ROCR

[RickyScott]

"It might portend a further softening of the radiation oncology job market as physicians are hired less frequently than they are now."

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[NotMattSpraker]

So you aren't opposed to ROCR because of ROCR, you are opposed to ROCR because ASTRO proposed it... got it.

I'm getting heated. I'll step away for a while

That's fairly reductive and a bit unfair given the time I have personally spent explaining my problem with ASTRO's approach.

You are more than welcome to disagree, but don't pretend this is a tantrum with no substance.

 

[communitydoc13]

But it does impact non-employed docs. So if we leave the system as is, employed docs are fine, hospitals get more technical rates, and it further accelerates the already-existing trend to consolidation.

This is wrong. I did not see the webinar, but it is interesting that they tried to address consolidation (perhaps due to concerns mentioned here).

My technical component is a significant support to a small, independent community hospital. It represents what my hospital is able to get reimbursed on the technical side. It does not represent what my hospital, it's catchment area and it's infrastructure might represent in terms of value to a larger system.

Reducing technical for community hospitals makes them more vulnerable, period. Their global bottom line is what makes them think about selling. Community hospitals stay around because there is a will to keep them around, not because they represent the most lucrative model of care (quite the opposite).

A community hospitals technical also does not represent what a larger system would be able to recoup (a single proton plan can make a big difference!). I have no doubt that a UPENN (as an example) could recoup multiples in terms of technical reimbursement from my patient population than my community hospital does.

Opinion | Your Exorbitant Medical Bill, Brought to You by the Latest Hospital Merger

Undoing hospital monopolies may be a lost cause.

www.nytimes.com

 

[deleted1111261]

I’m not deep in career, but I am mid career and personally I don’t feel like the sky is falling because of falling reimbursement, @CaesarRO. You’ll rarely hear me say that. I think our codes were over valued before and now are closer to rightly valued.

My own personal “conservatism” in this matter is - it is not perfect, but it’s the devil I know. I know what i can generate, I understand how billing works, how we get paid.

They could not answer basic questions about this.

1) if I treat a prostate for 5.5 weeks and submit M code or c61 and I miss 3 out of 6 weekly visits, what happens ?

2) what happens to supervision? Jordan / Bridge Oncology pursuing a model with much less supervision. What happens to charges if no physician is on site throughout consult to treatment?

3) If this program is the game changer they say it is, then why don’t the proton guys want to get in with a modification? Full payment for patients on an RCT, extra $5k per patient on top of our case rates if not on study but meets indications, and IMRT rates for the rest. And, also set up prior auth for MCR protons?

4) PPSE is bull****. If anyone of them comments on this program, they are talking out of line. They are beneficiaries of us taking any sort of hit.

5) The costs are higher for commercial and MA programs. They are not just going to put their heads in the sand. Clearly this is going to roll over to them. How are they going to work?

I’m against it because I don’t see how it helps overall. I’m allowed to share my lived experience as an RO - our system is not great, but it’s fine. ROCR furthers divisions between have and have nots. Disparities will worsen - the rich will go for protons and PPSE places and the rest of us will take on case rates and poor payors.

I will happily keep what we have vs known unknowns and unknown unknowns.

Hopefully, that answer doesn’t reek of just pure Astro haterade

 

[RickyScott]

But it does impact non-employed docs. So if we leave the system as is, employed docs are fine, hospitals get more technical rates, and it further accelerates the already-existing trend to consolidation.

It's an interesting bait-and-switch here at SDN where we complained for so long that ASTRO only had academics and ignored PP. They make a proposal to help PP/freestanding and now we're all employed docs who aren't helped by their proposals.

Academics dont distinguish between PP and non-academic employed. Most docs who work in freestanding centers (like Genesis) are employed. There are very few actual PP left. A worsening job market hurts all, including academics (but not chair and senior faculty). Vast majority of astros members are employed doctors, and astro does not act in their interest.

 

[elementaryschooleconomics]

So you aren't opposed to ROCR because of ROCR, you are opposed to ROCR because ASTRO proposed it... got it.

I'm getting heated. I'll step away for a while

Come on, you know that's not true. At least not from me.

ASTRO is not a singular, evil entity.

While there's some bad apples. the overwhelming majority of ASTRO folks are doing the best they can with good intentions.

This is what I'm against:

1) ASTRO hired outside consultants for both the workforce study and ROCR. The ROCR report cites the workforce report. Wakely, who wrote ROCR, is a subsidiary of HMA, who wrote the workforce. There was clearly behind-the-scenes communication from long, long before the rest of us heard about this.

2) I've talked to the people involved in the workforce paper. I know what ASTRO shared with them, and what they didn't. There were several key bits of data (like wRVUs) that ASTRO has and did not make available for the workforce paper, or even told junior people they had the data.

3) ROCR took almost everyone by surprise. It shouldn't need to be said but - if you're the major professional society representing an entire medical specialty, legislation proposing the overhaul of our entire reimbursement system is NOT something you do behind closed doors.

4) As this and other SDN threads have discussed, ASTRO continues to not demonstrate actual, meaningful engagement with the general RadOnc community, ASTRO members or not, and have published multiple contradictory statements across multiple platforms.

To pass unprecedented legislation which changes the entire system of reimbursement for the totality of a medical specialty, save for perverse exemptions - this is a heavy lift.

Unfortunately, ASTRO has treated ROCR the same way you'd approach a manuscript submission to the Red Journal.

Their behavior to this point is indicative of how they plan to continue to behave, which is what I'm against. Not bundled payments. Not the organization as an abstract whole.

 

[Exokie67]

Not against case rates in principal, but if 77427 OTV requirement disappears and hospital OPD only requires general supervision, why would the hospitals, whose technical component reimbursement has been cut by ROCR not simply contract a .25 FTE radonc to see consults and sign plans (and subsequently disappear), thereby almost instantly reducing the need for much of our specialty? I'm not one for "sky is falling" scenarios but I see this as the immediate danger if ROCR is implemented.

It was mentioned in the webinar that for medicare crossovers, one would still have to bill out the CPTs so its not clear to me what is intended. It's almost like they think nothing will change in hospital/corporate/physician behavior if ROCR is implemented

 

[RickyScott]

Not against case rates in principal, but if 77427 OTV requirement disappears and hospital OPD only requires general supervision, why would the hospitals, whose technical component reimbursement has been cut by ROCR not simply contract a .25 FTE radonc to see consults and sign plans (and subsequently disappear), thereby almost instantly reducing the need for much of our specialty? I'm not one for "sky is falling" scenarios but I see this as the immediate danger if ROCR is implemented.

It was mentioned in the webinar that for medicare crossovers, one would still have to bill out the CPTs so its not clear to me what is intended. It's almost like they think nothing will change in hospital/corporate/physician behavior if ROCR is implemented

exactly. Even if technical component is not cut (or somehow increases slightly) , we still have the same problem

 

[deleted1168505]

Not against case rates in principal, but if 77427 OTV requirement disappears and hospital OPD only requires general supervision, why would the hospitals, whose technical component reimbursement has been cut by ROCR not simply contract a .25 FTE radonc to see consults and sign plans (and subsequently disappear), thereby almost instantly reducing the need for much of our specialty? I'm not one for "sky is falling" scenarios but I see this as the immediate danger if ROCR is implemented.

It was mentioned in the webinar that for medicare crossovers, one would still have to bill out the CPTs so its not clear to me what is intended. It's almost like they think nothing will change in hospital/corporate/physician behavior if ROCR is implemented

It's not like we are producing 50-100 new grads each year who couldn't get residencies in anything else and have objectively demonstrated that they are willing to do literally anything to practice medicine (like take 0.25 FTE jobs in rural Nebraska), and the problem is repeatedly ignored by national leadership. Not like that at all...

 

[sirspamalot]

So you aren't opposed to ROCR because of ROCR, you are opposed to ROCR because ASTRO proposed it... got it.

I'm getting heated. I'll step away for a while

I think thats a good idea. Nobody except those that a) don't understand it or b) aren't affected by it wants ROCR.

Its "supposed benefits" are a whitewash and the manner in which it was 'given' for digestion to radoncs was even worse.

(Family Guy Narrator)

ROCR: When you can't fight any more, give up... and push those pp losers forward into the meat grinder.

 

[sirspamalot]

Not against case rates in principal, but if 77427 OTV requirement disappears and hospital OPD only requires general supervision, why would the hospitals, whose technical component reimbursement has been cut by ROCR not simply contract a .25 FTE radonc to see consults and sign plans (and subsequently disappear), thereby almost instantly reducing the need for much of our specialty? I'm not one for "sky is falling" scenarios but I see this as the immediate danger if ROCR is implemented.

It was mentioned in the webinar that for medicare crossovers, one would still have to bill out the CPTs so its not clear to me what is intended. It's almost like they think nothing will change in hospital/corporate/physician behavior if ROCR is implemented

And as long as there is a huge supply of "new" labor, hospitals must be salivating at the prospect of ROCR. Meanwhile, those with "Secure" academic jobs or sitting in exempt centers or proton sites are just laughing..

 

[NotMattSpraker]

And as long as there is a huge supply of "new" labor, hospitals must be salivating at the prospect of ROCR. Meanwhile, those with "Secure" academic jobs or sitting in exempt centers or proton sites are just laughing..

DEFINE_ME

 

[Doctorer]

And as long as there is a huge supply of "new" labor, hospitals must be salivating at the prospect of ROCR. Meanwhile, those with "Secure" academic jobs or sitting in exempt centers or proton sites are just laughing..

Depends on what you mean by "secure." Even if you're an associate professor (or higher), these forces will work to decrease your mobility and stagnate salaries in the face of inflation.

 

[elementaryschooleconomics]

Let's keep going, with Anne Hubbard/ASTRO in 2022 vs 2023:

Wither the RO Model: Focusing on Access to Spread the Value of Radiation Therapy

What was written in 2022:

ROCR version:

2022:

ROCR:

2022:

ROCR:

Several minutes talking about how value-based payment programs will "be better" for capital investments/reduce consolidation.

This.

This is my issue with what they're doing.

That RO-APM version of HEART sounds awesome!

But let's offer a ride voucher instead.

 

[TheWallnerus]

Well the question is, which version of the story do we want to believe?

In late 2021, the Red Journal had an issue on consolidation as @NotMattSpraker mentioned.

They did a podcast on it, with Zietman interviewing Miranda Lam and the new grad from the ROCR Town Hall, Milligan.

View attachment 374749

Go listen for yourself. Here are key excerpts with the opinion expressed on that podcast, and the opinion expressed on the Town Hall:

AZ:
One sort of economic threat on the horizon is the new alternative payment model, which is going to bundle payments and radiation oncologists specifically will take quite a hit from this. Do you think that is going to drive more groups into consolidation?

Lam:
My sense is that if we were to look at the data, that there may be an uptick in terms of consolidation. I do think that there is concern.

About practices that may not be able to feel comfortable financially to stay open and look for other practices to merge with other hospitals to work with, or, private equity firms to buy them. And so I do think that there is a real chance that consolidation may increase. I think another interesting component that Dr. Milligan and I have talked about is that the impact that the bundled payments in radiation oncology might have on vulnerable populations. So if we think about some of these practices that have one or two radiation oncologists, if they are randomized into the bundled payment model, they may feel more financial pressures.

and either have to close down or find ways to keep the practice open with less resources. And I think in those cases, we're really hurting some of these populations that may already have difficulty accessing care in our rural areas, in areas that care for, more minorities. And so I think it is definitely of concern on many levels, not just for, potential consolidation and increase in prices.

But, I think just the actual threat of what are going to happen to practices. Are we going to see practices, just the sheer number of radiation practices decrease overall?

AZ:
Is there anything that you can imagine that might change this trend to consolidation? Where is it all going to end?

Milligan:
That's an excellent question. In terms of factors that might slow down or reverse consolidation, it's... It's frankly hard to imagine what those might be.

But perhaps it's just my own lack of imagination that it's a little hard for me to come up with any particular factors that might reverse this trend we've seen. One in 11 dermatologists in the United States practiced in a PE or private equity owned firm. These practices were more likely to hire a larger share of advanced Practice providers like NPs or PAs and really drove much higher patient volumes in private equity owned firms compared to those firms that were not owned by private equity companies.

So patient volumes were five to 17% higher. The use of expensive interventions were, was also significantly higher. And, if we were to see similar trends in radiation oncology might portend a future where radiation oncologists are employed by only a few large firms with owners being hospitals, private equity companies, things like that.

It might portend a further softening of the radiation oncology job market as physicians are hired less frequently than they are now.

AZ:
Boy, that's a real doomsday scenario. I think private equity companies are getting involved in some practices in radiation oncology, though I think they've only just begun.

ROCR Town Hall -

Anne:
This next one is for Dr. Milligan. How would the shift to ROCR impact the trend towards consolidation of practices?

Milligan:
Radiation oncology is consolidating quick. It's one of the most consolidated specialties in the United States. And I think that ROCR will address some of those issues that will certainly make our finances more stable going forward, which can help in the prediction.

And, not having wide confidence intervals in our sensitivity analyses can sort of help not only provide more clarity about where we're going, but also allow you to use your capital a little more wisely. To summarize, ROCR, stabilizes or, at least stabilizes our payments and may address some of the increasing costs as well. So I think it will have it's hard to predict, but I think it will have a positive effect in sort of reducing the rates of consolidation going forward.

The reason consolidation is being talked about as a "benefit" of ROCR here is because it's not a benefit.

Dr Milligan, ASTRO, ROCR cmte, et al:

 

[deleted1168505]

Dr Milligan, ASTRO, ROCR cmte, et al:

What did the 5 fingers say to the face?

 

[medgator]

But it does impact non-employed docs. So if we leave the system as is, employed docs are fine, hospitals get more technical rates, and it further accelerates the already-existing trend to consolidation.

It's an interesting bait-and-switch here at SDN where we complained for so long that ASTRO only had academics and ignored PP. They make a proposal to help PP/freestanding and now we're all employed docs who aren't helped by their proposals.

You sound like an ASTRO shill with these posts honestly. It needs to be a fair and equally applied system and ignores the workforce elephant in the room

 

[medgator]

So you aren't opposed to ROCR because of ROCR, you are opposed to ROCR because ASTRO proposed it... got it.

I'm getting heated. I'll step away for a while

Not helping yourself here. Just look at Astro's history. They were on the wrong side of payment bundles and urorads over a decade ago. They are being reactive now just like they were with APM. Their attitude towards protons lately vs the imrt/fraction/urorads/pp shaming for years speaks volumes to their priorities and their interests.

Remember PP docs called for an ROCR literally 15+ years ago when the radiation therapy alliance (RTA) proposed it at the time. ASTRO was vehemently opposed

Shilling for them doesn't rewrite history or reality now. ROCR as endorsed by ASTRO is just bad and capricious policy. Full stop

 

[sirspamalot]

Poor ROCR and all its shills.

 

[elementaryschooleconomics]

Poor ROCR and all its shills.

Uh...as far as I can tell, there's the 6 distinct individuals from the original webinar and the Town Hall, then Sameer, and...I would say between Twitter and SDN, maybe 3-4 more "soft" supporters, recognizing that there might be some overlap because of the "anonymous" nature of SDN.

Literally, literally there seems to be <12 people supporting this at ASTRO, and two of those are non-physicians.

Which is...sort of my main point. For the same reason I don't think ASTRO as an entity is all bad, I also don't think "ASTRO" as an abstract entity can "support" anything.

It's the people within ASTRO that I'm curious about. Who are you, you mysterious authors? How many?

 

[sirspamalot]

Name and shame peeps

 

[NotMattSpraker]

Uh...as far as I can tell, there's the 6 distinct individuals from the original webinar and the Town Hall, then Sameer, and...I would say between Twitter and SDN, maybe 3-4 more "soft" supporters, recognizing that there might be some overlap because of the "anonymous" nature of SDN.

Literally, literally there seems to be <12 people supporting this at ASTRO, and two of those are non-physicians.

Which is...sort of my main point. For the same reason I don't think ASTRO as an entity is all bad, I also don't think "ASTRO" as an abstract entity can "support" anything.

It's the people within ASTRO that I'm curious about. Who are you, you mysterious authors? How many?

Consider that the president of ASTRO has never tweeted, messaged, or appeared on anything related to ROCR.

 

[elementaryschooleconomics]

Consider that the president of ASTRO has never tweeted, messaged, or appeared on anything related to ROCR.

In total:

There was a single newsletter (ASTROgram) email announcing ROCR
The email contained a link to the blog post discussing ROCR, with PDFs and a 12 minute pre-recorded video
The blog post was later updated slightly with a few questions (hilariously but inappropriately named FAQ)

ASTRO and a single ASTRO insider have discussed ROCR publicly 5 times. Sameer, of his own volition, talked a bit about it last month on Twitter but not subsequently:

Finally, we had the weird Town Hall webinar where many of us couldn't even see the chat, let alone ask questions, but at least one person (@Exokie67) was able to use the chat (his/her posts seem genuine, I think it's true).

This is everything.

What would I prefer instead?

Hmm...ah, you know, I remember ASTRO having some guidelines somewhere...

Let's see -

Dear ASTRO,

Please reference your 2019 Methodology Guide for how to approach drafting legislation.

For ROCR, it appears you skipped "Guideline Initiation", "Evidence Review", "Draft Development", and "Peer Review".

On the ROCR blog post, you state that the Board of Directors has approved the proposal. Per your own Guide, this is #3 of the "Approval" step.

Hope all is well!

Best,
ElementarySchoolEconomics
on behalf
of like, everyone.

 

[sirspamalot]

 

[Lamount]

Well the question is, which version of the story do we want to believe?

In late 2021, the Red Journal had an issue on consolidation as @NotMattSpraker mentioned.

They did a podcast on it, with Zietman interviewing Miranda Lam and the new grad from the ROCR Town Hall, Milligan.

View attachment 374749

Go listen for yourself. Here are key excerpts with the opinion expressed on that podcast, and the opinion expressed on the Town Hall:

AZ:
One sort of economic threat on the horizon is the new alternative payment model, which is going to bundle payments and radiation oncologists specifically will take quite a hit from this. Do you think that is going to drive more groups into consolidation?

Lam:
My sense is that if we were to look at the data, that there may be an uptick in terms of consolidation. I do think that there is concern.

About practices that may not be able to feel comfortable financially to stay open and look for other practices to merge with other hospitals to work with, or, private equity firms to buy them. And so I do think that there is a real chance that consolidation may increase. I think another interesting component that Dr. Milligan and I have talked about is that the impact that the bundled payments in radiation oncology might have on vulnerable populations. So if we think about some of these practices that have one or two radiation oncologists, if they are randomized into the bundled payment model, they may feel more financial pressures.

and either have to close down or find ways to keep the practice open with less resources. And I think in those cases, we're really hurting some of these populations that may already have difficulty accessing care in our rural areas, in areas that care for, more minorities. And so I think it is definitely of concern on many levels, not just for, potential consolidation and increase in prices.

But, I think just the actual threat of what are going to happen to practices. Are we going to see practices, just the sheer number of radiation practices decrease overall?

AZ:
Is there anything that you can imagine that might change this trend to consolidation? Where is it all going to end?

Milligan:
That's an excellent question. In terms of factors that might slow down or reverse consolidation, it's... It's frankly hard to imagine what those might be.

But perhaps it's just my own lack of imagination that it's a little hard for me to come up with any particular factors that might reverse this trend we've seen. One in 11 dermatologists in the United States practiced in a PE or private equity owned firm. These practices were more likely to hire a larger share of advanced Practice providers like NPs or PAs and really drove much higher patient volumes in private equity owned firms compared to those firms that were not owned by private equity companies.

So patient volumes were five to 17% higher. The use of expensive interventions were, was also significantly higher. And, if we were to see similar trends in radiation oncology might portend a future where radiation oncologists are employed by only a few large firms with owners being hospitals, private equity companies, things like that.

It might portend a further softening of the radiation oncology job market as physicians are hired less frequently than they are now.

AZ:
Boy, that's a real doomsday scenario. I think private equity companies are getting involved in some practices in radiation oncology, though I think they've only just begun.

ROCR Town Hall -

Anne:
This next one is for Dr. Milligan. How would the shift to ROCR impact the trend towards consolidation of practices?

Milligan:
Radiation oncology is consolidating quick. It's one of the most consolidated specialties in the United States. And I think that ROCR will address some of those issues that will certainly make our finances more stable going forward, which can help in the prediction.

And, not having wide confidence intervals in our sensitivity analyses can sort of help not only provide more clarity about where we're going, but also allow you to use your capital a little more wisely. To summarize, ROCR, stabilizes or, at least stabilizes our payments and may address some of the increasing costs as well. So I think it will have it's hard to predict, but I think it will have a positive effect in sort of reducing the rates of consolidation going forward.

The reason consolidation is being talked about as a "benefit" of ROCR here is because it's not a benefit.

Wasn't one of the major reasons that the APM was "pro-consolidation" was that there were draconian documentation/EMR requirements that would have required small centers to shell out huge sums of money to meet requirements? (whereas large centers already had the infrastructure to accommodate the requirements). My (albeit limited) understanding of the ROCR is that it wouldn't have these same requirements.

I think that @grenz raises a good point. It is unrealistic to expect any one intervention to solve the many problems faced by our field.

We should all start off by asking the right question: On average, would we be better off implementing the ROCR or allowing the current system to stay in place. It's not a question of whether ROCR will ELIMINATE the pain... but whether it will IMPROVE the pain. So would ROCR help or hurt? (personally, I haven't made up my mind yet)

 

[BobbyHeenan]

Wasn't one of the major reasons that the APM was "pro-consolidation" was that there were draconian documentation/EMR requirements that would have required small centers to shell out huge sums of money to meet requirements? (whereas large centers already had the infrastructure to accommodate the requirements). My (albeit limited) understanding of the ROCR is that it wouldn't have these same requirements.

I think that @grenz raises a good point. It is unrealistic to expect any one intervention to solve the many problems faced by our field.

We should all start off by asking the right question: On average, would we be better off implementing the ROCR or allowing the current system to stay in place. It's not a question of whether ROCR will ELIMINATE the pain... but whether it will IMPROVE the pain. So would ROCR help or hurt? (personally, I haven't made up my mind yet)

This is a fair/good post.

And it is REALLY hard to figure that out, and it will vary from practice to practice. So many considerations.

I think one heuristic about all of it is that if/when it's hard to figure it out, then you fall back on "gut feeling" and "trust" and "transparency." And that's where the challenges are for ASTRO. A lot of that trust is lost with past ASTRO misdeeds, proton exemptions and things like "registry trial" support in choosing wisely, blind eyes to PPS exemptions, people exempt from rules writing rules, etc.

Your post is a reminder though that at the end of the day the ROCR help/hurt, is the real question.

 

[sirspamalot]

This is a fair/good post.

And it is REALLY hard to figure that out, and it will vary from practice to practice. So many considerations.

I think one heuristic about all of it is that if/when it's hard to figure it out, then you fall back on "gut feeling" and "trust" and "transparency." And that's where the challenges are for ASTRO. A lot of that trust is lost with past ASTRO misdeeds, proton exemptions and things like "registry trial" support in choosing wisely, blind eyes to PPS exemptions, people exempt from rules writing rules, etc.

Your post is a reminder though that at the end of the day the ROCR help/hurt, is the real question.

It's going to hurt in the long run without question.

CPT CODES: HOLD THE LINE

 

[NotMattSpraker]

Wasn't one of the major reasons that the APM was "pro-consolidation" was that there were draconian documentation/EMR requirements that would have required small centers to shell out huge sums of money to meet requirements? (whereas large centers already had the infrastructure to accommodate the requirements). My (albeit limited) understanding of the ROCR is that it wouldn't have these same requirements.

Well, it requires accreditation. I personally do not know whether that would be more or less work than the uploading and reporting required under RO-APM, but accreditation is not insignificant cost or work. I talked with one person that knows a lot about that and they seemed to feel ROCR would be a slight improvement overall for administrative burden compared to RO-APM.

However, I was pretty concerned about the double coding described by Connie on the town webihall. That seems like a lot more work than the status quo.

By the way, if you haven't read it, this is a great open access editorial by Join Luh. It is a narrative from a small practice Rad Onc, describing their experience trying to keep up with the rapidly shifting "administrative" requirements under all these models.

https://ascopubs.org/doi/full/10.1200/OP.21.00286?role=tab

I think one heuristic about all of it is that if/when it's hard to figure it out, then you fall back on "gut feeling" and "trust" and "transparency."

This is well put. I'm actually pretty surprised at my personal experience trying to engage who seems to be the face of ROCR at ASTRO. There has been zero engagement with me personally. I wasn't allowed to ask questions at the town hall and the questions I had remain unanswered. They dont seem unprofessional or antagonistic, so Im struggling to understand why they are just being ignored.

I have to admit, I'm pretty discouraged. My own job will be okay under whatever payers throw at us, I am confident in that. I feel really lucky. I'm not willing to be a yes-man for ASTRO and they don't seem to want anything else, so it seems like the move is to just walk away.

Its too bad. As always, I really appreciate the comments and discussion here. I learn a ton.

 

[elementaryschooleconomics]

Wasn't one of the major reasons that the APM was "pro-consolidation" was that there were draconian documentation/EMR requirements that would have required small centers to shell out huge sums of money to meet requirements? (whereas large centers already had the infrastructure to accommodate the requirements). My (albeit limited) understanding of the ROCR is that it wouldn't have these same requirements.

I think that @grenz raises a good point. It is unrealistic to expect any one intervention to solve the many problems faced by our field.

We should all start off by asking the right question: On average, would we be better off implementing the ROCR or allowing the current system to stay in place. It's not a question of whether ROCR will ELIMINATE the pain... but whether it will IMPROVE the pain. So would ROCR help or hurt? (personally, I haven't made up my mind yet)

I would have to go back and listen to the Town Hall again to answer your point/question thoroughly. That was one of the concerns about APM, yes. I don't believe ROCR has the same level of documentation requirements, but it's not going to have less documentation requirements (that part I remember)...and documentation alone won't make or break a practice surviving. But it's definitely worth pointing out.

You're correct, though, about which is the lesser of two evils.

Which is driving my whole opinion on the topic.

To reiterate, I'm not against ASTRO as an organization. I'm not against bundled payments, or any payment system for that matter. Very few things are "all good" or "all bad".

When I ask myself "is RadOnc better under ROCR":

1) What version of ROCR? As in, the lack of transparency means ASTRO currently has zero allies. I don't mean that in a negative way, I mean that as in - literally no one but ASTRO is talking about this. It's possible beltway folks/politicians "know" and support ROCR, but extremely unlikely (given the grassroots reactions, I suspect ASTRO would be parading out allies at this point, if they existed). So my concern is ASTRO continues to limp along with this and gains enough steam to get it into the House - then what? What's stopping the House and Senate from tossing it back and forth making modifications? Does ASTRO have the firepower to step in? What's preventing Congress from talking to CMS and CMS writing RO-APM v2.0? The way this has been bungled thus far is ironic, given the siren call of RadOnc is "just network". So, ASTRO - where's your network for this? Can you call on (and pay) the "right" lobbyists if parts of ROCR are rewritten in the legislative process?

2) The AMA, a vastly, vastly more powerful organization, is pushing that reform bill already in Congress (Strengthening Medicare for Patients and Providers Act). The legislation ties MPFS to MEI so payments are better adjusted for inflation. So let's say that passes and ROCR somehow also passes - wouldn't that exclude us from benefitting from that because ROCR rates are calculated based on 2017-2020 data?

3) Why are protons exempt? The rationale of ROCR is that cuts will continue, and ROCR is the less painful option. Ok...so why would anyone say no to that? The "unable to calculate case rate" line is incorrect. The data exists. What's the real reason? I promise you, if the proton crew came out with a statement strongly supporting ROCR tomorrow...hoo boy, I would change my tune real quick. Because the question is - what do the people backing hundreds of millions of dollars of proton equipment know that I don't? I support what they support, even though I don't have protons. They don't support this...so...

4) They used the line "death by a thousand papercuts" in the Town Hall, regarding CPT codes and the existing system. But the cuts work both ways. We can all creatively adjust our practices and billing somewhat, if only a little, if we're billing a bunch of codes. But a single code? If CMS cuts an M Code reimbursement...it sounds like I'm out of luck.

Really, the transparency/support and giving CMS a single code to cut in the future are my major concerns.

Both the current system and ROCR mean we lose money. However, I prefer the devil I know. Because the one thing I can say for sure: the version of ROCR we see right now will not be the version the Senate votes on, if it gets that far.

 

[DebtRising]

I don’t understand what ROCR does to supervision requirements. If those codes are gone for weekly management, and there is only a 1% hit for not being accredited, then explain to me why the vast majority of us aren’t effectively laid off?

ROCR to me seems an olive branch to established private practice and academia - aka the previous generation. There’s a reason Genesis Care is promoting this, right? ASTRO made an olive branch to true private practice owners of large groups, not the employed doc who actually is invested in his/her community.

So if this passes, wouldn’t the most efficient work flow be filtering consults through a handful of seasoned providers, sim at a handful of locations, and then treat at different centers without need for an FTE MD and ship follow ups to NP / PAs? How many docs would this eliminate ? What am I missing? A number of people said they don’t believe in the doomsday scenarios. Why do you have a job under ROCR if you aren’t a practice owner or core member of your team? We already are overtrained, and the older generation sure as heck isn’t leaving.

Why does a community hospital not just contract out the plan generation to a Genesis Care or academic center, and keep the technical? Barely need a prof agreement at all and under ROCR may be more lucrative.

 

[Mandelin Rain]

We’re in end stage capitalism in this country.

The doomsday scenarios are all around.

Everyone trying to get their golden chair secured before the music ends.

 

[sirspamalot]

(Disclaimer: The following essay is written in the style of Eminem, focusing on strong and passionate language.)

Title: "Medical Care's Dark Melody: The Pitfalls of Bundled Payment Models"

Verse 1:
Yo, let me spit some truth, no games to play,
Bundled payment models, they lead us astray,
In the medical realm, it's all about the pay,
But these setups got us facing a darker day.

Chorus:
Bundled payments, they seem fine, at first sight,
But dig deeper, you'll see the hidden fight,
They're horrible, causing struggles day and night,
It's time to shed some light, to make things right.

Verse 2:
They say it's efficient, costs will go down,
But in reality, some patients will drown,
Providers rush, cutting corners all around,
Quality compromised, and care can't be found.

Chorus:
Bundled payments, they seem fine, at first sight,
But dig deeper, you'll see the hidden fight,
They're horrible, causing struggles day and night,
It's time to shed some light, to make things right.

Verse 3:
Complex cases, left in the dust,
Underpaid treatments, they start to rust,
Equality suffers, some get left unjust,
In this medical system, who can you trust?

Chorus:
Bundled payments, they seem fine, at first sight,
But dig deeper, you'll see the hidden fight,
They're horrible, causing struggles day and night,
It's time to shed some light, to make things right.

Verse 4:
The heart of medicine, it's empathy and care,
But bundled payments got us walking on thin air,
Profits dictate, leaving some in despair,
The essence of healing, they're starting to tear.

Chorus:
Bundled payments, they seem fine, at first sight,
But dig deeper, you'll see the hidden fight,
They're horrible, causing struggles day and night,
It's time to shed some light, to make things right.

Outro:
In conclusion, we gotta rethink this game,
Bundled payment models, they're not the same,
Let's find a balance, and break free from the shame,
Revive compassion, restore medicine's flame.

 

[Fpg1245]

(Disclaimer: The following essay is written in the style of Eminem, focusing on strong and passionate language.)

Title: "Medical Care's Dark Melody: The Pitfalls of Bundled Payment Models"

Verse 1:
Yo, let me spit some truth, no games to play,
Bundled payment models, they lead us astray,
In the medical realm, it's all about the pay,
But these setups got us facing a darker day.

Chorus:
Bundled payments, they seem fine, at first sight,
But dig deeper, you'll see the hidden fight,
They're horrible, causing struggles day and night,
It's time to shed some light, to make things right.

Verse 2:
They say it's efficient, costs will go down,
But in reality, some patients will drown,
Providers rush, cutting corners all around,
Quality compromised, and care can't be found.

Chorus:
Bundled payments, they seem fine, at first sight,
But dig deeper, you'll see the hidden fight,
They're horrible, causing struggles day and night,
It's time to shed some light, to make things right.

Verse 3:
Complex cases, left in the dust,
Underpaid treatments, they start to rust,
Equality suffers, some get left unjust,
In this medical system, who can you trust?

Chorus:
Bundled payments, they seem fine, at first sight,
But dig deeper, you'll see the hidden fight,
They're horrible, causing struggles day and night,
It's time to shed some light, to make things right.

Verse 4:
The heart of medicine, it's empathy and care,
But bundled payments got us walking on thin air,
Profits dictate, leaving some in despair,
The essence of healing, they're starting to tear.

Chorus:
Bundled payments, they seem fine, at first sight,
But dig deeper, you'll see the hidden fight,
They're horrible, causing struggles day and night,
It's time to shed some light, to make things right.

Outro:
In conclusion, we gotta rethink this game,
Bundled payment models, they're not the same,
Let's find a balance, and break free from the shame,
Revive compassion, restore medicine's flame.

GPT working hard

 

[sirspamalot]

When you're really truly ready to give up.. just know..

Your favorite UM company is hiring Rad Onc Directors. Used to be ~ 340k/4d work week (10 hrs/d) plus 5 weeks vacation years ago. And a year end bonus of maybe 10%. You know, when Radonc was still good. Not fun, but for those trapped, doable.

Wanna take a gander at what it is now?

Hows 250k and 2 week vacation sound.. hits ya right in the feelz don't it? And you will have every last ounce of productivity squeezed out of you.

On your knees, serf.

 

[sirspamalot]

GPT working hard

I need a real rapper to do this song. Then post someone to post it on ROhub.

 

[deleted1111261]

When you're really truly ready to give up.. just know..

Your favorite UM company is hiring Rad Onc Directors. Used to be ~ 340k/4d work week (10 hrs/d) plus 5 weeks vacation years ago. And a year end bonus of maybe 10%. You know, when Radonc was still good. Not fun, but for those trapped, doable.

Wanna take a gander at what it is now?

Hows 250k and 2 week vacation sound.. hits ya right in the feelz don't it? And you will have every last ounce of productivity squeezed out of you.

On your knees, serf.

I’ve never seen 340. I’m working for one now for $125. Evicore was $115 6 years ago.

 

[deleted1111261]

I’ve never seen 340. I’m working for one now for $125. Evicore was $115 6 years ago.

Oh, and full time get “unlimited time off” whatever that’s supposed to mean, as long as all cases get reviewed.

 

[sirspamalot]

I’ve never seen 340. I’m working for one now for $125. Evicore was $115 6 years ago.

Full time effort paying 125k a year?

Holy cow that is terrible.

Are you serious when you say they are paying radoncs 115k a year full time?

Wow. That is pathetic..

 

[madchemist89]

I think he meant those as hourly rates, but I may be wrong.

 

[deleted1111261]

Hourly rates

 

[radiaterMike]

Even with hourly rates, that is not awesome

Assuming a 40 hour work week, that equates to 260k per year without benefits or vacation.

Generally when you are acting as a consultant, you request a greater pay rate than what you make at your regular job.

 

[deleted1111261]

100%

But since I can do this during the day

For no extra time, I effectively give myself a raise. It was a no-brainer (for me)

We don’t hire non full-time docs. If you aren’t currently practicing, you just aren’t able to handle this effectively. See: many Evicore folks. The problem with people doing this 40 hours a week is that they forget that there is a woman/man that is calling your office every day for treatment to start.

This is just not a way to earn enough outside the clinic for us in UM, even at higher level. My goals are to assemble enough non-clinical work piecemeal to generate close to an MD salary, without working any more than I do. It’s hard - but some pieces are coming together.

You also have to understand that so many of us are dissatisfied that the amount of applicants to these positions are staggering. A name many of you have heard of was my predecessor. The full time positions get filled quickly at EC and others. We talk about “supply/demand”. I tried to negotiate and could not get $1 more per hour.

I keep editing and adding on. I had 3 denials/changes in last 3 weeks where the comment at end was “that was the best P2P I’ve ever had”. A chairman of a major program said same and then said “we should talk offline about things”.

I think there’s a way to make this better and I’m working on it.

 

[sirspamalot]

Well pm me and we can talk. But I do think the denials will continue to occur because while you and I are reasonable... There are those who aren't.

I too had thought and put to paper deeply about how to build a program to assist hospitals to help flag and avoid treatment delays.. All while capturing and collating denial information across the network.

Hospitals would rather offload it to salaried radoncs... They were not interested in a preflight software platform... At least for radonc.

The radonc program at the largest UM is alive and well. Inscos LOVED the savings and technical downcoding or elimination was epic.

Being pro payment is fundamentally against the mission of UM. The idea is to point at the obvious abusers while quietly denying as much grey/gray (lol) as possible.

 

[deleted1111261]

If something is better, it gets paid for, regardless of cost. The hard part is showing it’s better

You’re simply not going to convince me protons is better for prostate but If the data comes, I’ll approve

 

[DebtRising]

Still no word on supervision req changes with ROCR and code obliteration

 

[medgator]

Still no word on supervision req changes with ROCR and code obliteration

CMS already looking to extend tele into 2024.... I think many of us feel that genie isn't going back into the bottle

 

[elementaryschooleconomics]

Still no word on supervision req changes with ROCR and code obliteration

Yeah, I suspect you'll be hard pressed to find anyone giving a real answer there.

Rather than have any level of creativity, all efforts, as weak as they are, focus on maintaining the classic way clinical RadOnc gets reimbursement.

A big part of that for many years now has been linac babysitting.

When CMS announced the general supervision change in November 2019, it sent the establishment into panic. The multi-step argument construction they wrote as a white paper, pretzel-logic building IGRT as a diagnostic test, is...well, it's special. It hasn't been supported in any case law, we'll put it like that.

Then when the pandemic ushered in the tele-supervision rules, which are now in effect until the end of 2024, it became moot. I agree with @medgator - those are likely here to stay.

However, it appears the establishment knows it's out of fake arguments. I was recently in a billing seminar with one of the major RadOnc agencies and none of this was mentioned at all. Supervision was entirely glossed over until an audience member asked, then there was a lot of dodging, and finally they invoked site of service requirements for professional billing.

It was...magnificent.

 

[TheWallnerus]

Yeah, I suspect you'll be hard pressed to find anyone giving a real answer there.

Rather than have any level of creativity, all efforts, as weak as they are, focus on maintaining the classic way clinical RadOnc gets reimbursement.

A big part of that for many years now has been linac babysitting.

When CMS announced the general supervision change in November 2019, it sent the establishment into panic. The multi-step argument construction they wrote as a white paper, pretzel-logic building IGRT as a diagnostic test, is...well, it's special. It hasn't been supported in any case law, we'll put it like that.

Then when the pandemic ushered in the tele-supervision rules, which are now in effect until the end of 2024, it became moot. I agree with @medgator - those are likely here to stay.

However, it appears the establishment knows it's out of fake arguments. I was recently in a billing seminar with one of the major RadOnc agencies and none of this was mentioned at all. Supervision was entirely glossed over until an audience member asked, then there was a lot of dodging, and finally they invoked site of service requirements for professional billing.

It was...magnificent.

Rad onc billers/coders have had to put their goalposts on wheels these past few years

 

[RickyScott]

Rad onc billers/coders have had to put their goalposts on wheels these past few years

Cbct is diagnostic, despite the fda/varian explicitly stating that it is not diagnostic. Beyond abdsurd.

 

[medgator]

Cbct is diagnostic, despite the fda/varian explicitly stating that it is not diagnostic. Beyond abdsurd.

I've never seen a single diagnostic report generated from a CBCT sent to a referring physician. Ever