Lol! Not even addressed in the podcast! You guys are awesome !
Trying to drag this thread back to its intent: Simul, any chance you guys can do a follow-up episode on APM, specifically with Adler or Hubbard or Luh, with the release of the final ruling?
As has been talked about now for a couple years across scattered threads, I would love to hear if ASTRO/ACRO/ACR etc ever pressed CMS about their decision to essentially build a model with "pro bono" radiation services. There was nothing I could find in the final ruling about it.
To clarify what I mean for people just catching up on APM (
and written for the lurkers who might be medical students or docs from other specialties, because I think this is confusing to a lot of people): a common scenario is for a patient with metastatic cancer to be referred to us for palliation. Hypothetically, let's say a woman with newly diagnosed metastatic lung cancer, with mets only to bone. She presents with a lytic lesion in her left femur which causes her significant pain. MedOnc wants us to zap it for pain relief while they get things in place to start systemic treatment. Most of us would treat it with 1-10 fractions, either 3D or SBRT, and from seeing us in consult to completing treatment, she would be "done" for this bone met in 1-3 weeks, and then go on to systemic treatment with MedOnc.
Currently, this is billed to Medicare as FFS (fee-for-service), where each step along the way has a code, each code is submitted to CMS, and each code is reimbursed for a specific dollar amount. This reimbursement is split into a "professional fee" (pro fee) and a "technical fee". To
grossly over simplify, if this patient is being treated by a RadOnc in private practice, the pro fee goes to the doctor and the technical fee goes to the hospital.
Let's say we're super efficient and she's done with radiation to the femur lesion in 1 week from consult to completing treatment. 5 weeks later she develops acute aphasia and a brain MRI is obtained. It shows 2 new small lesions in the brain. For the sake of argument, she doesn't have any actionable mutations so we can't use a CNS-penetrant drug. MedOnc refers her back to use for SRS. We re-consult and treat her with SRS, and she's treated with 1-5 fractions. Again, from start to finish, she could be done in 1-3 weeks.
The brain treatment is also billed fee-for-service, so for every step in her care, the doctor and hospital are reimbursed for their work.
In this hypothetical scenario, this patient has received two different treatments to two different anatomical locations. From the first consult to the end of the second treatment, this all took place in no more than ~65 days.
Under APM this would be totally different. Using this same timeline, when the patient starts the treatment planning process for the bone met, it triggers the "Bone Met" episode of care. That means no matter what type of treatment you choose to do, you're getting reimbursed a flat amount (still split into a professional and technical component). That episode is 90 days in length, and
covers any and all radiation services delivered in those 90 days.
So, when that patient comes back for the brain mets 5 weeks after the bone treatment (and 6 weeks after first consult),
absolutely none of that work is reimbursed. Even though this second course of treatment has nothing to do with the femur treatment, and is completely new and requires significant effort by the entire Radiation Oncology team - it doesn't matter.
Well, I shouldn't say it doesn't matter entirely. CMS has decided in these instances of two (or more) treatments delivered in one 90 day window to different sites, it will graciously reimburse the doctor and hospital for whichever one has the higher flat rate (at least that's my understanding).
Now, a counter argument might be that this situation isn't common enough that this will matter. However, looking at the patients who received radiation treatment at my hospital this month, I would estimate that maybe 2-5% of patients would be described in this scenario. Is that a low number? Sure. But I picked the SRS case example because that's often what happens in this era of oligomets and hyper-precise radiation therapy. Metastatic patients are doing well, living longer, and coming to us for "spot welding" stubborn lesions.
Treating oligomets with SBRT and SRS requires significant manpower and expertise, and can have prolonged treatment times which means that other patients aren't getting treated, which can have additional downstream effects. As it is written, APM means all of this work would be done pro bono.
You might still be thinking eh, 2-5%, whatever dude, eat the costs. While 2-5% at any individual site might be a small number, multiply this across the system. For just this forced experimental period, there's somewhere between 900-1000 sites. That's a potentially tremendous amount of complex medicine being delivered by thousands of highly skilled professionals using millions of dollars in advanced technology for free.
EVEN IF this is an uncommon scenario, this will invariably alter how medicine is practiced, to the potential detriment to the patient. Perhaps, for our hypothetical woman with metastatic lung cancer, when the MedOnc tries to get her back in for the new brain lesions, the RadOnc clinic is "too booked up to get her scheduled", and she is pushed out several weeks till a new episode can be triggered (or FFS can be billed in the 28 day washout period). Maybe when MedOnc tries to make the referral, the patient is instead discussed at Tumor Board again and it is strongly recommended they try some sort of agent with dubious CNS penetrance before going to SRS. Maybe she is seen by RadOnc, and the lesions are small, and she is scheduled for short interval follow-up to "let the lesions declare themselves, maybe it's just an old infarct" or "the lesions are too small to be targeted safely right now".
It would be one thing if the patient developed some sort of side effect from the femur radiation, which required her to have a few follow-up appointments with some prescriptions or something, and all of that would be considered part of the flat episode reimbursement. It's entirely different to say that literally any and all radiation services delivered in a 90-day window will get one reimbursement, if those services include entirely new lesions with entirely new treatments.
That makes absolutely no sense, unless the government wants to incentivize delays in repeat courses of radiation treatment, which would likely cause MedOnc to prescribe more Keytruda or Opdivo to manage patients in those delays, meaning Merck and Bristol Myers Squibb make more money, so they can pay their lobbyists more and...oh wait, I get it now.
pubmed.ncbi.nlm.nih.gov
