First thing I saw as well. I'm sure there will be fierce pushback against it, but if it gets though, that's huge.
I had the same question! And wonder how it affects documentation/standard billing requirements. "RO participants would be required to submit encounter data (no-pay) claims that include all RT services identified on the RO Model Bundled HCPCS list (Table 2) as services are furnished and would otherwise be billed under the Medicare FFS system"...but could you not do a weekly status check the first week for a patient getting 6-8 weeks of prostate radiation? Could you not document each SBRT fraction? Could you just write a 1 line simulation note (instead of having to document each treatment device you used) and all the other stuff that doesn't clinically make a difference?Interested to see how the physician presence requirement will be impacted by bundled payments...Right now, you can get dinged on a per claim basis, but how would that work with what essentially appears to be a case rate??
Interested to see how the physician presence requirement will be impacted by bundled payments...Right now, you can get dinged on a per claim basis, but how would that work with what essentially appears to be a case rate??
Me too. I believe it would eliminate the silly kabuki theatre of "stand here... sign here... document here" at least. Chemo, which is way more dangerous/unsafe/lethal than radiotherapy even w/ SRS or SBRT at & during the moment of delivery, can be supervised by just an NP or PA in freestanding. Many big companies have been pushing for freestanding RT NP/PA supervision for a while. I also foresee the rise of, and allowance by CMS for, the rad onc "Virtualist." As we all know the rad onc has zero at-the-moment-of-delivery interaction/oversight of routine radiotherapy fractions... consults could be virtual, planning virtual, film checks virtual, even SRS/SBRT virtual. If just one of these three happen (less supervision/documentation requirements with APM, or NP supervision, or the "virtualist") there'd be need for ~1/3 less rad oncs perhaps (in the US; many other countries do not have the supervision requirement). (I expect and am fully not joking that after we have sufficiently de-fractionated there'll be randomized trials testing the elimination of weekly treatment management and its impact on outcomes. This would provide further cost savings with no impact clinically, I'm sure of it.)I had the same question! And wonder how it affects documentation/standard billing requirements. "RO participants would be required to submit encounter data (no-pay) claims that include all RT services identified on the RO Model Bundled HCPCS list (Table 2) as services are furnished and would otherwise be billed under the Medicare FFS system"...but could you not do a weekly status check the first week for a patient getting 6-8 weeks of prostate radiation? Could you not document each SBRT fraction? Could you just write a 1 line simulation note* (instead of having to document each treatment device you used) and all the other stuff that doesn't clinically make a difference?
If you're a proton center treating prostates and you're in included in this roll out that's going to really really hurt I'd imagine, as I *think* from reading this the baseline formula for what they're going to pay is largely based upon a national average....
Well the breast and lung wouldn't have same ICD codes. You mean CPTs? For that, in general, re: payment, 30 fraction IG-IMRT> 30 fraction 3d-IGRT > 15 fx IMRT (which could be used for 100% of early breast, see UK-IMPORT LOW and Evicore guidelines) >15 fx 3d-IGRT > SBRT. I'd predict, but who knows, there's going to be relative equality per clinical scenario. But what it may do is lead to hypofractionating Stage III lung e.g. (why not 2.1 Gy per day guys?) and treating all Stage I breast with five fractions. Maybe suddenly a big single electron dose to the tumor cavity looks appealing. IMHO. All would pay same: 33 fx, or 15 fx, or IMRT, or 3D, or partial breast. And another thing it will do: vastly decrease the number of on-beam patients in all depts across the United States.Is staging taken into account at all or is this based on ICD-10 codes?
For instance, for a stage I lung SBRT or a stage III IMRT/VMAT case they both often have the same ICD 10 codes, but payment/treatment here can vary wildly.
Or a stage I right sided breast may be treated with 15 fraction 3D plan, but with a locally advanced stage III you may be looking at 33 fraction breath hold 3D (or IMRT). Both may have the same ICD 10 code. Costs vary wildly. I guess it'll all wash out in theory and you'd get paid "more" on the stage I cases but less on the stage III cases based on current billing standards.
Any thoughts here?
Well the breast and lung wouldn't have same ICD codes. You mean CPTs? For that, in general, re: payment, 30 fraction IG-IMRT> 30 fraction 3d-IGRT > 15 fx IMRT (which could be used for 100% of early breast, see UK-IMPORT LOW and Evicore guidelines) >15 fx 3d-IGRT > SBRT. I'd predict, but who knows, there's going to be relative equality per clinical scenario. But what it may do is lead to hypofractionating Stage III lung e.g. (why not 2.1 Gy per day guys?) and treating all Stage I breast with five fractions. Maybe suddenly a big single electron dose to the tumor cavity looks appealing. IMHO. All would pay same: 33 fx, or 15 fx, or IMRT, or 3D, or partial breast. And another thing it will do: vastly decrease the number of on-beam patients in all depts across the United States.
My assumption is proton centers will be exempt...
That will probably be one of ASTROs proposed "modifications" to the planMy assumption is proton centers will be exempt...
i think so; last time I checked, no way to code for stageI now see the base formula rates are buried in the proposal. They make no distinction for stage. It literally just says Breast - professional fee $X.
Plus, correct me if I"m wrong, but if you have RUL lung tumor stage I, but a RUL lung tumor with mediastinal nodes, the ICD 10 code is still c34.11, no?
Could use overlapping lung code for locally advanced patientsI now see the base formula rates are buried in the proposal. They make no distinction for stage. It literally just says Breast - professional fee $X.
Plus, correct me if I"m wrong, but if you have RUL lung tumor stage I, but a RUL lung tumor with mediastinal nodes, the ICD 10 code is still c34.11, no?
That will probably be one of ASTROs proposed "modifications" to the plan
Why do you say that?
This is what I think may happen too. Though some chunk of the proton centers will be exempt from all of this anyway
If ASTRO pushes for proton centers to be exempt, well then it should be fairly obvious to all that the emperor truly has no clothes.
Those of us following data and guidelines welcome CMS's push to curtail 40/20 to bone mets and 60/33 to 70+ y/o early stage breast caQuoting verbatim-
"Our analysis also showed that, on average, freestanding radiation therapy centers furnished (and billed for) a higher volume of RT services within such episodes than did HOPDs. Based on our analysis of Medicare FFS claims data from that time period, episodes of care in which RT was furnished at a freestanding radiation therapy center were, on average, paid approximately $1,800 (or 11 percent) more by Medicare than those episodes of care where RT was furnished at a HOPD. We are not aware of any clinical rationale that explains for these differences, which persisted after controlling for diagnosis, patient case mix (to the extent possible using data available in claims), geography, and other factors. These differences also persist even though Medicare payments are lower per unit in freestanding radiation therapy centers than in HOPDs. Upon further analysis, we observed that freestanding radiation therapy centers use more IMRT, a type of RT associated with higher Medicare payments, and perform more fractions (that is, more RT treatments) than HOPDs."
I haven't looked deeply, but there are some weird exemptions (Vermont and Maryland excluded).
Agree entirely. For those of us who have adopted hypofractionation and treat reasonably, this could well represent a pay bump. Not as good of news for those that are treating bone mets with 1.8's...If you’ve been treating appropriately in freestanding centers, site parity via HOPPS will be great. I hypofractionate nearly all my intact breast patients, very, very rarely go above 30 in 10 for mets, and see almost no prostate patients (thanks urorads), so this has real potential to be good for my practice.
Choose one, search your feelings: 1) there are less rad oncs today than ~2015, 2) no one can really say if there are more or less rad oncs today than ~2015, or 3) there are more rad oncs today than ~2015. It wasn't the raw number(s) per se; it's the suggestion (unintentional I'm sure) by Harari/ASTRO that there are 10% less rad oncs today than 4 years ago. And if ASTRO can't consistently be on top of the workforce numbers in this day and age, so that they're not a mystery, that's inexcusable. I've tried to get real data before.I mean - if you think ASTRO is wrong in 2019 about how many rad oncs there are, then why wouldn't they have also possibly been wrong in 2015 to begin with? Maybe the 4500 number now is more accurate? Would want to see real data on this and not what you or anyone else 'feels' seems right
Nah, it's not digital tracking. Rad onc's cost to CMS is small. The amount of govt attention it gets is out of proportion to its size in CMS' budget. Public perception and attention matters. R. Kelly went years with no legal problems; once Lifetime did a documentary on him though he now seems destined for a reckoning. A very superficial look at the long view, in my view, would show a rad onc reimbursement explosion ~2000-2010 from IMRT. This got everybody's attention, including, like from this publication, from this guy (who's also this guy), who "tracked" IMRT spending for prostate. There was similar attention in other disease sites. All reasons for the rise in IMRT use were almost always ascribed to avarice; ASTRO's part in that was not zero. Since ~2010, CMS spending for rad onc has been on a downward trend; personally my CMS billing is down ~20% 2019 vs 2013 for about the same patient numbers (many things reimburse less, somethings you don't even get reimbursed at all for anymore, and hypofractionation; the billing/treating landscape is FAR different, and less lucrative, today than just ~6 years ago). At the same time, however, certain entities (large academic centers) are charging multiples of what some other entities are charging for RT (you bet that's tracked). ASTRO is lamenting self-referral and saying "don't do IMRT for breast," but ASTRO gets indignant when proton non-reimbursement is suggested e.g. It's all a stew. I can't point to one thing, and wouldn't. But ASTRO hasn't been a staunch and consistent helper to all its members due to its actions and inactions. I linked this above, but from 7 years ago Dr. Zeitman was saying:Also - CMS was ALWAYS going to pay more attention to all fields of medicine as medicine began to cost more and there were easier (digital) ways to track everything - whether or not there was ever a concern about self-referral
The biggest job growth market, by far, in rad onc the last ~15 years has been in academic positions (~2.2-fold increase). This has outmatched the percent growth in resident slots (~1.6-fold increase). And this has outmatched the growth in private practice jobs (~1.3 fold increase). So freestanding/private practice has been doing all the overbilling, but academics has been able to afford a >200% increase in jobs? C'mon CMS. Everyone should easily see where the real money's been flowing (facility fees? special treatment?). The freestanding centers will either close (small ones especially) or simply not hire to increase ranks for a very long time. The latter has been happening for a while. So I predict, just by looking at the trends, the real job market contraction will be in academics. This will put a major monkeywrench in future job seekers' plans as this, "academics" (academic satellites etc.), has been the "absorber" of all the new rad oncs. Recent ASTRO workforce data back this supposition up: academic jobs growing at the expense of private practice.When Medicare takes away financial incentives for overutilization, this is hard data that the job market, propped up by overutilization in freestanding centers,will be further harmed,not that we didn’t know that.
Moderator note: the post previously referenced here was removed for trolling.
The biggest job growth market, by far, in rad onc the last ~15 years has been in academic positions (~2.2-fold increase). This has outmatched the percent growth in resident slots (~1.6-fold increase). And this has outmatched the growth in private practice jobs (~1.3 fold increase). So freestanding/private practice has been doing all the overbilling, but academics has been able to afford a >200% increase in jobs? C'mon CMS. Everyone should easily see where the real money's been flowing (facility fees? special treatment?). The freestanding centers will either close (small ones especially) or simply not hire to increase ranks for a very long time. The latter has been happening for a while. So I predict, just by looking at the trends, the real job market contraction will be in academics. This will put a major monkeywrench in future job seekers' plans as this, "academics" (academic satellites etc.), has been the "absorber" of all the new rad oncs. Recent ASTRO workforce data back this supposition up: academic jobs growing at the expense of private practice.
Send back the caskets, the specialty might not be dead yet!
The biggest job growth market, by far, in rad onc the last ~15 years has been in academic positions (~2.2-fold increase). This has outmatched the percent growth in resident slots (~1.6-fold increase). And this has outmatched the growth in private practice jobs (~1.3 fold increase). So freestanding/private practice has been doing all the overbilling, but academics has been able to afford a >200% increase in jobs? C'mon CMS. Everyone should easily see where the real money's been flowing (facility fees? special treatment?). The freestanding centers will either close (small ones especially) or simply not hire to increase ranks for a very long time. The latter has been happening for a while. So I predict, just by looking at the trends, the real job market contraction will be in academics. This will put a major monkeywrench in future job seekers' plans as this, "academics" (academic satellites etc.), has been the "absorber" of all the new rad oncs. Recent ASTRO workforce data back this supposition up: academic jobs growing at the expense of private practice.
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APMs are gonna end up being just another Paycut to your Dept and ultimately to you.
Only to those ill prepared for it. Lean, mean, evidence based practice machines will be fine
So you think hospitals should get paid more fraction? If so, why?Nope...just lean.
So you think hospitals should get paid more fraction? If so, why?
Only to those ill prepared for it. Lean, mean, evidence based practice machines will be fine.
There is no reason for different sites of service to be reimbursed differently. A linac is a linac, regardless of location
No but that's what APM is trying to do. It will probably be more of a pay cut if you:Huh? Did I suggest that?