ROCR

[TheWallnerus]

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

An excellent example of it doesn’t matter who’s right, and reality doesn’t matter, and consensus opinion doesn’t matter… when the government establishes a law, it is what it is.

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[RickyScott]

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

Varian also states that the new hypersight specifically is not diagnostic nor does it have diagnostic approval yet (they plan to submit one) Apparently, there is an fda device pathway for diagnostic approval.

 

[medgator]

Varian also states that the new hypersight specifically is not diagnostic nor does it have diagnostic approval yet (they plan to submit one) Apparently, there is an fda device pathway for diagnostic approval.

Medicolegal issues there out the wazoo I'm sure. Rads get sued more often than we do iirc

If varian was smart, they'd keep it all for guidance the way it was intended

 

[Mandelin Rain]

It’ll be great when we could be getting paid to read daily diagnostic CTs on 20ish patients a day, but….ROCR has us locked into a payment model no one wants.

 

[elementaryschooleconomics]

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

I'm not a lawyer, but in a world where the tele-supervision Genie goes back in the bottle (won't happen), and this question comes up in an audit (remember those? they stopped about 6 years ago) or a qui tam case (the government is no longer interested in this after that run of copycat whistleblower cases, the pre-2020 Maryland case that just finished will be the last) - I would ask the following questions:

1) Would anyone be willing to use kV/MV or CBCT images as the sole source of information to make a new diagnosis, and then treat/manage that diagnosis?

2) If someone used kV/MV or CBCT images as the only diagnostic modality and there was a malpractice suit that went to trial, how would that play out?

3) Even if you're willing to, for example, diagnose pneumonia using only CBCT and start antibiotics - would you submit the relevant CPT codes? In this case, would you submit 76380? Even if you did, would that survive audit or qui tam?

4) The relevant Social Security legislation ASTRO cites also contains the following language:

While not explicitly spelled out, isn't a Radiation Therapist performing the IGRT and shifting the setup as needed a "nonphysician practitioner operating within the scope of their authority under State law and within the scope of their Medicare statutory benefit"? The Radiation Therapists are arguably engaged in personal supervision, but at minimum direct supervision, during IGRT. Though "Radiation Therapist" isn't specifically named in the legislation, isn't this situation literally precisely within the spirit?

I could go on but...either these arguments are lost on ASTRO, or they're being intentionally slippery about this - and it doesn't matter anymore.

 

[RadOncDoc21]

I'm not a lawyer, but in a world where the tele-supervision Genie goes back in the bottle (won't happen), and this question comes up in an audit (remember those? they stopped about 6 years ago) or a qui tam case (the government is no longer interested in this after that run of copycat whistleblower cases, the pre-2020 Maryland case that just finished will be the last) - I would ask the following questions:

1) Would anyone be willing to use kV/MV or CBCT images as the sole source of information to make a new diagnosis, and then treat/manage that diagnosis?

2) If someone used kV/MV or CBCT images as the only diagnostic modality and there was a malpractice suit that went to trial, how would that play out?

3) Even if you're willing to, for example, diagnose pneumonia using only CBCT and start antibiotics - would you submit the relevant CPT codes? In this case, would you submit 76380? Even if you did, would that survive audit or qui tam?

4) The relevant Social Security legislation ASTRO cites also contains the following language:

View attachment 374990

While not explicitly spelled out, isn't a Radiation Therapist performing the IGRT and shifting the setup as needed a "nonphysician practitioner operating within the scope of their authority under State law and within the scope of their Medicare statutory benefit"? The Radiation Therapists are arguably engaged in personal supervision, but at minimum direct supervision, during IGRT. Though "Radiation Therapist" isn't specifically named in the legislation, isn't this situation literally precisely within the spirit?

I could go on but...either these arguments are lost on ASTRO, or they're being intentionally slippery about this - and it doesn't matter anymore.

Why are you trying to understand something that will never make sense?

 

[elementaryschooleconomics]

Why are you trying to understand something that will never make sense?

I want to stop...but...it's a compulsion...

 

[sirspamalot]

I want to stop...but...it's a compulsion...

You cannot force a man to understand something when his paycheck depends on him not understanding it.

 

[sirspamalot]

Why are you trying to understand something that will never make sense?

And the CBCT that is bundled into a IMRT delivery code.. And that code is General Supervision?

Make it stop...

 

[sirspamalot]

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

Ron G unit has entered the chat..

 

[medgator]

And the CBCT that is bundled into a IMRT delivery code.. And that code is General Supervision?

Make it stop...

Only in hospital

 

[sirspamalot]

Only in hospital

Yes that's my point..

 

[TheWallnerus]

Only in hospital

Yes that's my point..

77014-26 ok in hospital.

Residents… try to keep up! I mean “try” like as in: try to guard Steph Curry.

 

[Reaganite]

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.

I would argue the only codes for which you need to be on site when a patient is receiving a service in real time are simulation codes like 77280 and 77290 (+ brachytherapy/gamma knife, although this is more for nuclear regulatory purposes; no supervision requirement actual listed in CMS billing rules). As far as I can tell, 77280 and 77290 are the only codes where you are billing for something related to a real time evaluation of the patient and for which a telehealth modifier or a supervision exclusion does not exist. Direct supervision of technical applies only to IGRT, and CMS has said it's general in hospitals and virtual in freestanding. No treatment code, including SRS, has an attached supervision requirement. Other professional codes like 77263, IGRT checks, etc. may need to be done when you're "in the office" (although everyone other than certain billing companies think IGRT can be checked anywhere), but I see no reason it has to be at the time the patient is present. I'm actually interested in how Jordan Johnson would deal with simulation charges in the context of his remote supervision company. He has also maintained you need to be present for sims even in the era of general/virtual supervision. Would you just sim patients once a week? What about emergencies? I suppose in a hospital setting you could just avoid billing the prof component of the sim (and I guess you aren't committing fraud because you really didn't do the service?), but how would that play out medicolegally if you ended up in a lawsuit...."correct, judge, I didn't check that simulation."

 

[RickyScott]

I would argue the only codes for which you need to be on site when a patient is receiving a service in real time are simulation codes like 77280 and 77290 (+ brachytherapy/gamma knife, although this is more for nuclear regulatory purposes; no supervision requirement actual listed in CMS billing rules). As far as I can tell, 77280 and 77290 are the only codes where you are billing for something related to a real time evaluation of the patient and for which a telehealth modifier or a supervision exclusion does not exist. Direct supervision of technical applies only to IGRT, and CMS has said it's general in hospitals and virtual in freestanding. No treatment code, including SRS, has an attached supervision requirement. Other professional codes like 77263, IGRT checks, etc. may need to be done when you're "in the office" (although everyone other than certain billing companies think IGRT can be checked anywhere), but I see no reason it has to be at the time the patient is present. I'm actually interested in how Jordan Johnson would deal with simulation charges in the context of his remote supervision company. He has also maintained you need to be present for sims even in the era of general/virtual supervision. Would you just sim patients once a week? What about emergencies? I suppose in a hospital setting you could just avoid billing the prof component of the sim (and I guess you aren't committing fraud because you really didn't do the service?), but how would that play out medicolegally if you ended up in a lawsuit...."correct, judge, I didn't check that simulation."

I assume his centers have a rural exception or those codes/sims are billed the one day a week a doc is present

 

[elementaryschooleconomics]

I would argue the only codes for which you need to be on site when a patient is receiving a service in real time are simulation codes like 77280 and 77290 (+ brachytherapy/gamma knife, although this is more for nuclear regulatory purposes; no supervision requirement actual listed in CMS billing rules). As far as I can tell, 77280 and 77290 are the only codes where you are billing for something related to a real time evaluation of the patient and for which a telehealth modifier or a supervision exclusion does not exist. Direct supervision of technical applies only to IGRT, and CMS has said it's general in hospitals and virtual in freestanding. No treatment code, including SRS, has an attached supervision requirement. Other professional codes like 77263, IGRT checks, etc. may need to be done when you're "in the office" (although everyone other than certain billing companies think IGRT can be checked anywhere), but I see no reason it has to be at the time the patient is present. I'm actually interested in how Jordan Johnson would deal with simulation charges in the context of his remote supervision company. He has also maintained you need to be present for sims even in the era of general/virtual supervision. Would you just sim patients once a week? What about emergencies? I suppose in a hospital setting you could just avoid billing the prof component of the sim (and I guess you aren't committing fraud because you really didn't do the service?), but how would that play out medicolegally if you ended up in a lawsuit...."correct, judge, I didn't check that simulation."

To me, the simulation is no different than a CT scan taking place in Diagnostic Radiology.

Ergo:

Obviously, everything is extremely murky now thanks to the pandemic. And I'm also usually talking about hospital outpatient, not freestanding or IDTF etc etc.

But even before the pandemic enabled virtual supervision, CMS seemed to be on a course of permitting more general supervision (specifically, general supervision from a physician as long as qualified personnel were providing direct/personal supervision...which is always, because CT scans don't happen by themselves).

Looking into my crystal ball:

Virtual supervision will stay, unless like, crazy safety incidents start being reported (won't happen - we're on year 3, everything is fine).
CMS will lose any semblance of patience for our games, and will state in the Federal Register that radiation therapy in hospital outpatient = general supervision (that's more of a longshot on my part, but still possible).

Which does indeed make this ROCR proposal myopic.

Right now we're riding the wave of Boomers retiring, and also becoming patients themselves. That will end. We're still producing 200 new grads a year.

Sometime in the 2030s, the "market cap" of our potential patients will start to drop. A veritable army of early and mid-career RadOncs will still exist. And in this world, we have episodic reimbursement and virtual supervision?

Neat.

 

[Reaganite]

To me, the simulation is no different than a CT scan taking place in Diagnostic Radiology.

Ergo:

View attachment 375000
View attachment 375001

Obviously, everything is extremely murky now thanks to the pandemic. And I'm also usually talking about hospital outpatient, not freestanding or IDTF etc etc.

But even before the pandemic enabled virtual supervision, CMS seemed to be on a course of permitting more general supervision (specifically, general supervision from a physician as long as qualified personnel were providing direct/personal supervision...which is always, because CT scans don't happen by themselves).

Looking into my crystal ball:

Virtual supervision will stay, unless like, crazy safety incidents start being reported (won't happen - we're on year 3, everything is fine).
CMS will lose any semblance of patience for our games, and will state in the Federal Register that radiation therapy in hospital outpatient = general supervision (that's more of a longshot on my part, but still possible).

Which does indeed make this ROCR proposal myopic.

Right now we're riding the wave of Boomers retiring, and also becoming patients themselves. That will end. We're still producing 200 new grads a year.

Sometime in the 2030s, the "market cap" of our potential patients will start to drop. A veritable army of early and mid-career RadOncs will still exist. And in this world, we have episodic reimbursement and virtual supervision?

Neat.

I agree-no supervision of the technical component required. Medicare fee schedule states "supervision does not apply" in reference to 77290 and 77280. I'm speaking to the professional component of simulation itself. Is real time presence an inherent aspect of simulation? CMS definition of simulation is, as usual, vague. Per ASTRO: "The simulation codes describe the work and complexity of establishing the proper patient positioning and obtaining adequate imaging with the patient in the treatment position." Ron's group has argued the physician must be on site for simulation since viewing the set up in real time (i.e. establishing proper positioning) is inherent to the code and no telehealth modifier exists for simulation.

 

[sirspamalot]

I agree-no supervision of the technical component required. Medicare fee schedule states "supervision does not apply" in reference to 77290 and 77280. I'm speaking to the professional component of simulation itself. Is real time presence an inherent aspect of simulation? CMS definition of simulation is, as usual, vague. Per ASTRO: "The simulation codes describe the work and complexity of establishing the proper patient positioning and obtaining adequate imaging with the patient in the treatment position." Ron's group has argued the physician must be on site for simulation since viewing the set up in real time (i.e. establishing proper positioning) is inherent to the code and no telehealth modifier exists for simulation.

It's all bs until someone tries (and fails) to qui Tam one of these scenarios.

As for supervision.. In the HOPPS or MPFA setting an NP or PA is acceptable as fulfilling the direct supervision requirement per NCD.

And THAT is what BO is proposing. Now you only can bill 85% of the MD rate but that still beats 100% of nothing.

However as soon as the BO model stinks up the place the private payors will modify their contractual requirements.. And with the loophole exploit coming to the news cycle.. Congress might push to rewrite the rules specifically for our specialty...perhaps..

 

[elementaryschooleconomics]

I agree-no supervision of the technical component required. Medicare fee schedule states "supervision does not apply" in reference to 77290 and 77280. I'm speaking to the professional component of simulation itself. Is real time presence an inherent aspect of simulation? CMS definition of simulation is, as usual, vague. Per ASTRO: "The simulation codes describe the work and complexity of establishing the proper patient positioning and obtaining adequate imaging with the patient in the treatment position." Ron's group has argued the physician must be on site for simulation since viewing the set up in real time (i.e. establishing proper positioning) is inherent to the code and no telehealth modifier exists for simulation.

Ron's group argues a lot of things.

I like to criticize RCCS a lot, so I should say that, in general, their material is excellent.

Which might be the true source of my criticism. At the end of the day, this is all opinion. Sure, there's actual rules, regulations, legislation - but it depends on the context, the era, the expert witnesses, the lawyers. Very little is clear, and even the clear stuff can be argued.

His agency errs on the side of extreme conservatism, which you can only "see" if you already understand "the system". Given how small RadOnc is, how different and confusing it is from the rest of medicine - it's not a lot of folks who go that deep, at least on the doctor side. So it's a lot easier to just believe everything in Navigator. They trot out various rationales supporting why linac babysitting needs to continue, and that alone makes their supervision opinions...questionable.

Regardless, the coding and billing conversation in just this thread alone is complex than what most of us could get in real life.

Anyone who doesn't believe me should go find a random colleague and ask what the acronym MPFS stands for. Let us know how it goes...

 

[sirspamalot]

Ron like Bogardus has software and services to sell. Does it benefit him to be ultra conservative?

" I guarantee it."

 

[TheWallnerus]

Ron like Bogardus has software and services to sell. Does it benefit him to be ultra conservative?

" I guarantee it."

It benefits him because it also adds an air of authority because when clueless-about-radiation DOJ has rad onc cases, it “appears”(to them) Ron has the ear of the CMS God. And DOJ pays consultants AMAZINGLY well.

 

[sirspamalot]

Inquiring minds need to know... Just how much does Ron hoover up from the DOJ and does he help ruin good radoncs or just the truly egregious?

I wanna believe it's only the bad guys.. But money can corrupt..

 

[OTN]

Inquiring minds need to know... Just how much does Ron hoover up from the DOJ and does he help ruin good radoncs or just the truly egregious?

I wanna believe it's only the bad guys.. But money can corrupt..

I have direct knowledge into this part of his operation, but I'm not going to say how so I don't get doxxed.

We as a group would be very happy with the medical entities that Ron's company has helped the DOJ prosecute and would be on the side of the DOJ and Ron. I'm not going to go into details, but dermatology in particular has "difficulty" getting XRT billing right.

 

[medgator]

I have direct knowledge into this part of his operation, but I'm not going to say how so I don't get doxxed.

We as a group would be very happy with the medical entities that Ron's company has helped the DOJ prosecute and would be on the side of the DOJ and Ron. I'm not going to go into details, but dermatology in particular has "difficulty" getting XRT billing right.

Urologists owning linacs have nothing on the egregiousness coming out of dermrads shops

 

[TheWallnerus]

Inquiring minds need to know... Just how much does Ron hoover up from the DOJ and does he help ruin good radoncs or just the truly egregious?

I wanna believe it's only the bad guys.. But money can corrupt..

I’d like to know what a “good” rad onc is. I mean, honestly.

Is it someone who does IMRT for every stage one breast. Someone who doesn’t constantly watch the screen when virtually supervising IGRT. Someone who bills a complex sim with IMRT. Someone who bills a CBCT with SBRT. Or maybe a proton doc who treats T1 tonsillar with protons. Maybe a good rad onc is at the academic center that is billing multiple IMRT plans as “adaptive.” Or the academic center doing multiple rounds of SBRT met zapping.

Anymore I’m rather of a mind of “For all have sinned and fallen short of the glory of God.” But to throw out another quote, after seeing how rad oncs all across the country bill and code and treat, “I used to be Snow White. But I drifted.”

 

[sirspamalot]

Its all a game. Can you guess what the central purpose of the game is?

 

[deleted1168505]

Is it someone who does IMRT for every stage one breast. Someone who doesn’t constantly watch the screen when virtually supervising IGRT. Someone who bills a complex sim with IMRT. Someone who bills a CBCT with SBRT. Or maybe a proton doc who treats T1 tonsillar with protons. Maybe a good rad onc is at the academic center that is billing multiple IMRT plans as “adaptive.” Or the academic center doing multiple rounds of SBRT met zapping.

All of that is fine. The bad guy is the community rad onc doing 30/10 3D palliation. </thingsilearnedinresidency>

 

[TheWallnerus]

Its all a game. Can you guess what the central purpose of the game is?

Like The Comedian in ‘Watchmen.’

To OTN’s point. I think one of the things derms do mostly likely to get Ron’s goat is the derms billing a daily 77280 along with superficial code. Bad right?

In residency we got a Novalis and treated prostate on it. It was one of first machines to be IGRT capable with kV X-ray (Exactrac technology). However this was many years before IGRT codes existed. So all the good doctors and good billers and coders in the department billed a daily 77280 for the daily kV’s. We were getting $50K plus per prostate, a lot of money in those days.

I’m sure what they were doing, in their minds, was good and honorable. What was that Marc Antony said about the senate… “So are they all, all honorable men.”

 

[communitydoc13]

Which might be the true source of my criticism. At the end of the day, this is all opinion. Sure, there's actual rules, regulations, legislation - but it depends on the context, the era, the expert witnesses, the lawyers. Very little is clear, and even the clear stuff can be argued.

What was that Marc Antony said about the senate… “So are they all, all honorable men.”

We are making our own argument for case based payment here.

You guys are definitely on top of the particulars of coding, and in our field, coding is granular.

But, it's the culture baby, not the regulatory or legal details. Sodomy laws lost their teeth ages ago. (Although it's important to get bad laws off the books, lest a crazy political turn means people will again enforce them.)

What matters are commitment to an idea (culture) and fear.

In our case, there is still commitment in some areas to an idea of in-person supervision (culture) and a fear of Qui-Tam suits in the setting of complicated professional coding.

I am pro machine babysitting btw, because I'm selfish and my practice is set-up this way, with more docs than sites and enough patient's that I am not infrequently being called over for patient issues during the day. It is also a (perhaps artificial) way of preserving our value and propping up our demand.

Regarding case based payment, I'll be damned if I will support any carve outs. But case based would keep us away from righteously committing little sins over and over again.

In an ideal world, ASTRO could have made the following simple proposal (if in fact the goal is payment stabilization). View this as a path to true site neutrality and global radonc cost stabilization. View it as a righteous proposal.

1. Assume that nationally, utilization at present is judicious (not my assumption, I think protons and adaptive are overvalued and protons overutilized, but this is the assumption our advocacy group should make when pursuing payment stabilization). This means that protons, adaptive, fractionation choice, image guidance, SBRT, all this stuff is assumed to be roughly done correctly and in proper proportions presently. (+/- the 6% fraud margin) However, we have existing incentives to maximize cost per patient, including the use high cost interventions without proven clinical benefit.

2. Our goal regarding stability is to stabilize both payments and costs (to the government). We also want to tie payment to inflation, because this makes sense (we have all been taking a cost of living hit for years).

3. Calculate payments presently for all cases (by cancer type) as well as the number of cases at a national level and come up with your case rates. This should include all cases, including protons, adaptive (as a single case), and brachy.

4. Use this as the number to designate national case rates. (Feds can throw on a geographic adjustment multiplier like they do already).

Now if this number is radically different than what ASTRO is presently proposing, this tells us some important things. (I would think they could come up with an alternate calculator relatively easily).

5. Propose research dollars for ions and other progressive interventions. Make it a radonc moonshot type deal. Give it to the big guys and factor it into the proposal. You could even run the calculator for UPENN or MSKCC and figure out what type of research allocation they would need to make up for the loss of revenue. (My guess is, given their payor mix, they would be fine anyway). I'm not opposed to academics getting research money, I'm opposed to the perverse things that happen when they get paid more for equivalent care. This could radically change the culture of academic radonc back to what it should be (tough cases and research).

This is a true case based payment model. Now, what would it incentivize?

1. Judicious use of tech...and science
2. Emphasizing cost effectiveness of new technologies (important when it's all radiation anyway).
3. Seeing patients.

What would it dis-incentivize?
1. Consolidation (your cases are worth what they are worth)
2. New proton centers
3. New tech unless it is cost effective

Regarding increasing radiation oncology's value? There are authentic ways to do this. Like adding different types of interventions to our practice.

 

[sirspamalot]

Ron sells compliance with heavy dose of detail and a dash of fear.

I recall his lecture where he said IGRT was going to be a rich source of lawsuits... but other than freestanding ie. Maryland, its a fat 0. That was freestanding, and even that is gone with telehealth.

While at first private auditors went wild.. that has largely been shut down via a change in the appeals process (as best I can recall) and so auditing for radonc is really pretty quiet these days. Hell, with the UM, I would think it would largely be a waste of time for the most part.

 

[elementaryschooleconomics]

What would it dis-incentivize?
1. Consolidation (your cases are worth what they are worth)

Excellent post, in general, as always.

There's a lot to unpack in what you're saying there.

Just to focus specifically on consolidation for a moment, I don't think ROCR or anything like it will slow consolidation, let alone stop it.

Importantly, there's not many practices left to be rolled up. There were a few hundred in 2017 - three years before the pandemic, before the RadOnc bubble burst even. Who knows how small the number is now.

Regardless, we often talk about this like it's a vacuum, which is not how the C-suite sees it. Well - at least the smart executives, some "bad" business folks see it that way. But: there's a massive halo effect that comes with our practices.

So even if some of the tricks for maximizing RadOnc-specific reimbursement are no longer an option, we order a lot of diagnostic tests, refer to other providers, generate facility fees for every little E&M visit, etc etc.

I also just find it weird that this is a talking point now. Other than that single Red Journal article in 2021...this is not something RadOnc generally seems to care about outside of SDN, and even then, it's not a super active point of conversation.

Why, ASTRO, why?

 

[sirspamalot]

SK has left the building, the parking lot, and the entire State of SDN

 

[communitydoc13]

I don't think ROCR or anything like it will slow consolidation, let alone stop it.

You're right. Consolidation is so much bigger than radonc anyway. Most of us are tied to hospitals and valuation of a hospital is going to dwarf radonc considerations.

That being said, I am aware of academic places staffing community practices on the cheap, as well as radonc takeovers of departments as a first step for total takeover of hospitals.

I suspect ASTRO addressed consolidation because we mentioned it here. Of course they have no good arguments regarding ROCR as a deterrent to consolidation.

I would guess that the greatest contribution ROCR would make to consolidation would be to make some community places more vulnerable due to loss of technical fees. Plenty of places running close to margin (or in red since covid). CEOs of sinking ships tend to look for a buyer.

 

[RickyScott]

ROCR will increase consolidation in proton markets due to the carve out.

 

[TheWallnerus]

radonc takeovers of departments as a first step for total takeover of hospitals.

E.g., UAB took over this hospital's rad onc department in 2017. Six years later they're on their way to take over the whole hospital. You get hired as an academic rad onc at UAB, you're at a pretty high risk of needing to drive one hour one way twice-a-day to the Boonies Satellite.

(I know one of the rad oncs one time overslept or something, Bonner got mad, and the "oversleeping"/no-fan-of-long-drives academic rad onc fired off a doozy of a letter about wellness and "me time" and that sort of thing. A few months later the oversleeper went to private practice Good for him, or her.)

UAB Health System continues expansion with RMC of Anniston as a potential affiliate

The UAB Health System is in the process of bringing in another Alabama hospital to join the dozen or so they currently have agreements with.

www.al.com

 

[deleted1111261]

Consolidation itself isn't a dirty word.

It's one thing when academic centers buy a bunch of satellites, jack up contracted rates, employ the docs and ruin things.

But, if a small hospital system gets a little bit bigger and allows the private docs to stay private, there are benefits.

Some scale is good. Too much scale is not so good.

We have some of the lowest rates in the state, yet, we aren't considered a preferred partner for these insurance plans b/c we are tiny (in MI). We have 45 hospitals nationally that aren't very connected, but working on some things.

I think if a place like ours gets 6-7 smaller hospitals in MI, we can do better in terms of contracts, improve quality through the network, etc.

It's all very fascinating and the discussion on the town hall was overly simplistic. I think this is going to be one of the more interesting things in medicine over the next decade.

I think we tend - on this board - focus on the individual doc or practice. And that's okay - someone has to do that. But, there is an interconnected world out there. Just like everything, there is good and bad in VC, PE, consolidation, academic centers, etc. It's hard to visualize all the relationships and even harder to guess what the interplay will be.

 

[sirspamalot]

Why of course.. if you connect 6 practices into one within a geographical zone you instantly have my favorite flavor: leverage.

Once academic RO realized the powah of doing this rather than staying focused on the academic mission, and instead chasing the almighty dollar, you end up where we are today - massive pointless consolidation for $ sake and no other purpose.

The biggest dogs who start the race always win.

You consolidate now, or you croak when someone else eats you and forces terms upon you.

Exceptions: rural 1-offs that are not valuable enough to consolidate and too far to make anyone go work at 1 day a week on a rotational basis.

#

ps. no stinking BO needed here

 

[communitydoc13]

Some scale is good. Too much scale is not so good.

Preach

there is good and bad in VC, PE, consolidation, academic centers, etc

Just not clear to me how PE is ever the set-up you want as an employee. When all emphasis in on shareholders, there is no room long term for human values (how you treat employees).

We are all invested to some degree in PE through our mutual funds.

 

[deleted1111261]

Preach

Just not clear to me how PE is ever the set-up you want as an employee. When all emphasis in on shareholders, there is no room long term for human values (how you treat employees).

We are all invested to some degree in PE through our mutual funds.

“Good” PE finds inefficiencies in the businesses and create scale, all the buzzwords

Rare that this is good in medicine, you’re right. It is inherently inefficient, and duplication often is necessary for safety and other reasons.

The first principles are actually not terrible. It’s the craven focus on $$ (which many have anyway) that makes it so problematic.

I’m at a for profit hospital and I like how we run. Much leaner and cleaner than non-profit. We don’t have random Vice chairs or non-medical chairs. Maybe many would not like it. It is music to my ears

 

[RickyScott]

Ron sells compliance with heavy dose of detail and a dash of fear.

I recall his lecture where he said IGRT was going to be a rich source of lawsuits... but other than freestanding ie. Maryland, its a fat 0. That was freestanding, and even that is gone with telehealth.

While at first private auditors went wild.. that has largely been shut down via a change in the appeals process (as best I can recall) and so auditing for radonc is really pretty quiet these days. Hell, with the UM, I would think it would largely be a waste of time for the most part.

Ron tries to scare you into buying his services.

 

[BobbyHeenan]

Ron tries to scare you into buying his services.

In my experience not limited to Ron.

Compliance, billing, and consult companies have to justify their heavy price by letting you know you'd be rotting in jail had it not been for their keen oversite.

I still contend the billing wisdom of SDN is far superior than what you're getting for letting any of the above companies anywhere near your clinic.

Tons of billing stuff is murky. if you're worried, post about it here, see what others are doing, and make sure you're not the outlier. Boom, I just saved you and your clinic work flow and six figures.

 

[RickyScott]

In my experience not limited to Ron.

Compliance, billing, and consult companies have to justify their heavy price by letting you know you'd be rotting in jail had it not been for their keen oversite.

I still contend the billing wisdom of SDN is far superior than what you're getting for letting any of the above companies anywhere near your clinic.

Tons of billing stuff is murky. if you're worried, post about it here, see what others are doing, and make sure you're not the outlier. Boom, I just saved you and your clinic work flow and six figures.

true, but he is by far the worst. He once claimed it is fraud if you bill for a cbct at a satellite (covered by another doctor) when you review the film remotely.

 

[sirspamalot]

I remember that lecture at ACRO a couple years ago. Just remember, when Ron grins, someone, somewhere is getting $*)@* I mean billed again.. HARD.

 

[deleted1168505]

true, but he is by far the worst. He once claimed it is fraud if you bill for a cbct at a satellite (covered by another doctor) when you review the film remotely.

Did someone stand up and scream LIAR!?

They should have.

Bridge oncology better watch out... Ron's coming for them.

 

[sirspamalot]

Eliminate that BO with.. another form of manipulative market making.

BO will die a quiet death, but Ron lives on forever. Nowhere have I seen in any other specialty a clever intertwining of a corporate interest and not 1 but 2 major medical societies. Gotta tip the hat. #ronliveson

 

[RickyScott]

Did someone stand up and scream LIAR!?

They should have.

Bridge oncology better watch out... Ron's coming for them.

Actually many in the audience objected.

 

[sirspamalot]

Yes they did.... it caused quite stir.

 

[BobbyHeenan]

true, but he is by far the worst. He once claimed it is fraud if you bill for a cbct at a satellite (covered by another doctor) when you review the film remotely.

Around 12-15 years ago (?maybe longer than that, it's blurry to me?) one of those companies (I can't remember if it was Bogardus or *trigger warning* Cyndi Parham) told us we needed to DICTATE a unique note for every single CBCT we billed for. We couldn't just approve it in mosaiq or aria, we have to generate a unique note. Could it be auto-generated by a physics/Word document and put in the chart? No, that wasn't ideal. Well maybe they said. They STRONGLY recommended we literally dictate a note every.single.fraction.

F THAT.

 

[sirspamalot]

Thats what my current location requires - a note is 'generated' and I have to sign it. Every. Single. Day. Its nuts.

I've never seen this before: at every other place I've worked, I simply 'checked' (e-signed) the image itself, not another page with a template report and snapshot pic.

What a waste of time. Good thing its the # lyfe and I'm not that busy.

 

[BobbyHeenan]

Thats what my current location requires - a note is 'generated' and I have to sign it. Every. Single. Day. Its nuts.

I've never seen this before: at every other place I've worked, I simply 'checked' (e-signed) the image itself, not another page with a template report and snapshot pic.

What a waste of time. Good thing its the # lyfe and I'm not that busy.

yes, we did that for a while but eventually went back to just approving images.

Physics had written a script that auto populated everything for us to sign for each image. Insane to me.