ROCR

[deleted1111261]

Aside from obvious issues (proton/adaptive/SGRT carve out, PPS exemption exemption, etc., lack of transparency, etc.), what are you all thinking?

- case rates make a lot of sense in our world; however, prior auth cannot be the rationale - pure MCR does not have prior auth
- playing with spreadsheet, pro fees actually do quite well in the model, especially if you tx SOC with regards to fx
- they actually go up faster than FFS estimates up until 2028 and the spread between ROCR and FFS actually grows with time
- stability ... well, until 2028. What I don't understand is how our reimbursement is protected / stabilized and for what time period. I've asked Keole and others this, and they circle around answer by saying "it will be worse if we don't do it" rather than why/how it is protected/stabilized.
- the 90 day episode length is problematic for mets; that is going to have to get adjusted. I think the most noise needs to be made about this and I do believe it will be modified.
- technical takes a hit; and b/c technical is majority of reimbursement, it appears that the gross total payment is decreased - the spreadsheet does not combine the spreadsheets which is super annoying but I'm sure @elementaryschooleconomics can fix that for us.
- if I were pro fee guy, I'd be generally okay with this; if I am overall looking at it as a hospital, I'm a little less okay with it b/c my guess is that as prof:tech increases, prof+tech decreases.
- this is a small percentage of my patients b/c Medicare Advantage and commercial insurers are exempted; this is for most people in practice these days.
- the accreditation measure is 100% bullsh*t, please do not undervalue this statement, it is yet another money grab
- "quality" can also mean too few fractions or under-utilization of technology; why do IMRT even if better if you can do 3D cheaper? Why do 67/15 when you can 50/5? Can lead to some risk taking in the opposite direction
- if commercial and MA plans do not follow suit in a meaningful way, I am uncertain that this will be affecting us other than on the margins - i.e. - If I earned 600,000 in pro fees and 100,000 were Medicare and I'm getting a 4% increase to 104,000, but the hospital is getting a 1% decrease in their 400,000, it's a wash and they may decide to reduce your $/RVU

But, I'm interested in hearing a technical discussion of this part. I see no path to getting rid of the proton or PPS exemption exemptions, as their lobby is their lobby + ASTRO.

Burning it down is an option and it is very possible with grassroots effort, but for the near short future, that means we are gonna take a decent hit with no guarantees that cuts won't be deeper later.

Have asked Keole to come on to SDN and give some long form thoughts rather than tweets, hopefully he can do that soon. Maybe Vapiwala can join, too.

---

Members don't see this ad.

 

[fiji128]

Aside from obvious issues (proton/adaptive/SGRT carve out, PPS exemption exemption, etc., lack of transparency, etc.), what are you all thinking?

- case rates make a lot of sense in our world; however, prior auth cannot be the rationale - pure MCR does not have prior auth
- playing with spreadsheet, pro fees actually do quite well in the model, especially if you tx SOC with regards to fx
- they actually go up faster than FFS estimates up until 2028 and the spread between ROCR and FFS actually grows with time
- stability ... well, until 2028. What I don't understand is how our reimbursement is protected / stabilized and for what time period. I've asked Keole and others this, and they circle around answer by saying "it will be worse if we don't do it" rather than why/how it is protected/stabilized.
- the 90 day episode length is problematic for mets; that is going to have to get adjusted. I think the most noise needs to be made about this and I do believe it will be modified.
- technical takes a hit; and b/c technical is majority of reimbursement, it appears that the gross total payment is decreased - the spreadsheet does not combine the spreadsheets which is super annoying but I'm sure @elementaryschooleconomics can fix that for us.
- if I were pro fee guy, I'd be generally okay with this; if I am overall looking at it as a hospital, I'm a little less okay with it b/c my guess is that as prof:tech increases, prof+tech decreases.
- this is a small percentage of my patients b/c Medicare Advantage and commercial insurers are exempted; this is for most people in practice these days.
- the accreditation measure is 100% bullsh*t, please do not undervalue this statement, it is yet another money grab
- "quality" can also mean too few fractions or under-utilization of technology; why do IMRT even if better if you can do 3D cheaper? Why do 67/15 when you can 50/5? Can lead to some risk taking in the opposite direction
- if commercial and MA plans do not follow suit in a meaningful way, I am uncertain that this will be affecting us other than on the margins - i.e. - If I earned 600,000 in pro fees and 100,000 were Medicare and I'm getting a 4% increase to 104,000, but the hospital is getting a 1% decrease in their 400,000, it's a wash and they may decide to reduce your $/RVU

But, I'm interested in hearing a technical discussion of this part. I see no path to getting rid of the proton or PPS exemption exemptions, as their lobby is their lobby + ASTRO.

Burning it down is an option and it is very possible with grassroots effort, but for the near short future, that means we are gonna take a decent hit with no guarantees that cuts won't be deeper later.

Have asked Keole to come on to SDN and give some long form thoughts rather than tweets, hopefully he can do that soon. Maybe Vapiwala can join, too.

Burn it down b/c "stability ... well, until 2028. What I don't understand is how our reimbursement is protected / stabilized and for what time period. I've asked Keole and others this, and they circle around answer by saying "it will be worse if we don't do it" rather than why/how it is protected/stabilized."

I just don't understand why if you enter into this model cuts won't made in the future. I have seen zero explanation from anyone on Twitter or where ever as to how/why this buys us "stability." In the long term, I would think cuts will be even easier to make with this model.

Don't trust it, don't trust the people behind it, so its a hard pass for me.

 

[BobbyHeenan]

Good post.

I too think it would actually increase my pro fees.

The 90 day period for mets absolutely needs changed. It's one thing to pay me less, but it's another to suggest I do work and can't get paid at all just because we found something else that needs treated within 3 months.

Accreditation is trash. We are getting "quality metric'd" to death (MIPS, CoC, etc) without any high quality data to suggest it helps. And all of these have cost and labor issues associated with them. You want to know why we have so many do-nothing middle managers, because there's so many quality metrics to show on paper you meet.

I still haven't seen any mention of by what mechanism this would "stabilize" payments. Why wouldn't they just continue to decrease by X%/year the same way they have been in FFS?

 

[communitydoc13]

It's fine. Agree with all of your points. The carve outs are the most pathological part, but I guess this process of consolidation and pushing ions is inexorable. (as an aside, just personally heard of 2 cases of brain/brainstem necrosis in 2 peds patients treated for medulloblastoma by protons, and to think what these dose regimens are!)

Nobody at CMS is looking to preserve big baller docs (and they shouldn't), but I wish they could see that you need to emphasize decentralization and local investment when it comes to clinical care.

I could take a 50% haircut, true single payor, no PPS exemption, no ion carve out, a more generous grant environment for true academic research and a commitment from the feds to support community medical care any day. (I would like to stay richer of course.)

All of a sudden, radonc leadership would take it upon themselves to address our single biggest question, "how do we continue to make radiation oncologists more relevant and more useful in today's changing oncology landscape"......it's not ions.

What I don't understand is how our reimbursement is protected / stabilized

It's never really protected/stabilized. We are prone to discretionary whims no matter what. It's a cultural thing/gesture, and feds don't like to hear about docs driving super cars.

 

[metallica81788]

, and feds don't like to hear about docs driving super cars.

:time to go private with the car thread:

 

[elementaryschooleconomics]

We are prone to discretionary whims no matter what. It's a cultural thing/gesture, and feds don't like to hear about docs driving super cars.

What if we rolled our discussions about super cars into tranches, called them something fancy....like, "here are some bespoke physician mental securities", assigned them a value using some AI-powered fintech platform, and sold them to politicians and regulators?

Sure, on an individual level, threads about cars might have no value, but roll them together and give 'em Castle Connolly's "Best Triple AAA" rating: BOOM. We're in business, baby!

 

[communitydoc13]

threads about cars might have no value

Thread is great, but I know how (at least some) feds think.

 

[elementaryschooleconomics]

Thread is great, but I know how (at least some) feds think.

Politicians and federal employees are real interested in keeping us pesky doctors in line...

...until either they or a loved one gets sick. Then it suddenly becomes "spare no expense".

 

[NotMattSpraker]

Aside from obvious issues (proton/adaptive/SGRT carve out, PPS exemption exemption, etc., lack of transparency, etc.), what are you all thinking?

- case rates make a lot of sense in our world; however, prior auth cannot be the rationale - pure MCR does not have prior auth
- playing with spreadsheet, pro fees actually do quite well in the model, especially if you tx SOC with regards to fx
- they actually go up faster than FFS estimates up until 2028 and the spread between ROCR and FFS actually grows with time
- stability ... well, until 2028. What I don't understand is how our reimbursement is protected / stabilized and for what time period. I've asked Keole and others this, and they circle around answer by saying "it will be worse if we don't do it" rather than why/how it is protected/stabilized.
- the 90 day episode length is problematic for mets; that is going to have to get adjusted. I think the most noise needs to be made about this and I do believe it will be modified.
- technical takes a hit; and b/c technical is majority of reimbursement, it appears that the gross total payment is decreased - the spreadsheet does not combine the spreadsheets which is super annoying but I'm sure @elementaryschooleconomics can fix that for us.
- if I were pro fee guy, I'd be generally okay with this; if I am overall looking at it as a hospital, I'm a little less okay with it b/c my guess is that as prof:tech increases, prof+tech decreases.
- this is a small percentage of my patients b/c Medicare Advantage and commercial insurers are exempted; this is for most people in practice these days.
- the accreditation measure is 100% bullsh*t, please do not undervalue this statement, it is yet another money grab
- "quality" can also mean too few fractions or under-utilization of technology; why do IMRT even if better if you can do 3D cheaper? Why do 67/15 when you can 50/5? Can lead to some risk taking in the opposite direction
- if commercial and MA plans do not follow suit in a meaningful way, I am uncertain that this will be affecting us other than on the margins - i.e. - If I earned 600,000 in pro fees and 100,000 were Medicare and I'm getting a 4% increase to 104,000, but the hospital is getting a 1% decrease in their 400,000, it's a wash and they may decide to reduce your $/RVU

But, I'm interested in hearing a technical discussion of this part. I see no path to getting rid of the proton or PPS exemption exemptions, as their lobby is their lobby + ASTRO.

Burning it down is an option and it is very possible with grassroots effort, but for the near short future, that means we are gonna take a decent hit with no guarantees that cuts won't be deeper later.

Have asked Keole to come on to SDN and give some long form thoughts rather than tweets, hopefully he can do that soon. Maybe Vapiwala can join, too.

Please send these comments to that ASTRO “feedback” email. No idea what will happen to them but at least they were sent then. They are great comments.

I too am wondering why this guarantees stability?

As one of the growing group of employed rad oncs, I’m worried what decreased technical will do to my life as a cog haha.

 

[TheWallnerus]

ASTRO data showing about 315K Medicare patients irradiated per year.

Spread that out over 5000 rad oncs? That’s 1-2 patients per week per rad onc.

Unless the ROCR is crazy bad, it’s not going to hurt at the individual MD level that bad. It may wind up being net positive, but the benefit (again at individual level) will be barely felt also.

The reason to get ROCR right and/or fear it is: it crafts a complete new payment rubric for insurances to follow. And they will.

 

[Ray D. Ayshun]

What if we rolled our discussions about super cars into tranches, called them something fancy....like, "here are some bespoke physician mental securities", assigned them a value using some AI-powered fintech platform, and sold them to politicians and regulators?

Sure, on an individual level, threads about cars might have no value, but roll them together and give 'em Castle Connolly's "Best Triple AAA" rating: BOOM. We're in business, baby!

Perception ain't reality. All 3 of my therapists have pricier cars than I. I just can get a 911. I suspect I never will.

 

[medgator]

Perception ain't reality. All 3 of my therapists have pricier cars than I. I just can get a 911. I suspect I never will.

That's what I like about having A Tesla now vs in 2015 when i bought. Fun but far less exclusive

 

[Rad Onc SK]

Aside from obvious issues (proton/adaptive/SGRT carve out, PPS exemption exemption, etc., lack of transparency, etc.), what are you all thinking?

- case rates make a lot of sense in our world; however, prior auth cannot be the rationale - pure MCR does not have prior auth
- playing with spreadsheet, pro fees actually do quite well in the model, especially if you tx SOC with regards to fx
- they actually go up faster than FFS estimates up until 2028 and the spread between ROCR and FFS actually grows with time
- stability ... well, until 2028. What I don't understand is how our reimbursement is protected / stabilized and for what time period. I've asked Keole and others this, and they circle around answer by saying "it will be worse if we don't do it" rather than why/how it is protected/stabilized.
- the 90 day episode length is problematic for mets; that is going to have to get adjusted. I think the most noise needs to be made about this and I do believe it will be modified.
- technical takes a hit; and b/c technical is majority of reimbursement, it appears that the gross total payment is decreased - the spreadsheet does not combine the spreadsheets which is super annoying but I'm sure @elementaryschooleconomics can fix that for us.
- if I were pro fee guy, I'd be generally okay with this; if I am overall looking at it as a hospital, I'm a little less okay with it b/c my guess is that as prof:tech increases, prof+tech decreases.
- this is a small percentage of my patients b/c Medicare Advantage and commercial insurers are exempted; this is for most people in practice these days.
- the accreditation measure is 100% bullsh*t, please do not undervalue this statement, it is yet another money grab
- "quality" can also mean too few fractions or under-utilization of technology; why do IMRT even if better if you can do 3D cheaper? Why do 67/15 when you can 50/5? Can lead to some risk taking in the opposite direction
- if commercial and MA plans do not follow suit in a meaningful way, I am uncertain that this will be affecting us other than on the margins - i.e. - If I earned 600,000 in pro fees and 100,000 were Medicare and I'm getting a 4% increase to 104,000, but the hospital is getting a 1% decrease in their 400,000, it's a wash and they may decide to reduce your $/RVU

But, I'm interested in hearing a technical discussion of this part. I see no path to getting rid of the proton or PPS exemption exemptions, as their lobby is their lobby + ASTRO.

Burning it down is an option and it is very possible with grassroots effort, but for the near short future, that means we are gonna take a decent hit with no guarantees that cuts won't be deeper later.

Have asked Keole to come on to SDN and give some long form thoughts rather than tweets, hopefully he can do that soon. Maybe Vapiwala can join, too.

Disclaimer: I wasn’t a part of designing ROCR. I learned about it 2-3 weeks prior to its announcement to the RO community, but only the generalities of it. I didn’t see the meat of it until everyone else did. The following thoughts are my personal opinions and in no way, shape, or form represent ASTRO or the ROCR architects. I’ll try to follow Simul’s bullet points.

Case rates make sense, as you said. It’s not easy to put together something that is logical and has a defense, which ROCR does (CMS 90 day case episodes).

As a pure MC model, this does not directly help with PA, as SP noted. But as we see, MA plans are already piloting far more extreme bundle pilots. We have one in the PHX market although I don’t know the details. I suspect the involved practices are in an NDA, but I don’t know that for a fact. I do think a case rate methodology from RO community stakeholders will be strongly considered by MA Plans and commercial plans, but that’s a hunch.

Reimbursement in ROCR is not within CMS. ROCR is going through Congress. That’s why it’s more likely to be stabilized.

Agree on 90-day episode,…potentially. ROCR developers thought about this. The current 90-day episode is a weighted average and therefore includes additional treatment courses, driving it up. That being said, I can see the concerns over 90-day episode for mets. ASTRO Webinar will tackle this as many stakeholders have brought this up. They can explain it far better than me.

Accreditation – upside, this would replace MIPS. My former practice in OK has more people working on MIPS than billing and coding. I think it’s necessary to get Congressional buy-in but you can ask the experts yourself on July 21.

I don’t think I understand “why do IMRT even if better if you can do 3D cheaper?” These days, you can often do IMRT faster and plans are better. Coverage policies don’t always allow this, however. ROCR fixes this.

Usually, as MC goes, MAP and commercial follow. But as you say, there’s no guarantee they would. But why wouldn’t they? Insurance wants stability and predictability even more than we do. It makes their actuaries happy.

As you said, PPSE and P+ are difficult/impossible to include. PPSE had a GAO report (in 2015) that didn’t move the needle one bit. P+ lobby was very effective vs. RO-APM. Including either, in my PERSONAL opinion, makes ROCR impossible to pass. That’s my PERSONAL opinion.

“Burning it down”,…always a possibility. But be careful what you wish for. Todd S had a great graph of 77295 reductions over the past 20 years. Why would 77301 (and other codes) be different?

Plea: Please model your own practice. Give feedback. ASTRO staff and volunteers are looking at it. There are a lot of GREAT points coming in.

One final note: I spoke with a rad onc who didn’t think ASTRO has done a good job in preventing code cuts. I could not disagree more. I wish people who felt this way would participate in HP and see the work that goes into preparing for RUC meetings. Our staff and volunteers pour their hearts out to defend the value of the services we provide to our patients. They have done an incredible job and it’s sad that their efforts are not recognized and/or appreciated.

 

[elementaryschooleconomics]

One final note: I spoke with a rad onc who didn’t think ASTRO has done a good job in preventing code cuts. I could not disagree more. I wish people who felt this way would participate in HP and see the work that goes into preparing for RUC meetings. Our staff and volunteers pour their hearts out to defend the value of the services we provide to our patients. They have done an incredible job and it’s sad that their efforts are not recognized and/or appreciated.

Conflating criticism of ASTRO's strategy and efficacy with the people who are volunteering on this work is how this usually goes off the rails.

I would never question the motivations or intent of the volunteers working on various advocacy issues.

What I would always question, however, is the high-level vision and tactics of the organization itself.

At the end of the day, CMS will do what it wants to do. The AMA RUC meeting can, in the end, only make suggestions. Eichler's Red Journal article is a great summary of how this has played out over the last decade:

When IMRT rocketed on the scene and the government noticed, ASTRO's plan was to go after UroRads by focusing on self-referral??? One of the smallest specialty societies in all of medicine openly targeted bad actors in a significantly larger, more powerful specialty, and chose for a weapon SELF-REFERRAL? Something that birthed Stark and AKS 30 years ago, some of the murkiest and worst legislation ever written? I genuinely feel bad for the volunteers who put effort into ASTRO's strategy then.

So the government demanded to/through RUC something be done about it. So ASTRO got the RUC to agree to revised codes...only for the government to do what they wanted to do anyway.

While technically true, RadOnc is just a piece:

PAMPA is what birthed RO-APM in the first place, which the government, as always, did what it wanted to do for it:

Let's be honest here: if COVID hadn't happened, then we'd be living in an APM world right now. A once-in-a-century pandemic happened JUST as comments were supposed to be delivered? Come on. What are the odds?

"ASTRO spent considerable time and money" to write that 2019 letter. What does that mean? Let's go check the 990 filing from 2019 for ASTRO:

They put a whole $150k in the PAC...with over $23 million in revenue that year. The top 5 contractors (paid over $100k) ASTO is required to disclose were all related to the conference, so if they hired anyone outside to help, they spent less than $400k (the lowest of the top 5).

What it really boils down to is this: when ASTRO is criticized for not defending the specialty, specifically pertaining to reimbursement, the same two-part counter-argument is always made:

1) The members and volunteers work hard
2) It could have been worse

It's not compelling. Working hard on a bad strategy doesn't change the fact that it's a bad strategy.

But to your other point: if I were to pay my membership dues and join again, and ask to be on the Health Policy Committee to see the hard work for myself, I'm sure ASTRO would bring me on the committee without issue, right?

Right?

 

[medgator]

@elementaryschooleconomics

 

[Chartreuse Wombat]

Related.

The Medicare Physician Fee Schedule and Unethical Behavior

This Viewpoint discusses the Medicare Physician Fee Schedule and its flaws, including how they might be remedied by severing CMS dependence on Relative Value Update Committee estimates of time and intensity.

jamanetwork.com

"When physicians’ judgments of time determine their own payment through the MPFS’s relative ranking of services, then inaccuracies, distortions, and false statements become incentivized and accepted as the social norm."

 

[Mandelin Rain]

Reimbursement in ROCR is not within CMS. ROCR is going through Congress. That’s why it’s more likely to be stabilized.

The attempt is to pass this as Congressional legislation? And still not going for the gold? Now I know Congresspeople notoriously comb every line and detail of bills that get approved, but if you're already making the correct campaign contributions and have a powerful proton lobby glad handing them, why not go for a 15-20% raise? After years of cuts, this could easily be justified. The cost is not even a crumb on a congressional budget.

Completely feckless.

 

[communitydoc13]

+ lobby was very effective vs. RO-APM

Why? Per assessment of proton volumes through 2018, you were talking about low single digits percentile wise in terms of total XRT.

If you add up all Canadian patients deemed appropriate for transfer to US for proton care per annum, you are talking about ~50 patients. (This is a system that presumably actually makes value based judgements on care).

Who is in this lobby?

By the time you consider relative proton treatment volumes nationally and scale to the entire expenditure of radonc relative to costs of individual drugs in cancer care (as appropriately delineated in proposed ROCR), you are talking about what % of the layouts associated with a given drug? If it's more than a few %, it tells you all you need to know about protons in terms of high value care.

How is this lobby so powerful? Is it the disproportionate amount of proton care given to our most affluent? Is it the convergence of protons, PPSE and elite financial interests?

Reimbursement in ROCR is not within CMS. ROCR is going through Congress. That’s why it’s more likely to be stabilized.

Is this true? Recent supreme court ruling on student loans aside, doesn't CMS (as an executive branch entity) have remarkable discretionary power regarding actual payments year over year?

 

[elementaryschooleconomics]

The attempt is to pass this as Congressional legislation? And still not going for the gold? Now I know Congresspeople notoriously comb every line and detail of bills that get approved, but if you're already making the correct campaign contributions and have a powerful proton lobby glad handing them, why not go for a 15-20% raise? After years of cuts, this could easily be justified. The cost is not even a crumb on a congressional budget.

Completely feckless.

Bingo.

ASTRO has never gotten anything through Congress. They can grandstand about PAMPA but...RadOnc was mostly along for the ride with that one.

So now they're throwing a Hail Mary and attempting something without precedent? Authoring the model in secret and then surprising the vast majority of Radiation Oncologists with it via their email newsletter? And they're seeking stakeholder support?

ASTRO. Come on guys. This isn't how you rally the troops. This is how you drive more folks away.

 

[Mandelin Rain]

How is this lobby so powerful? Is it the disproportionate amount of proton care given to our most affluent? Is it the convergence of protons, PPSE and elite financial interests?

They have buy in, investment, and financial entanglements with the right people.

It almost seems like the "proton lobby" wants to ensure the only financially viable way forward is to buy a cyclotron.

Virtuous.

 

[communitydoc13]

Authoring the model in secret and then surprising the vast majority of Radiation Oncologists with it via their email newsletter?

They have buy in, investment, and financial entanglements with the right people.

It's almost anti-democratic. Which is how many young people view our system overall.

Bottom line to me on the model?

Per case payment makes sense to most practitioners (me included), but proposed model will likely make XRT less of a money maker for most community hospitals, many of which are already teetering financially. If your community hospital goes under, your practice goes under.

Many community hospitals are already looking to merger type agreements/buy outs and @elementaryschooleconomics has already proposed several reasonable avenues for community hospitals to cede independence to preserve viability. None of these avenues works to benefit the community radiation oncologist. All of these avenues work towards consolidation of XRT services to a few large players. This model only incentivizes further consolidation. The UPENNs will only get bigger.

The carve outs for P+ and PPSE are of course the most important part. The most important thing is establishing P+ and XRT at elite places as being a "sacred cow" as inevitable major changes in health care payment move forward over the next several decades.

There are two opposing power dynamics that any prospective radonc should be aware of.

1. Within oncology at a national scale (and medicine overall), radonc is tiny, is considered ancillary, and will be a small player regarding global payment and other decisions (including clinical guidelines) going forward.

2. Because of peculiarities regarding remuneration, a radonc chair at a large academic place may be disproportionately influential within upper admin and particularly within the c-suite crowd. This relative influence has much more to do with the scale of capitol outlays, the relative prevalence of prostate cancer among the elite (including 60+ year old men in positions of power within their institution), and the finances of their department, than it does with any meaningful research coming from their department.

 

[elementaryschooleconomics]

2. Because of peculiarities regarding remuneration, a radonc chair at a large academic place may be disproportionately influential within upper admin and particularly within the c-suite crowd. This relative influence has much more to do with the scale of capitol outlays, the relative prevalence of prostate cancer among the elite (including 60+ year old men in positions of power within their institution), and the finances of their department, than it does with any meaningful research coming from their department.

 

[TheWallnerus]

Because of peculiarities regarding remuneration, a radonc chair at a large academic place may be disproportionately influential within upper admin and particularly within the c-suite crowd

I think this is true but that said still worth mentioning the pride swallowing siege Halperin seemed to have to go through on the way to a deanship (if there’s a specialty other specialties seem prejudiced or dismissive towards it’s rad onc)

 

[NotMattSpraker]

It's almost anti-democratic. Which is how many young people view our system overall.

Bottom line to me on the model?

Per case payment makes sense to most practitioners (me included), but proposed model will likely make XRT less of a money maker for most community hospitals, many of which are already teetering financially. If your community hospital goes under, your practice goes under.

Many community hospitals are already looking to merger type agreements/buy outs and @elementaryschooleconomics has already proposed several reasonable avenues for community hospitals to cede independence to preserve viability. None of these avenues works to benefit the community radiation oncologist. All of these avenues work towards consolidation of XRT services to a few large players. This model only incentivizes further consolidation. The UPENNs will only get bigger.

The carve outs for P+ and PPSE are of course the most important part. The most important thing is establishing P+ and XRT at elite places as being a "sacred cow" as inevitable major changes in health care payment move forward over the next several decades.

There are two opposing power dynamics that any prospective radonc should be aware of.

1. Within oncology at a national scale (and medicine overall), radonc is tiny, is considered ancillary, and will be a small player regarding global payment and other decisions (including clinical guidelines) going forward.

2. Because of peculiarities regarding remuneration, a radonc chair at a large academic place may be disproportionately influential within upper admin and particularly within the c-suite crowd. This relative influence has much more to do with the scale of capitol outlays, the relative prevalence of prostate cancer among the elite (including 60+ year old men in positions of power within their institution), and the finances of their department, than it does with any meaningful research coming from their department.

These points are so vital and I suspect these are the crux of why ASTRO feels the need to be so secretive here.

In case people missed it, ASTRO covered consolidation in Nov 2021 in the Red Journal and PRO. Then they had a surprisingly one-sided podcast about the benefits of consolidation featuring Zietman and Harvard Faculty. Direct link to that below if interested. It seemed so odd to me at the time, but it makes total sense in the big picture.

https://www.redjournal.org/pb-assets/Health%20Advance/journals/rob/111_3_November_1_2021_RJ_Highlights-1632252965060.mp3

 

[elementaryschooleconomics]

These points are so vital and I suspect these are the crux of why ASTRO feels the need to be so secretive here.

In case people missed it, ASTRO covered consolidation in Nov 2021 in the Red Journal and PRO. Then they had a surprisingly one-sided podcast about the benefits of consolidation featuring Zietman and Harvard Faculty. Direct link to that below if interested. It seemed so odd to me at the time, but it makes total sense in the big picture.

https://www.redjournal.org/pb-assets/Health%20Advance/journals/rob/111_3_November_1_2021_RJ_Highlights-1632252965060.mp3

Whoa whoa whoa, we don't talk about that issue, because these Harvard Faculty wizards produced a significantly different, significantly higher workforce estimate than the super special mega-awesome ASTRO Workforce Analysis from March of 2023.

 

[elementaryschooleconomics]

Just wanted to make sure everyone got my reference:

This is why I don't trust ASTRO. November of 2021, they did an issue with practice consolidation and even produced a podcast on it, with the Harvard crew and the former EIC of the Red Journal himself.

5,415 RadOncs in 2017, per that paper.

Less than two years later, in the same journal, the same professional society is publishing wildly different numbers, projecting 400 fewer RadOncs in 2030 than what was previously reported in 2017...

And this isn't even mentioned. No reference to prior numbers or estimates.

Yeah, it's hard to get behind a society's secret payment model when they've got a track record like this.

 

[Jaguaranna27]

Hey all,

I'm new to SDN but have been vocal on Twitter (@Jaguaranna27) and on our podcast and various committees I volunteer for. I'm a community doc but trained at big box academic centers.

The points raised by Simul and Sameer are all excellent. Would highly encourage those who may be less familiar with advocacy work to sit in on a health policy / economics talk (many great ones offered at ACR, AMA, ASTRO, ACRO, ASCO, etc) to fully appreciate the nuances involved in advocacy work on the Hill. I've only learned about all this through volunteer extracurricular work with the AMA and local state medical societies -- not something that is taught in med school or residency.

My personal thoughts on ROCR are all over Twitter. I was highly critical of the way that ASTRO rolled it out (surprise attack!!) which immediately raised suspicions, particularly in light of the flawed workforce and proton policies they rolled out with somewhat perverse stakeholder contributions (listen to Spraker's monologue on The Accelerators Podcast and Beckta's OOTB podcast on these topics, as well as the Jordan Johnson panel webinar that I was featured on to learn more). However, I concede that after talking with Sameer Keole, Ankit Agarwal, and other people who I trust and respect greatly that there are some good features of ROCR. I think the product is good, just the way it was rolled out was bad. I think there could be some helpful changes "with a little help from (#communityoncology) friends"... however, overall I generally agree with Sameer Keole that perfect is the enemy of good and my personal motto is that done is better than perfect.

As I said on Jordan's panel and on my Twitter (@Jaguaranna27), we need a united "house" of #RadOnc to get this done right. ASTRO going out on an island of secrecy and releasing a policy in the middle of the night with limited public channels for input was NOT the right approach. But at least it's a starting point and I do think that ROCR is better than the CMMS RO APM would have been.

Just need to involve ALL the stakeholders of RadOnc, including our allies in oncology (ASCO) and radiology (ACR) as well as the house of medicine (AMA) if we realistically think there's any chance of getting this through Congress. We also need to have some sort of pay cut because it's a dog eat dog world out there and there has to be some reason for Congress to go along with this because they're chomping at the bit to cut health care expenditures generally. I would love to keep the HEART transportation incentive and find some way to make it even more inclusive (though I fully recognize I may have the minority viewpoint there). The fact that there's a transportation stipend at all is a huge win.

To conclude this thought, I think I'm coming around to see the benefit of ROCR but sincerely hope that ASTRO will show by its actions (and not just buzzwords) that it wants to involve all of radonc, not just academic viewpoints, in development of its policies and on important committees.

Fin.

=)

~Anna M Brown, MD, MPhil (formerly Laucis)
Board-Certified Radiation Oncologist
The Accelerators Podcast co-host
Twitter: @Jaguaranna27
Instagram: @ drannambrown
LinkedIn: https://www.linkedin.com/in/annambrownmdmphil

 

[sirspamalot]

ROCR: Realistically Only Reducing Reimbursement

CMS thinks you're an a$$hole for determining your own value. ASTRO laughs at you while excluding you from the conversation and spends nothing in its budget worth mentioning, to make reimbursement a priority for you.

I propose a new model. One you will truly be able to "get behind" and vociferously support. FYPM#.

In this model, you pay me what another highly trained expert procedural based physician specialist gets. You know, like a neurosurgeon. Or interventional cardiologist.

Now, its true, the only way they could possibly screw me out of my leverage is to make sure there are plenty of hungry, poorly trained, desperate masses willing to take my place. They surely wouldn't go that route right? I mean, that would be terrible for patients.

Just kidding, they don't actually care about patients. Or physician quality. Its about the money.

ITS ALWAYS ABOUT THE MONEY. No amount of waving alphabet soup (ROCR, APM, QI/QA/Accreditation/MIPS) will distract me from understanding this core principle.

FYPM#

"But Sirspam, I can't do anything. I'm just a schmuck trying to make a living out here!"

QUIT PAYING ASTRO. JOIN ACRO. 100.0% of non academic physicans should be in ACRO and 0% in ASTRO (unless of course, they are grifting for something or referrals).

Do something.

 

[Jaguaranna27]

Yeah, it all boils down to money *honey* which is why ASTRO shouldn't have released something as big as ROCR overnight and so secretly when they had been working on it for months and when it would have an arguably dramatic impact on everyone's bottom line (which has the downstream effect of impacting patient care).

But I'm more of an "The only way is through" (Nike slogan) fangirl than a "burn it to the ground" fan. Better to start somewhere than from scratch, but I'm totally with you that for this ROCR to have any chance of gaining more widespread support within the RadOnc community and to even have a chance at getting through Congress, the methodology of ASTRO needs to fundamentally change and be actually inclusive of diverse opinions rather than just say they are whilst featuring the same 10 people of different demographic backgrounds in all their blogs / panels.

Those are my two cents anyway.

And alphabet soup is the bread and butter of Congress and this country, unfortunately. Can't invent a new system - have to work with what we've got. 🤷‍♀️

~AB

 

[TheWallnerus]

Whoa whoa whoa, we don't talk about that issue, because these Harvard Faculty wizards produced a significantly different, significantly higher workforce estimate than the super special mega-awesome ASTRO Workforce Analysis from March of 2023.

View attachment 374203

Just wanted to make sure everyone got my reference:

View attachment 374204

This is why I don't trust ASTRO. November of 2021, they did an issue with practice consolidation and even produced a podcast on it, with the Harvard crew and the former EIC of the Red Journal himself.

5,415 RadOncs in 2017, per that paper.

Less than two years later, in the same journal, the same professional society is publishing wildly different numbers, projecting 400 fewer RadOncs in 2030 than what was previously reported in 2017...

And this isn't even mentioned. No reference to prior numbers or estimates.

Yeah, it's hard to get behind a society's secret payment model when they've got a track record like this.

Have said it before. Will say it again. The lack of a clear, accurate number of practicing radiation oncologists as presented in the Red Journal through the years beclowns it, and thus, by association, beclowns us all. 🤡

 

[Jaguaranna27]

Have said it before. Will say it again. The lack of a clear, accurate number of practicing radiation oncologists as presented in the Red Journal through the years beclowns it, and thus, by association, beclowns us all. 🤡

Yup.

It's not just a transparency issue with ASTRO. It's the issue that disproportionately the leadership is academic ppl who barely practice clinical medicine. Those are not people who should be making key decisions about reimbursement that will affect a large proportion of clinically focused radoncs in the community, imo. Let's get some community radonc representation up in herrrrrr. Or at least give us a seat at the table / allow us to be "in the room where it happens" not in another room silo'ed off while we listen to a webinar with no ability to give live or public feedback.

ROCR rollout rawr

 

[Jaguaranna27]

Sidebar - can I just say I kinda love SDN already...?

Just got awarded a participation trophy lmao

 

[Jaguaranna27]

ROCR: Realistically Only Reducing Reimbursement

CMS thinks you're an a$$hole for determining your own value. ASTRO laughs at you while excluding you from the conversation and spends nothing in its budget worth mentioning, to make reimbursement a priority for you.

I propose a new model. One you will truly be able to "get behind" and vociferously support. FYPM#.

In this model, you pay me what another highly trained expert procedural based physician specialist gets. You know, like a neurosurgeon. Or interventional cardiologist.

Now, its true, the only way they could possibly screw me out of my leverage is to make sure there are plenty of hungry, poorly trained, desperate masses willing to take my place. They surely wouldn't go that route right? I mean, that would be terrible for patients.

Just kidding, they don't actually care about patients. Or physician quality. Its about the money.

ITS ALWAYS ABOUT THE MONEY. No amount of waving alphabet soup (ROCR, APM, QI/QA/Accreditation/MIPS) will distract me from understanding this core principle.

FYPM#

"But Sirspam, I can't do anything. I'm just a schmuck trying to make a living out here!"

QUIT PAYING ASTRO. JOIN ACRO. 100.0% of non academic physicans should be in ACRO and 0% in ASTRO (unless of course, they are grifting for something or referrals).

Do something.

But why cant we just all get along...

can't be an either / or thing. Gotta unite ASTRO / ACRO / ASCO / ACR / AMA somehow.

Agreed ACRO is filling a void right now and giving a space for us to more openly discuss stuff that ASTRO refuses to, which is good. But unless ASTRO vanishes (which it won't bc of generational loyalty) then we have to work with it... they need to be receptive to criticism and hopefully forums like the Early Career Committee (which I'm on and will debut some events at ASTRO annual meeting this year in San Diego) will allow for paving the way for some much needed change and some more actually diverse perspectives.

Most of us in radonc just want to take care of patients and have a good life.

Well, community radonc anyway.

I'm sick of chasing academic titles... would rather enjoy the rivers and lakes of Wisconsin lol. And cheese yummmm 🧀

 

[grenz]

Advocacy Radiation Oncology Case Rate Program FAQs - American Society for Radiation Oncology (ASTRO) - American Society for Radiation Oncology (ASTRO)

The ASTRO-proposed Radiation Oncology Case Rate (ROCR) program represents a bold initiative to reverse disastrous payment trends that are expected to continue. Search here for ROCR FAQs.

www.astro.org

ROCR FAQ just dropped. Answers a lot of the questions that are coming up in this thread.

 

[sirspamalot]

It won't answer the real question: Who stands to really gain from ROCR and who does not.

But we already know the answer don't we...

Why are proton therapy, brachytherapy and radiopharmaceuticals not included in ROCR?​

Proton therapy treatment delivery codes (77520-77525) are currently not valued under the Medicare Physician Fee Schedule. Payments for proton therapy services are instead determined regionally by each Medicare contractor and vary significantly. Additionally, the volume of traditional Medicare patients treated with proton beam therapy is lower than other modalities. These factors make it very challenging to appropriately value the service within an episode-based payment model.


-- And if you can't tell the truth here, then why should I believe another word of any of it?

Why are PPS Exempt Cancer Hospitals excluded from ROCR?​

Because the PPS Exempt Cancer Hospitals are PPS Exempt and paid outside of the Medicare Physician Fee Schedule (MPFS) and the Hospital Outpatient Prospective Payment System, they are effectively part of a unique Medicare payment system and cannot be included in other payment programs.

-- Thats some really good 100% organic cage free vegan USA based premium grade BULL **** (George Carlin has entered the chat....)

 

[Jaguaranna27]

Advocacy Radiation Oncology Case Rate Program FAQs - American Society for Radiation Oncology (ASTRO) - American Society for Radiation Oncology (ASTRO)

The ASTRO-proposed Radiation Oncology Case Rate (ROCR) program represents a bold initiative to reverse disastrous payment trends that are expected to continue. Search here for ROCR FAQs.

www.astro.org

ROCR FAQ just dropped. Answers a lot of the questions that are coming up in this thread.

Well it's actually kinda not so good for the important Qs. Has an "answer" but as I tweeted there's some circular logic going on. Also kinda sucks to spend 8 hours of my life trying my very hardest to understand something complex and send a detailed 6 paragraph email and get a form letter response back of "see our FAQ page". Um... no.

And then the FAQ page circularly directs people to email that weird [email protected] email again. Um... no.

Like why can't you (ASTRO) treat me like a human being and acknowledge that I'm trying to understand ROCR and support it? I have legitimate concerns! Some of which were definitely not fully answered by the FAQs. #sadgirlwednesday

Their form letter impersonal responses after 13 painful days of waiting kinda tell me more than their words that they don't care. That they see me (and perhaps others) as an annoying pest.

Well, I'm gonna keep treating patients in my community. And hope that any alternative payment models proposed will help me continue to keep doing that, rather than actively harm me or my patients.

 

[NotMattSpraker]

It won't answer the real question: Who stands to really gain from ROCR and who does not.

But we already know the answer don't we...

Why are proton therapy, brachytherapy and radiopharmaceuticals not included in ROCR?​

Proton therapy treatment delivery codes (77520-77525) are currently not valued under the Medicare Physician Fee Schedule. Payments for proton therapy services are instead determined regionally by each Medicare contractor and vary significantly. Additionally, the volume of traditional Medicare patients treated with proton beam therapy is lower than other modalities. These factors make it very challenging to appropriately value the service within an episode-based payment model.


-- And if you can't tell the truth here, then why should I believe another word of any of it?

Why are PPS Exempt Cancer Hospitals excluded from ROCR?​

Because the PPS Exempt Cancer Hospitals are PPS Exempt and paid outside of the Medicare Physician Fee Schedule (MPFS) and the Hospital Outpatient Prospective Payment System, they are effectively part of a unique Medicare payment system and cannot be included in other payment programs.

-- Thats some really good 100% organic cage free vegan USA based premium grade BULL **** (George Carlin has entered the chat....)

Some people are so damn good at talking around hard questions where they can't say the real answer. ASTRO should seek out and hire one of these people. I can't even talk to representatives from ASTRO anymore because they are so sleezy in the way they talk, everything they say sounds like a lie.

I've personally said my piece about protons and am pretty shocked that few radiation oncologists are willing to speak out about the updated model policy (separate from ROCR). But, it is what it is I guess.

Since learning they are going the congressional route, I'm now more surprised at their behavior. Any RO can write their representative and speak out for or against this policy if they want. It's not like ASTRO dumps all this money in to congress. You'd think theyd be working harder to win the support of doctors they claim to want to engage.

 

[communitydoc13]

It won't answer the real question: Who stands to really gain from ROCR and who does not.

But we already know the answer don't we...

Why are proton therapy, brachytherapy and radiopharmaceuticals not included in ROCR?​

Proton therapy treatment delivery codes (77520-77525) are currently not valued under the Medicare Physician Fee Schedule. Payments for proton therapy services are instead determined regionally by each Medicare contractor and vary significantly. Additionally, the volume of traditional Medicare patients treated with proton beam therapy is lower than other modalities. These factors make it very challenging to appropriately value the service within an episode-based payment model.


-- And if you can't tell the truth here, then why should I believe another word of any of it?

Agree. This is the definition of specious.

We are talking about tiny amounts of money across the board at a national level. Nothing wrong with using this opportunity to try to address radiopharm compensation, which is clearly a barrier to dissemination. It is also an intervention with a unique set of cases. This means there are not significant, discretionary technical costs associated with choosing radiopharm over another equivalent intervention (there is no equivalent intervention). I would advocate for more radiopharm services in my community if it weren't so easy for it to become a loss leader. Just pick a value that works!

The fact is, appropriately valuing anything is close to impossible. The values assigned to external beam treatment here are assigned because they make sense to the writers in terms of existing culture, risk and perceived opportunity cost (what we could end up getting paid). That is all.

But, the significant benefit of case based payment is that one is not incentivized financially to pick one intervention over another. The doc is incentivized to provide value based care.

If I were in congress, I would ask what the goals of any legislative initiative regarding health care payment and quality should be.

The answers are obvious. The goals should be safer, cheaper, equally effective and more available healthcare services. (I hate to use the term high quality as quality is exceptionally hard to measure).

Safer means less protons and less brachy. Sorry, but safety is largely a measure of avoiding catastrophic outcomes, not the practice of measuring proxy measures. Accreditation is something, but an intrinsic increased potential for catastrophic dosimetry is much more.

Cheap means photons not protons.

Effective? We are talking about interventions that are all roughly isoeffective.

Availability means supporting community hospitals by evening the playing field and making the intervention easy to justify at the community level (peds is obviously undervalued).

But, why does ASTRO think they are going to get this through? Is there some legislative strategy/impending sponsorship that we are not aware of?

 

[elementaryschooleconomics]

Advocacy Radiation Oncology Case Rate Program FAQs - American Society for Radiation Oncology (ASTRO) - American Society for Radiation Oncology (ASTRO)

The ASTRO-proposed Radiation Oncology Case Rate (ROCR) program represents a bold initiative to reverse disastrous payment trends that are expected to continue. Search here for ROCR FAQs.

www.astro.org

ROCR FAQ just dropped. Answers a lot of the questions that are coming up in this thread.

This...this is not an FAQ. This is loading up Google Bard and asking it to rephrase things from the existing documents.

The half-hearted attempt at answering about adaptive is hilarious. They're missing the point (probably intentionally).

Yes, there isn't an "adaptive CPT code".

While I'm sure billing styles vary, it's usually dropping additional sim/planning/etc codes.

How will this be accounted for with the episode/disease site model? Let's say I have a head and neck patient. If I do "regular" VMAT, 70gy in 35fx, I would drop the M-code, but if I do "adaptive" and resim/replan at least once, I get to use the "regular" CPT code mix?

Man, I sense a lot of patients are gonna be in dire need of adaptive radiotherapy. Sign me up for those registry trials!

 

[NotMattSpraker]

This...this is not an FAQ. This is loading up Google Bard and asking it to rephrase things from the existing documents.

The half-hearted attempt at answering about adaptive is hilarious. They're missing the point (probably intentionally).

Yes, there isn't an "adaptive CPT code".

While I'm sure billing styles vary, it's usually dropping additional sim/planning/etc codes.

How will this be accounted for with the episode/disease site model? Let's say I have a head and neck patient. If I do "regular" VMAT, 70gy in 35fx, I would drop the M-code, but if I do "adaptive" and resim/replan at least once, I get to use the "regular" CPT code mix?

Man, I sense a lot of patients are gonna be in dire need of adaptive radiotherapy. Sign me up for those registry trials!

Agree. This is the definition of specious.

We are talking about tiny amounts of money across the board at a national level. Nothing wrong with using this opportunity to try to address radiopharm compensation, which is clearly a barrier to dissemination. It is also an intervention with a unique set of cases. This means there are not significant, discretionary technical costs associated with choosing radiopharm over another equivalent intervention (there is no equivalent intervention). I would advocate for more radiopharm services in my community if it weren't so easy for it to become a loss leader. Just pick a value that works!

The fact is, appropriately valuing anything is close to impossible. The values assigned to external beam treatment here are assigned because they make sense to the writers in terms of existing culture, risk and perceived opportunity cost (what we could end up getting paid). That is all.

But, the significant benefit of case based payment is that one is not incentivized financially to pick one intervention over another. The doc is incentivized to provide value based care.

If I were in congress, I would ask what the goals of any legislative initiative regarding health care payment and quality should be.

The answers are obvious. The goals should be safer, cheaper, equally effective and more available healthcare services. (I hate to use the term high quality as quality is exceptionally hard to measure).

Safer means less protons and less brachy. Sorry, but safety is largely a measure of avoiding catastrophic outcomes, not the practice of measuring proxy measures. Accreditation is something, but an intrinsic increased potential for catastrophic dosimetry is much more.

Cheap means photons not protons.

Effective? We are talking about interventions that are all roughly isoeffective.

Availability means supporting community hospitals by evening the playing field and making the intervention easy to justify at the community level (peds is obviously undervalued).

But, why does ASTRO think they are going to get this through? Is there some legislative strategy/impending sponsorship that we are not aware of?

Whoever you all are, I hope you come to one of these open sessions and raise these points, either the webinar or at ASTRO, assuming they let people talk.

Many brush away SDN, but this has been by far the best and most nuanced discussion of this policy that I have seen. I think the field would learn a lot from you.

 

[sirspamalot]

LOL. All pp radoncs should join the cheer, for something more important than a football game...

BULL SHYT!

 

[Jaguaranna27]

Some people are so damn good at talking around hard questions where they can't say the real answer. ASTRO should seek out and hire one of these people. I can't even talk to representatives from ASTRO anymore because they are so sleezy in the way they talk, everything they say sounds like a lie.

I've personally said my piece about protons and am pretty shocked that few radiation oncologists are willing to speak out about the updated model policy (separate from ROCR). But, it is what it is I guess.

Since learning they are going the congressional route, I'm now more surprised at their behavior. Any RO can write their representative and speak out for or against this policy if they want. It's not like ASTRO dumps all this money in to congress. You'd think theyd be working harder to win the support of doctors they claim to want to engage.

Yes. This exactly.

I can’t believe it took them 13 days to say “see our FAQ page” and then the FAQ page says to email the [email protected] email…

Circular logic much…?

Also Matt I don’t think Astro needs to hire someone to tell them how to do double speak, they seem to be doing that pretty effectively themselves. That is to say, they are the definition of ineffective.

-poor communicators — check.
-poor representation of all of radonc — check
-murky financial incentives - check

And I have stories about some weird dynamics on the staff side. As most of us on Astro committees do.

Of all the orgs im involved with, Astro is the least approachable, the least receptive to feedback, and the least respectful.

Change can start from bottom or top.

But gotta start somewhere!!

 

[Jaguaranna27]

Agree. This is the definition of specious.

We are talking about tiny amounts of money across the board at a national level. Nothing wrong with using this opportunity to try to address radiopharm compensation, which is clearly a barrier to dissemination. It is also an intervention with a unique set of cases. This means there are not significant, discretionary technical costs associated with choosing radiopharm over another equivalent intervention (there is no equivalent intervention). I would advocate for more radiopharm services in my community if it weren't so easy for it to become a loss leader. Just pick a value that works!

The fact is, appropriately valuing anything is close to impossible. The values assigned to external beam treatment here are assigned because they make sense to the writers in terms of existing culture, risk and perceived opportunity cost (what we could end up getting paid). That is all.

But, the significant benefit of case based payment is that one is not incentivized financially to pick one intervention over another. The doc is incentivized to provide value based care.

If I were in congress, I would ask what the goals of any legislative initiative regarding health care payment and quality should be.

The answers are obvious. The goals should be safer, cheaper, equally effective and more available healthcare services. (I hate to use the term high quality as quality is exceptionally hard to measure).

Safer means less protons and less brachy. Sorry, but safety is largely a measure of avoiding catastrophic outcomes, not the practice of measuring proxy measures. Accreditation is something, but an intrinsic increased potential for catastrophic dosimetry is much more.

Cheap means photons not protons.

Effective? We are talking about interventions that are all roughly isoeffective.

Availability means supporting community hospitals by evening the playing field and making the intervention easy to justify at the community level (peds is obviously undervalued).

But, why does ASTRO think they are going to get this through? Is there some legislative strategy/impending sponsorship that we are not aware of?

Love love love this whole post. Yassss

 

[Jaguaranna27]

This...this is not an FAQ. This is loading up Google Bard and asking it to rephrase things from the existing documents.

The half-hearted attempt at answering about adaptive is hilarious. They're missing the point (probably intentionally).

Yes, there isn't an "adaptive CPT code".

While I'm sure billing styles vary, it's usually dropping additional sim/planning/etc codes.

How will this be accounted for with the episode/disease site model? Let's say I have a head and neck patient. If I do "regular" VMAT, 70gy in 35fx, I would drop the M-code, but if I do "adaptive" and resim/replan at least once, I get to use the "regular" CPT code mix?

Man, I sense a lot of patients are gonna be in dire need of adaptive radiotherapy. Sign me up for those registry trials!

Ya. My thoughts exactly. This half ass FAQ just regurgitated some of the more detailed text from the full documents except did so more poorly.

It got nowhere close to answering the questions I emailed.

Infuriating because the FAQ says if you have questions email us. But…. No. I refuse. Cuz essentially then you’re just gonna create some other half ass FAQ to *not* answer my actual Qs.

I think ROCR could actually be a good direction for us with some major modifications, but so far Astro seems very unwilling to move the needle. My gestalt is they want us to sign & smile a blundered attempt at payment reform with misguided incentives. No…. Just no.

Back to not being a fan of ROCR. Primarily because of who produced it (anonymous Astro committee members) and who refuses to actually be transparent (whichever anonymous author wrote the FAQs).

Makes my blood boil sometimes grrr

Good thing I can go rock climbing to relieve some stress. Denver yayyyyy

 

[Jaguaranna27]

Whoever you all are, I hope you come to one of these open sessions and raise these points, either the webinar or at ASTRO, assuming they let people talk.

Many brush away SDN, but this has been by far the best and most nuanced discussion of this policy that I have seen. I think the field would learn a lot from you.

Fully agreed. Though it’s quite dubious any of these “town hall” or “education” sessions will allow for meaningful conversations.

I remember the RO APM educational session back when I was a resident at Astro annual. Pretty much it went like this — on the podium were the same Astro staffers who have been the face of ROCR so far. And the “Q&A” in the overpacked standing room only room was like 5 min after being talked at for 55 min.

That’s not a discussion. It’s a beat down.

I imagine more of the same at Astro annual this year based on the vague description on the FAQ page. And the town hall is a webinar format (on Teams too, worst virtual platform imo) so we’ll be restricted to typing in the chat, all muted of course, and then they can easily say “well that’s all folks” after doing politician style double talk and pivoting around all of our pointed Qs. In true lack of transparency style I bet all of our questions will be filtered so they won’t even be posted publicly on the group chat on the webinar.

I bet $100 it’s gonna be this way.

Next week we shall see.

If I’m wrong I’ll buy y’all in this forum a drink at ACRO next year (yep I meant ACRO - it’s in Orlando in 2024 then Vegas 2025 woohoo)

 

[pikachu]

But why cant we just all get along...

can't be an either / or thing. Gotta unite ASTRO / ACRO / ASCO / ACR / AMA somehow.

Agreed ACRO is filling a void right now and giving a space for us to more openly discuss stuff that ASTRO refuses to, which is good. But unless ASTRO vanishes (which it won't bc of generational loyalty) then we have to work with it... they need to be receptive to criticism and hopefully forums like the Early Career Committee (which I'm on and will debut some events at ASTRO annual meeting this year in San Diego) will allow for paving the way for some much needed change and some more actually diverse perspectives.

Most of us in radonc just want to take care of patients and have a good life.

Well, community radonc anyway.

I'm sick of chasing academic titles... would rather enjoy the rivers and lakes of Wisconsin lol. And cheese yummmm 🧀

Is this a coded reference to the timeless exhortations of TLC??

 

[Jaguaranna27]

Is this a coded reference to the timeless exhortations of TLC??

View attachment 374219

Yasss of course. Pretty much I write poetry and think about songs nonstop so I often reference songs, musicals etc in my passionate replies to things. Have to have a lil humor anyway, even if it’s dark.

Love the pikachu name btw. My fave Pokémon!!

 

[pikachu]

Yasss of course. Pretty much I write poetry and think about songs nonstop so I often reference songs, musicals etc in my passionate replies to things. Have to have a lil humor anyway, even if it’s dark.

Love the pikachu name btw. My fave Pokémon!!

Right on, even the meter matches

 

[thecarbonionangle]

Why? Per assessment of proton volumes through 2018, you were talking about low single digits percentile wise in terms of total XRT.

If you add up all Canadian patients deemed appropriate for transfer to US for proton care per annum, you are talking about ~50 patients. (This is a system that presumably actually makes value based judgements on care).

Who is in this lobby?

By the time you consider relative proton treatment volumes nationally and scale to the entire expenditure of radonc relative to costs of individual drugs in cancer care (as appropriately delineated in proposed ROCR), you are talking about what % of the layouts associated with a given drug? If it's more than a few %, it tells you all you need to know about protons in terms of high value care.

How is this lobby so powerful? Is it the disproportionate amount of proton care given to our most affluent? Is it the convergence of protons, PPSE and elite financial interests?

Is this true? Recent supreme court ruling on student loans aside, doesn't CMS (as an executive branch entity) have remarkable discretionary power regarding actual payments year over year?

It has long been suspected by many that proton lobby had a role in killing APM. I have been told by people it was one of the biggest factors in killing it. It is a very interesting admission to say that the new proposal basically would never be allowed to pass if protons are not carved out. Tells you that the proton cabal, with animal horned masks, is a lot of more powerful than many think. In the end it is all about the pecuniary advantage!

 

[NotMattSpraker]

It has long been suspected by many that proton lobby had a role in killing APM. I have been told by people it was one of the biggest factors in killing it. It is a very interesting admission to say that the new proposal basically would never be allowed to pass if protons are not excepted. Tells you that the proton cabal, with animal horned masks, is a lot of more powerful than many think. In the end it is all about the pecuniary advantage!

I agree, and importantly, many in this cabal... whatever you want to call it... they aren't doctors.

Have a look at the board of the NAPT About NAPT: The Voice of the Proton Community - NAPT