useless position to be in. See supervision regulations fiasco
RO APM Dies!
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They simply have no political power. Imagine if 40% of cardiologists were forced into a bundled plan. The cardiology interest groups would not allow it to happen. Our message should be that we have already self-regulated (the data supports this)...leave us alone
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But to ASTRO's credit, they remain vocal about letting everyone know they're still very concerned about CMS's supervision changes.
Very, very concerned.
ASTRO: supine protoplasmic invertebrate jellies.
O
Neither option is looking good for our field. 1) Take the RO APM (with hopefully some additional improvements), 80% of physician groups will get +5% to the PC, take the technical cut in the model, increase reporting burdens to physicians, "possibly" have stronger footing to delay further cuts to G-codes outside the RO APM or 2) Get rid of the RO APM, experience the larger G-code cuts, not get the +5% incentive payment to the PC, and continue with MIPS. Either way, looking bearish for rad onc.
Neither option is looking good for our field. 1) Take the RO APM (with hopefully some additional improvements), 80% of physician groups will get +5% to the PC, take the technical cut in the model, increase reporting burdens to physicians, "possibly" have stronger footing to delay further cuts to G-codes outside the RO APM or 2) Get rid of the RO APM, experience the larger G-code cuts, not get the +5% incentive payment to the PC, and continue with MIPS. Either way, looking bearish for rad onc.
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Guess what folks... rad onc over-supply does the same same thing (decrease your PC), mathematically.
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Who are you including as "us" ? Rank and file rad oncs at the exceptional eleven aren't getting paid any more than they would elsewhere in academics. From experience in a few of those centers, I'm pretty sure if pay elsewhere goes down, their pay will also go down.
Yea, not looking good on any front...
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Have heard some of those centers pay fairly well actually, depending on the center (at least on the 100% clinical sure once you're full professor)
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Full professor takes 10+ years and is not easy to achieve at many centers. At a lot of these academic satellite positions I'm convinced that it's impossible.
I've only worked at two of these centers. Your mileage may vary, I guess.
Basically every academic center I've ever been at or interviewed at cares only about AAMC asst/assoc/full prof numbers. In competitive markets, they go at the very low ends of those numbers (not median) for pay or total compensation. PPS exemption doesn't factor in at all. Full prof total comps can get to MGMA sorts of levels, but only if you manage to get promoted, and it takes a long time to get there. Don't assume these are cushy jobs either--RVU targets in the 10-12k range are common.
I know there are some exceptions at places that never interviewed me or less desirable locations.
Still, point still stands. Just because you're at a PPS exempt center doesn't mean your job is going to be any better. Pay already is in no way correlated to collections at those places--only to what you would make at another institution they consider their peer.
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A bit of a tangent, but any of you all watching "Doctor Death" on the Peacock? WILD story. True story. Crazy! (I mean the guy looked legit. Normal even. I digress!) In one of the episodes they're talking like "Hey you pay this neurosurgeon $600K a year." And the hospital admin is like "Yes but he brings us $2.4m in revenue a year." Imagine if rad oncs got ~25% of the revenue they generate from the hospital!?! The average rad onc pay would be $800K to $1.25m a year.
A rad onc truism... your butt will be one of the most unkissed butts in all of medicine. If you abhor lips on your butt, rad onc is for you! I'd make another joke about APM and our butts, but demur for now.
D
deleted1111261
Not referring to my pay individually. Just how much centers will stand to lose.
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The bad administrators though think that the machine and the brick and mortar address is pulling those patients in. THey think any board certified rad onc will do.
I think some % of the volume certainly is just location or non-physician....but I think admin grossly over estimates that. In my experience (especially with rural centers), if you get a revolving door of doctors out there the volume starts to dip back to "location baseline" and it'll cost you in the long run.
Convincing admin of that is challenging though, it takes one of them getting burnt one time to finally recognize it.
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I would even add some intangibles in rad onc beyond that.
Imagine you ran a small cell lung cancer service. Wild notion but stay with me.
The reimbursement levels possible on the service could vary GREATLY from MD to MD, and they wouldn't be doing wrong care per se. One guy might be doing 30 fractions of 3D, never replanning, limited PCI'ing, limited PET staging, and the other guy 40 fractions of IMRT with two replans along the course of therapy and PCI'ing everyone and PETting almost everybody.
Those two good docs will be worth vastly different sums of money to their respective systems.
Not for everyone. It's not as if I'm going to hire a radonc to split my practice with just because they're available.
Additionally, I'm not so sure the cardiologists wouldn't have to acquiesce as well. After all, they "episode of care'd" orthopedics several years ago- I believe it was one of the first APM experiments that was run.
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Fake news… neurosurgeons can’t live off 600k a year. To be honest, they definitely deserve to be one of the highest paid.
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MGMA
| 2021 REPORT FROM 2020 DATA | COMPENSATION | |||
| 25 % tile | Median | 75 % tile | 90 % tile | |
| Surgery: Neurological | $693,034 | $869,385 | $1,146,291 | $1,393,600 |
Around my part of the country, the local neurosurgery group has far better hours and WLB than either my rad onc group or the med onc group. Most are spine/endovascular/tumor.
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We could learn a lot from the neurosurgeons. They learn from us... a neurosurgery resident has to PERFORM (in the eyes of ACGME) 10 radiation procedures before graduating.
There were roughly as many rad oncs as neurosurgeons ~10 years ago. Now the rad onc numbers are comfortably larger than NSG numbers, and look what's happened: NSG's fortunes are improved and/or just fine and ours are falling.
Neurosurgeons don't know from over-supply.
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Dennis Hallahan got sick of paying high faculty salaries. The rest, as they say, is history
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Neurosurgeons are also nearly universally worshipped by hospital admin while we are still the catfish. Not that I generally care about that, just an observation.
A local hospital published their rates for a spine surgery in accordance with the transparency executive order.... they make $75,000 just on the procedure alone. That's not including all of the ancillary charges they collect surrounding the operation. Not hating.... those guys and gals absolutely deserve to be the highest paid in medicine. But something tells me that if CMS eliminated the direct supervision requirement for neurosurgery... they might still have to be present for the procedure to occur (and for the hospital to bill accordingly)
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The neurosurgery comparison is a bad one. We are like the anti-neurosurgery.
There could never be a radonc Dr. Death. It would take ages to uncover a grossly incompetent radonc and there are plenty around who through the hard work of dosimetry, physics and partners are still clicking along just fine. The closest example is the brachy guy from Penn VA and that was brachy! and it still took years to uncover. The fact that happened is as much an indictment of the team and (leadership) as the guy who couldn't visualize the prostate.
None of us worked 100+ hours a week during residency and if we did, a small portion of that was clinical work.
Almost none of our work is on benign disease.
We lend almost no prestige to the hospital. The public calls us radiologists or radiologist oncologists! No one ever says, "I'm no neurosurgeon or rocket scientist or radiation oncologist!"
The demands of NS are such that it remains almost completely self selecting. Pretty much the opposite of peak radonc.
There could never be a radonc Dr. Death. It would take ages to uncover a grossly incompetent radonc and there are plenty around who through the hard work of dosimetry, physics and partners are still clicking along just fine. The closest example is the brachy guy from Penn VA and that was brachy! and it still took years to uncover. The fact that happened is as much an indictment of the team and (leadership) as the guy who couldn't visualize the prostate.
None of us worked 100+ hours a week during residency and if we did, a small portion of that was clinical work.
Almost none of our work is on benign disease.
We lend almost no prestige to the hospital. The public calls us radiologists or radiologist oncologists! No one ever says, "I'm no neurosurgeon or rocket scientist or radiation oncologist!"
The demands of NS are such that it remains almost completely self selecting. Pretty much the opposite of peak radonc.
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LOL. True. But it's (surgery etc) actually "personal" supervision, which is a step above direct, which means "in the room with the patient during the procedure." Radiotherapy IGRT was personal supervision up until 2006. Which meant you had to be in the room with the patient during the IGRT. Which is kind of silly.
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Get a load of this s**t if you want your blood >100 Celsius
I may be naive, but I can't help but think APM will never come to pass. It feels like there is a group of folks who keep on trying to jam a square peg into a round hole... but the shock of the rollout will produce a uproar and they will fold.
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This is just maddening.
One question I had after reading....
I was under the (?false?) impression that in the scenario where you treat a bone met say on January 1st, but then the patient developed a brain met on February 1st and you treated the brain met you would get paid for both due to different ICD10 codes.
However, is it not implied in this editorial that it's all bundled in 90 days from the first bone met "episode of care?"
Anyone want to weigh in?
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In my reading of the this and other APM stuff is that anything RT related will be bundled into the 90 days from the initial episode of care. So lets say treat a definitive SSC of the H and N and then SBRT an incidentally discovered stage I adeno of the lung. All will be bundled into the initial episode of care if you treat it within that 90 day window.
As the editorial points out and has been mentioned else where there will be a big problem with cervical cancer where the brachy portion is sent out from an unaffiliated community practice. Same could be said for a patient who has bone mets treated in the community then needs SRS for a brain met and the initial practice does not have SRS capabilities.
As the editorial points out and has been mentioned else where there will be a big problem with cervical cancer where the brachy portion is sent out from an unaffiliated community practice. Same could be said for a patient who has bone mets treated in the community then needs SRS for a brain met and the initial practice does not have SRS capabilities.
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Brachy is excluded from APM
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Man, it's almost like the medical director of RO-APM (from a PPS exempt hospital) wanted to damage small clinics around them first and then expand it to damage non-PPS exempt larger systems, next.
Crazy.
I'm sure it was much more altruistic.
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One thing is for sure, from the passage of the ACA to present, it seems that every involvement of the feds in medicine has had the (at least) secondary objective of destroying the independent physician in America.
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The best lobbyists (usually) win
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Brachytherapy is included in APM unless this has been changed from the final rule published Sept 2020 "Given that physicians sometimes contract with others to supply and administer brachytherapy radioactive sources (or radioisotopes), we explained in the proposed rule that we considered omitting these services from the episode payment. After considering either including or excluding brachytherapy radioelements from the RO Model, we proposed to include brachytherapy radioactive elements, rather than omit these services, from the episodes because they are generally furnished in HOPD (hospital outpatient departments) and the hospitals are usually the purchasers of the brachytherapy radioactive elements. When not furnished in HOPDs, these services are furnished in ASC (ambulatory surgical centers) , which we noted were proposed to be excluded from the Model.
See the final rule from CMS.
There is a lot of stuff in that document but from what I can tell brachytherapy is generally included in the APM.
"We proposed at 84 FR 34502 through 34503 to include the following RT modalities in the Model: Various types of external beam RT, including 3- dimensional conformal radiotherapy (3DCRT), intensity-modulated radiotherapy (IMRT), stereotactic radiosurgery (SRS), stereotactic body radiotherapy (SBRT), and proton beam therapy (PBT); intraoperative radiotherapy (IORT); image-guided radiation therapy (IGRT); and brachytherapy. We proposed to include all of these modalities because they are the most commonly used to treat the 17 proposed cancer types..."
"We thank commenters for their support of including brachytherapy as well as those commenters expressing their concerns and their suggestions. An episode-based payment covers all included RT services furnished to an RO beneficiary during a 90-day episode. Bundled episode payment rates are premised on the notion of averages. The cases including a combination of EBRT and brachytherapy described by the commenters are part of the set of historical episodes included in the averages that determine the national base rates and contribute to how payment amounts are valued, and, therefore, an adjustment for multiple modalities that include brachytherapy is not warranted at this time. Also, the case mix and historical experience adjustments help account for the costlier beneficiary populations in the participant-specific episode payment amounts. We will be monitoring for change in treatment patterns throughout the Model performance period and will consider modifications to the pricing methodology in future years of the Model should it be warranted. We believe that including brachytherapy in the Model supports this modality as high value, and also that including it preserves the goal of the Model in establishing a true bundled approach to radiotherapy that is also site neutral and modality agnostic. And, we believe that the proposed and finalized pricing methodology and subsequent national base rates for each cancer type accounts for the cost of brachytherapy as a primary modality and if furnished in conjunction with EBRT. We recognize the billing complexity when separate RT providers and RT suppliers furnish the brachytherapy and EBRT and will address this in billing guidance provided to RO participants. We will monitor for any unintended consequences of the Model on multimodality treatment that includes both external beam and brachytherapy. As for the concern that errors in the claims data (specifically those that commenters believe stem from incorrect attribution of CPT®/HCPCS codes to certain modalities) underrepresented the true cost of delivering a combination of modalities like EBRT and brachytherapy, we rely on the data submitted on claims by providers and suppliers to be accurate per Medicare rules and regulations. We are finalizing the provision to include brachytherapy in the RO Model."
See the final rule from CMS.
There is a lot of stuff in that document but from what I can tell brachytherapy is generally included in the APM.
"We proposed at 84 FR 34502 through 34503 to include the following RT modalities in the Model: Various types of external beam RT, including 3- dimensional conformal radiotherapy (3DCRT), intensity-modulated radiotherapy (IMRT), stereotactic radiosurgery (SRS), stereotactic body radiotherapy (SBRT), and proton beam therapy (PBT); intraoperative radiotherapy (IORT); image-guided radiation therapy (IGRT); and brachytherapy. We proposed to include all of these modalities because they are the most commonly used to treat the 17 proposed cancer types..."
"We thank commenters for their support of including brachytherapy as well as those commenters expressing their concerns and their suggestions. An episode-based payment covers all included RT services furnished to an RO beneficiary during a 90-day episode. Bundled episode payment rates are premised on the notion of averages. The cases including a combination of EBRT and brachytherapy described by the commenters are part of the set of historical episodes included in the averages that determine the national base rates and contribute to how payment amounts are valued, and, therefore, an adjustment for multiple modalities that include brachytherapy is not warranted at this time. Also, the case mix and historical experience adjustments help account for the costlier beneficiary populations in the participant-specific episode payment amounts. We will be monitoring for change in treatment patterns throughout the Model performance period and will consider modifications to the pricing methodology in future years of the Model should it be warranted. We believe that including brachytherapy in the Model supports this modality as high value, and also that including it preserves the goal of the Model in establishing a true bundled approach to radiotherapy that is also site neutral and modality agnostic. And, we believe that the proposed and finalized pricing methodology and subsequent national base rates for each cancer type accounts for the cost of brachytherapy as a primary modality and if furnished in conjunction with EBRT. We recognize the billing complexity when separate RT providers and RT suppliers furnish the brachytherapy and EBRT and will address this in billing guidance provided to RO participants. We will monitor for any unintended consequences of the Model on multimodality treatment that includes both external beam and brachytherapy. As for the concern that errors in the claims data (specifically those that commenters believe stem from incorrect attribution of CPT®/HCPCS codes to certain modalities) underrepresented the true cost of delivering a combination of modalities like EBRT and brachytherapy, we rely on the data submitted on claims by providers and suppliers to be accurate per Medicare rules and regulations. We are finalizing the provision to include brachytherapy in the RO Model."
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Yikes. Surprise! It’s a confusing law. It’s a feature not a bug. CMS generally has a nice history of effing with rad onc in inscrutably obtuse and maddening ways. Nice to see they aren’t changing their ways.
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ASTRO's latest summary indicates brachytherapy is OUT. Page 5
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I thought so. Right now we are all in what McNamara called “the fog of war.”
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Who is the APM rad onc who was chosen to lead it from a zip not on APM?
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I can't figure this out.
Though I want to point out something that's not in the excellent article by Dr. Luh.
There are centers in metros covered by APM who are PPS exempt. Since they will be exempt from APM, but all centers in the area will be subject to APM, they will have a massive advantage over all area competition.
Examples:
MD Anderson
Dana-Farber
Ohio State
Moffitt
U Miami
Fred Hutchinson/SCCA
Are all their satellites also going to be PPS exempt? Several of those systems are already rapidly expanding, and this would be a completely unfair advantage for those systems.
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Lawyers ready to pounce. Incredibly unfair (full disclosure my practice is IN but competitors next county over are OUT)
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What a boondoggle this all is.
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I would imagine that the PPS exemption doesn't only apply to the main sites but to the whole enterprise and all of its tentacles.
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If I treat a patient and get paid by CMS but don’t send a treatment summary to referring, is that fraud?
If I don’t have another rad onc peer review my 8 Gy 1 fraction bone met plan and CMS pays me for the treatment, is that fraud?
I think the answer is yes to the previous questions.
If I don’t have another rad onc peer review my 8 Gy 1 fraction bone met plan and CMS pays me for the treatment, is that fraud?
I think the answer is yes to the previous questions.
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You only get to bill for half the payment at the start of an episode. You must wait 28 days to bill the last half. So there will be some of our palliative patients who will die after palliative RT is finished to whom we must send a bill for the final 50% of their treatment.
CMS has designed a model where we will be forced to send medical bills with “date of service” for a time after the patient is dead.
Haley Joel Osment saw dead people.
In the RO-APM we bill dead people.
CMS has designed a model where we will be forced to send medical bills with “date of service” for a time after the patient is dead.
Haley Joel Osment saw dead people.
In the RO-APM we bill dead people.
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I cant’t imagine being the APM czar for a quick buck. That gal/guy will for sure be a very well liked individual. I would like to nominate exemplars of our great community like LK/PW. I mean what the hell do they have to lose?
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This is the craziness of it all. APM is going to widen the gulf between have and have nots.
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Yes, it's truly anti-competitive nonsense.
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There is one common thread--all of us rank-and-file rad oncs will be the have nots.
The PPS exempt centers don't pay better, and they aren't going to share that wealth with us.
The message for the rad oncs working at the PPS centers will be: "where are you going to go? Everyone else is having their pay cut, so should you."
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You're still very early in the grieving process. Give it time!
I can't help but think the Anger portion this Kubler Ross rad onc cycle is going to be someone with some stroke standing up (Bill Murray in Rushmore style speech - "take dead aim") and firing at the PPS exempt places.
We had some rumblings (?a paper and then some twitter chatter), but the potential is there for it to gain some steam.
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