Virtual Supervision

[TheWallnerus]

CMS is seeking comments on virtual direct supervision. Comment period closes tomorrow.

Anyone can comment. Below is what someone else said; you could copy it and use it as your comment, or change it completely. Or ignore CMS's comment request altogether.

Of the ~29,000 comments submitted thus far, there has been one comment re: rad onc specifically. It's from ASTRO. They are asking CMS to kill the virtual direct supervision flexibility which was created by CMS during the COVID PHE.

LETTER TO CMS
In proposed rule CMS-1751-P, CMS seeks input regarding the following:

We continue to seek information on whether this [direct supervision] flexibility should be continued beyond the later of the end of the PHE for COVID-19 or CY 2021. Specifically, we are seeking comment on the extent to which the flexibility to meet the immediate availability requirement for direct supervision through the use of real-time, audio/video technology is being used during the PHE, and whether physicians and practitioners anticipate relying on this flexibility after the end of the PHE. We are seeking comment on whether this flexibility should potentially be made permanent, meaning that we would revise the definition of “direct supervision” at § 410.32(b)(3)(ii) to include immediate availability through the virtual presence of the supervising physician or practitioner using real-time, interactive audio/video communications technology without limitation after the PHE for COVID-19, or if we should continue the policy in place for a short additional time to facilitate a gradual sunset of the policy. We are soliciting comment on whether the current timeframe for continuing this flexibility at § 410.32(b)(3)(ii), which is currently the later of the end of the year in which the PHE for COVID-19 ends or December 31, 2021, remains appropriate, or if this timeframe should be extended through some later date to facilitate the gathering of additional information in recognition that, due to the on-going nature of the PHE for COVID-19, practitioners may not yet have had time to assess the implications of a permanent change in this policy. We also seek comment regarding the possibility of permanently allowing immediate availability for direct supervision through virtual presence using real-time audio/video technology for only a subset of services, as we recognize that it may be inappropriate to allow direct supervision without physical presence for some services, due to potential concerns over patient safety if the practitioner is not immediately available in-person. We are also seeking comment on, were this policy to be made permanent, if a service level modifier should be required to identify when the requirements for direct supervision were met using two-way, audio/video communications technology.​

In summary, CMS asks:

1) Do MDs now rely on direct supervision flexibility?
2) Should the flexibility be made permanent, or “sunset” at a future time?
3) Should all, or only a portion, of direct supervision services fall under this flexibility; specifically, are there safety concerns?
4) Should service modifiers be in place to note when virtual direct supervision is being used?

A HISTORY OF CHANGING RADIATION THERAPY SUPERVISION STANDARDS

In theory, radiation therapy in both hospitals and non-hospital settings has always required direct supervision (the physician should be present in the building and/or immediately available, but is not actively participating in the procedure nor in the room with the patient). However, CMS explicitly stated a direct supervision requirement in 2011. But this was not evenly applied to all doctors/facilities throughout the U.S.: there were specific rules in place allowing for non-enforcement of direct supervision in rural hospitals. It has been noted by CMS that “[there were no] supervision-related complaints from beneficiaries and… no data showing quality was adversely affected at CAHs and small rural hospitals that have only been required to maintain general supervision (for radiation therapy).”

There were numerous supervision inconsistencies on CMS’s part before 2011. Image guided radiation therapy (IGRT) came into use clinically in the early 2000s using cone beam CTs and in-room 2D kV X-raying. However, there were no billing codes for its use until Jan 1, 2005. The first true IGRT code was C9722 for stereoscopic X-ray guidance. Since this was a “C” code, there was no supervision level assigned the code by CMS. CMS then created CPT code 77421 on Jan 1, 2006; C9722 was thus eliminated. The 77421 code was assigned a personal level (physician must be in the room with the patient) of supervision. Then in mid-2009, CMS assigned a personal level of supervision to 77421-26 but a direct level to 77421-TC. Within months, CMS changed the IGRT supervision levels again to pure direct supervision for 77421 and making this retroactive to Jan 1, 2009. (77421 was eventually replaced by G6002.) IGRT code 77014 for cone beam CT, which is a much more complex form of IGRT and involves more radiation dose than 77421/G6002, had always been a direct, not personal, level of supervision. Finally, CPT 77417, weekly port films, which is also technically a very simple form of IGRT, has always been listed and assigned as a general supervision code in the CMS CPT database (i.e. requiring no physician physical presence). Throughout all these confusing/conflicting/changing supervision requirements, not a single adverse incident associated with a physician not being in the building when the radiation therapists were performing radiation or doing IGRT has been reliably reported.

The last few years have seen CMS changing supervision levels in radiation therapy again. In 2020, CMS allowed general supervision for radiation therapy in hospitals. (As noted, these requirements have been “vexing” for hospitals. In truth, they have been vexing for freestanding centers, and all radiation oncologists, as well.) Then in 2021 CMS eliminated the requirement for physician physical presence for diagnostic tests (which cover IGRT) in hospitals thereby allowing non-physician practitioners to “cover” these “tests” (IGRT is not a test, nor diagnostic… but this is how CMS quixotically defines IGRT). Again, notably, no safety incidents have been published or reported as a result of these last two mentioned supervision “sea changes.” Since the COVID PHE and CMS’s start of direct virtual supervision, we are also unaware of safety incidents or beneficiary complaints from virtual, instead of non-virtual, direct supervision.


A PRAGMATIC VIEW?

In most of the world the concept of the “direct supervision” of radiation therapy as an inviolable rule does not exist. In Canada, there are too many rural centers and locales to insist on a doctor being in the building every time a patient receives radiotherapy. Therefore, the Canadian public health service explicitly allows for direct supervision flexibility (and it needn’t even be virtual; it can be general). This concept is also true in the United Kingdom (whose breast treatment protocols especially have now been widely adopted in the U.S.) where “specialist radiographers,” equivalent to the “techs” in U.S. departments, see and supervise patients. There are no known radiation safety incident issues in these countries versus U.S. outcomes pertaining to where the MDs were exactly located at the time of patients’ treatments.

For rural, solo rad oncs the pure direct supervision requirement is burdensome and probably unsafe in and of itself. Patients started on radiation therapy should, in general (except for weekends and holidays), not take “days off” from the radiation therapy. However, if a radiation oncologist has a family or health emergency and he/she is the only physician in the clinic there is really no choice but shut the clinic down for a day or two and let patients experience potentially harmful treatment breaks… or simply let the Medicare patients not get treated whilst the private insurance patients continue on (there is no specific direct supervision rule per se for most private insurance reimbursement situations). It’s the proverbial “rock and a hard place” for many providers.

This is why the COVID PHE direct supervision flexibility has been so valuable. Much of the radiation oncology physician’s patient care work, including radiation planning and design and image analysis, is done via computer… and most times this is done when the patient is not even in the department where a supervision concept has zero applicability. Even when the physician is analyzing patient parameters “real time” while the patient is in the department getting treated, the physician is not in the room with the patient but instead viewing a screen or monitor some remote distance from the patient. All of these activities are highly amenable to the routine safe provisioning of virtual direct supervision.

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[TheWallnerus]

WORRY OF ABUSE

If CMS is concerned that virtual direct supervision of radiation therapy could be abused somehow (although it doesn’t seem abused in other countries like Canada or the U.K. e.g.), it could require a modifier for virtual direct supervision. This modifier could be added to the treatment or IGRT codes when virtual direct supervision is being performed. CMS could place a limit on the modifier; e.g. the modifier would not be allowed to be used more than five times consecutively in any particular patient’s course of treatment. We are not suggesting this, but it may be a “middle ground” before virtual direct supervision is normative in the U.S.

 

[TheWallnerus]

VIEW OF OTHER RADIATION ONCOLOGISTS

The professional society of radiation oncologists, ASTRO, espoused no view on the “whiplash” of IGRT supervision changes pre-2010. Yet in 2019 ASTRO spoke out vigorously against CMS changing radiation supervision in hospitals from direct to general. (CMS changed the supervision level regardless ASTRO’s objections in 2020.) Next, as previously mentioned, CMS decided to change the supervision level for a subset of radiation therapy, IGRT, in hospitals, in 2021. ASTRO objected to that too. ASTRO’s objections were always based on patient safety concerns. When CMS changed to not requiring physician physical presence during the COVID PHE, ASTRO somewhat inexplicably agreed with this change and was silent re: patient safety worry. If patient safety were truly at risk why would ASTRO agree to the COVID PHE supervision change? Yet ASTRO is now in favor of virtual direct supervision being eliminated. It says “It is critical that practices provide direct supervision to ensure the continued delivery of safe and high-quality radiation therapy services.” Why is direct supervision “critical” in 2022 but not during the PHE of 2020 and 2021? About 2 million patients will have received radiotherapy in the U.S. in that timeframe, many ostensibly “unsafely” exposed to virtual direct supervision. As outlined earlier, direct supervision of radiation therapy—either in America in rural or non-rural locations, or in other countries—has never been shown to increase safety over and above that of general supervision. And ASTRO never openly objected to general supervision in rural hospitals. Virtual direct supervision would at least in theory be safer than general supervision. And what if physicians still have COVID PHE worries were virtual direct supervision to sunset? What if a physician has a serious flu and doesn’t want to come in to the clinic and infect other patients? What if a physician has a car accident on the way to the office in the morning? Or has a sick child that needs to be picked up from daycare at noon? Supervision flexibility is important for good patient care so that patient care needn’t be interrupted. The course ASTRO has plotted on physician supervision has been inscrutable and not based on any actual clinical evidence. Do not let ASTRO’s lack of leadership here be cause for concern re: patient safety.


SUMMARY

Many of America’s radiation oncologists now rely on the flexibility of virtual direct supervision. It should not be eliminated. The alternative to supervision flexibility has been a source of constant controversy in radiation oncology and unfairly burdensome on rural radiation oncologists who care for beneficiaries in rural locations. There are no safety concerns over virtual direct supervision of radiation therapy which have any rational basis in fact. If “guardrails” must be set, this could be accomplished with modifier limits.

 

[TheWallnerus]

CMS ELIMINATES DIRECT SUPERVISION REQUIREMENT FOR HOSPITALS. CMS Eliminates Direct Supervision Requirement for Hospitals

A New Stereotactic Localization Code for IGRT

In 2006, radiation oncologists can bill for professional services associated with comparing portal images to the treatment plan for delivery of IGRT

axisimagingnews.com

Image-Guided and Adaptive Radiation Therapy

CMS finalizes major cut in radiology reimbursement

Radiology will see a significant cut in Medicare reimbursement in 2021 if a new final rule is applied without a change to the budget neutrality requirement in the law. Sandy Coffta of Healthcare Administrative Partners offers an analysis.

www.auntminnie.com

https://downloads.regulations.gov/CMS-2021-0119-25905/attachment_1.pdf

 

[radoncopotamus]

Can you post Astros comment? (I cannot tell if you did)

 

[TheWallnerus]

Can you post Astros comment? (I cannot tell if you did)

https://downloads.regulations.gov/CMS-2021-0119-25905/attachment_1.pdf

 

[fiji128]

Reading through this stuff really makes it seem like the powers at CMS have placed a giant target on rad onc's back.

 

[BobbyHeenan]

Reading through this stuff really makes it seem like the powers at CMS have placed a giant target on rad onc's back.

That and they're talking to the wrong people.

Reading the initial APM long form document, I made the assumption that a number of years back, IMRT for prostate got their antennae up. Then protons for prostate pushed it over the edge. Protons for prostate is the "case study" that they list as a low value radiation procedure.

Then, to make matters worse, from what I'm reading now the people in their ear guiding APM policy are from UPenn and MDA. Their (UPenn/MDA) models of care/reimbursement/operating procedures are so far different than the vast majority of cancer centers.

I'm not an expert here, but from my limited reading of the highlights of how this ball is rolling leads to me the above.

 

[RickyScott]

That and they're talking to the wrong people.

Reading the initial APM long form document, I made the assumption that a number of years back, IMRT for prostate got their antennae up. Then protons for prostate pushed it over the edge. Protons for prostate is the "case study" that they list as a low value radiation procedure.

Then, to make matters worse, from what I'm reading now the people in their ear guiding APM policy are from UPenn and MDA. Their (UPenn/MDA) models of care/reimbursement/operating procedures are so far different than the vast majority of cancer centers.

I'm not an expert here, but from my limited reading of the highlights of how this ball is rolling leads to me the above.

Exactly, the greed backfires on all is us. Same true for evercore. We are all paying the price for protons and prices 10 x cms. If goodwill of cms is a “commons” than this is another tragedy just like residency expansion.

 

[elementaryschooleconomics]

Remember kids, we should omit radiation for early-stage breast patients older than 70...

...unless you have a proton center, in which case our ULTRA HIGH PRECISION HEAVY ION BEAMS OF HOPE are your only chance at life!

What's that, CMS? You'd like me to design policy for you? Don't mind if I do.

 

[jondunn]

this is a tricky topic. I see where the OP is coming from - as a PP doc, it certainly does help ME to have less supervision rules. It does NOT help the rad onc job market at large, nor does it help the locums market. I feel like if we are going to put our money where out mouth is, in terms of protecting the health of the field, I think ASTRO has a point that it is important to protect supervision rules

am i the only one torn about this?

 

[BobbyHeenan]

this is a tricky topic. I see where the OP is coming from - as a PP doc, it certainly does help ME to have less supervision rules. It does NOT help the rad onc job market at large, nor does it help the locums market. I feel like if we are going to put our money where out mouth is, in terms of protecting the health of the field, I think ASTRO has a point that it is important to protect supervision rules

am i the only one torn about this?

No, I completely agree and we've had some discussion about this on this board before.

You don't want to under value yourself. I also think of how many times I get called to the machine to check a CBCT set up on a challenging case....

 

[TheWallnerus]

this is a tricky topic. I see where the OP is coming from - as a PP doc, it certainly does help ME to have less supervision rules. It does NOT help the rad onc job market at large, nor does it help the locums market. I feel like if we are going to put our money where out mouth is, in terms of protecting the health of the field, I think ASTRO has a point that it is important to protect supervision rules

am i the only one torn about this?

Why wouldn’t ASTRO come out in favor of IMRT and protons for everything. That would REALLY help the job market and the health of the field. There’s scads more data that IMRT and protons are clinically efficacious than data that physician MD presence in a building is clinically efficacious. ASTRO isn’t cloaking supervision inside a protect-the-specialty argument, they’re wrapping the argument in patient safety.

If we are going to disagree, let’s at least keep things honest IMHO.

 

[TheWallnerus]

No, I completely agree and we've had some discussion about this on this board before.

You don't want to under value yourself. I also think of how many times I get called to the machine to check a CBCT set up on a challenging case....

Which is a great argument for virtual direct

You could be in the OR doing an implant… take a brief break, check the iPad and shift the CBCT yourself, discuss w/ the therapist on screen… then back to the implant.

 

[BobbyHeenan]

Which is a great argument for virtual direct

You could be in the OR doing an implant… take a brief break, check the iPad and shift the CBCT yourself, discuss w/ the therapist on screen… then back to the implant.

AGree.

But to the CMS bureaucrat they likely see checking on i-pad as something that shouldn't be reimbursed.

 

[TheWallnerus]

AGree.

But to the CMS bureaucrat they likely see checking on i-pad as something that shouldn't be reimbursed.

Telerads has had no problem. ACR prob had role in that. And there’s the virtual ICU model.

We are already essentially not getting reimbursed for this under RO-APM. (And with SBRT and SRSs.)

 

[BobbyHeenan]

Telerads has had no problem. ACR prob had role in that. And there’s the virtual ICU model.

We are already essentially not getting reimbursed for this under RO-APM. (And with SBRT and SRSs.)

Will be interested to see what APEX/ACR does then if this goes through for their accreditation.

Right now they're sticking with in person supervision as a requirement.

 

[Burt Radnolds]

Will be interested to see what APEX/ACR does then if this goes through for their accreditation.

Right now they're sticking with in person supervision as a requirement.

In the end they just want your money. No way they are going to yank accreditation if you are following CMS guidelines in good faith and running a safe clinic following general standard of care otherwise. We have had some dialogue with ACR, whom we are accredited by, and weren't getting the sense the hammer would be dropped over this issue.

 

[RickyScott]

Will be interested to see what APEX/ACR does then if this goes through for their accreditation.

Right now they're sticking with in person supervision as a requirement.

Seems lime ACR/accreditation has become increasingly less valued as a byproduct of the branding of cancer by the likes of mdacc. If a patient cares about name/brand they will go to a big name satellite /franchise. No one cares about ACR. If remote supervision saves hundreds of thousands, drop the ACR or go with acro, if they are stubborn.

 

[TheWallnerus]

Seems lime ACR/accreditation has become increasingly less valued as a byproduct of the of branding cancer by the likes of mdacc. If a patient cares about name/brand they will go to a big name satellite /franchise. No one cares about ACR. If remote supervision saves hundreds of thousands, than drop the ACR or go with acro, if they are stubborn.

ACR accreditation in rad onc is like that scene in Tommy Boy where the guy asks Farley if his product is “guaranteed.”

 

[medgator]

this is a tricky topic. I see where the OP is coming from - as a PP doc, it certainly does help ME to have less supervision rules. It does NOT help the rad onc job market at large, nor does it help the locums market. I feel like if we are going to put our money where out mouth is, in terms of protecting the health of the field, I think ASTRO has a point that it is important to protect supervision rules

am i the only one torn about this?

The problem is Astro lacks credibility on this after letting exempt rural clinics have general supervision the entire time since the 2000s and then raising a stink after CMS extrapolated that to everyone else after seeing no obvious compromise in care

 

[TheWallnerus]

The problem is Astro lacks credibility on this after letting exempt rural clinics have general supervision the entire time since the 2000s and then raising a stink after CMS extrapolated that to everyone else after seeing no obvious compromise in care

That was loss of credibility (LoC) part one.

LoC part deux was COVID. With the PHE, instead of physicians running headlong into proper clinical care and keeping things as safe as possible for patients, those in the ASTRO Ivory Tower said “You know what? Staying home a day or two sounds great. The patients are fine.” When every other MD was being asked to step up, ASTRO said it’s ok to step back. Which was sensible. But totally hypocritical.

LoC part 3 is ASTRO saying that safety is back at the forefront and doctors need to be present. Except maybe at hospitals where CMS has already said they don’t need to be present. So, at the end of the day, ASTRO is picking on supervision flexibility against one group only:

Freestanding private practice centers.

Taking all these LoCs in toto, what we have is total LoCO (loss of credibility overall).

 

[jondunn]

The problem is Astro lacks credibility on this after letting exempt rural clinics have general supervision the entire time since the 2000s and then raising a stink after CMS extrapolated that to everyone else after seeing no obvious compromise in care

to me this is just common sense/pragmatism. I think they were right on the money. allowing rural hospitals to have exemption solves the problem that is raised by the OP where it is an undue burden on small centers who may have to cancel therapy for the patients if there is an emergency. I have no problem with this.

expanding it to everyone is a dangerous dangerous slippery slope for the field and our value writ large.

I don't see it as a double standard, but rather we as a field trying to have it both ways. I agree with ASTRO on this.

 

[medgator]

to me this is just common sense/pragmatism. I think they were right on the money. allowing rural hospitals to have exemption solves the problem that is raised by the OP where it is an undue burden on small centers who may have to cancel therapy for the patients if there is an emergency. I have no problem with this.

expanding it to everyone is a dangerous dangerous slippery slope for the field and our value writ large.

I don't see it as a double standard, but rather we as a field trying to have it both ways. I agree with ASTRO on this.

Then why the dichotomy between freestanding vs hospital supervision requirements? @TheWallnerus nailed it above

 

[TheWallnerus]

to me this is just common sense/pragmatism. I think they were right on the money. allowing rural hospitals to have exemption solves the problem that is raised by the OP where it is an undue burden on small centers who may have to cancel therapy for the patients if there is an emergency. I have no problem with this.

expanding it to everyone is a dangerous dangerous slippery slope for the field and our value writ large.

I don't see it as a double standard, but rather we as a field trying to have it both ways. I agree with ASTRO on this.

Dude. You (we) slid down the slope and hit the bottom. It’s already general supervision in the hospital setting which is the vast majority of rad onc. Virtual direct won’t apply to hospitals. This will still be a higher supervision burden in all of freestanding.

 

[SubserviantToABR]

ACR accreditation in rad onc is like that scene in Tommy Boy where the guy asks Farley if his product is “guaranteed.”

The next thing you know, there's money missing off the dresser and your daughter's knocked up, I seen it a hundred times.

 

[deleted1111261]

Seems lime ACR/accreditation has become increasingly less valued as a byproduct of the branding of cancer by the likes of mdacc. If a patient cares about name/brand they will go to a big name satellite /franchise. No one cares about ACR. If remote supervision saves hundreds of thousands, drop the ACR or go with acro, if they are stubborn.

I worked for a MD Anderson network site. This is a separate issue than accreditation - all of our sites were ACR certified. I am certain that most of the MDACC network sites get ACR or APEX accreditation.

That being said, I have some reservations about APEX/ACR. They are a 'minimum standard'. If you look at the wording for peer review, it's really "whatever you want to do". I'd rather promote and develop an internal program that isn't a minimum standard, but one that is thoughtful and logical. I'm not plugging our little project, but I do discuss what we did for our peer review and I think we are doing it right - certainly need to develop it further. Chart rounds is the past and the way the majority of community sites do it - it is low value and not improving quality in a meaningful way. Currently, we plan on continuing on with APEX accreditation. I'm going to deep dive into it for this go-around and if it seems high value, we will keep it.

Mudit C and I have had some conversations regarding this and though he is more radical than I am, I'd rather he come on here and state his case.

I'm not torn about supervision. Supervision should not make up for terrible decisions made by leadership. If it was truly safer to have someone on site for all treatments, it would not just be a Medicare requirement - it would be for all carriers. And it would not be just for IMRT/SBRT, it would be for all techniques, etc. We have to be logical/efficient and promote practices that improve the health of the field. Sometimes doing the right thing for patient care and the business may be harmful to career prospects of fresh grads. That's not my fault, is it?

 

[dieABRdie]

this is a tricky topic. I see where the OP is coming from - as a PP doc, it certainly does help ME to have less supervision rules. It does NOT help the rad onc job market at large, nor does it help the locums market. I feel like if we are going to put our money where out mouth is, in terms of protecting the health of the field, I think ASTRO has a point that it is important to protect supervision rules

am i the only one torn about this?

I feel the same. I hate being stuck in a building all day but at least I'm being paid. It would give our practice tremendous flexibility but it would wreak further havoc on the job market.

 

[Gfunk6]

If we are going to be under-employed, under-compensated and miserable we may as well be all of those things at home instead of hospital/clinic. Glass is half full folks.

 

[Reaganite]

I don't see how CMS can justify general supervision in hospitals while requiring direct supervision in freestanding clinics. Seems like a blatantly anti-competitive contradiction that puts unnecessary burden on freestanding clinics. At least ASTRO has been consistent in rec' direct supervision at all sites. Also, how would direct supervision work within the context of APM? Other than radioactive source-related stuff, it has never been illegal to treat a Medicare patient without a doctor on site. The illegal part has been the submission of a claim. So if CMS keeps supervision requirements of any kind, but plans to pay essentially case rates...how would CMS account for the days you didn't directly supervise some component of the treatment?

 

[deleted1111261]

I don't see how CMS can justify general supervision in hospitals while requiring direct supervision in freestanding clinics. Seems like a blatantly anti-competitive contradiction that puts unnecessary burden on freestanding clinics. At least ASTRO has been consistent in rec' direct supervision at all sites. Also, how would direct supervision work within the context of APM? Other than radioactive source-related stuff, it has never been illegal to treat a Medicare patient without a doctor on site. The illegal part has been the submission of a claim. So if CMS keeps supervision requirements of any kind, but plans to pay essentially case rates...how would CMS account for the days you didn't directly supervise some component of the treatment?

Astute and unanswered question.

 

[medgator]

I don't see how CMS can justify general supervision in hospitals while requiring direct supervision in freestanding clinics. Seems like a blatantly anti-competitive contradiction that puts unnecessary burden on freestanding clinics. At least ASTRO has been consistent in rec' direct supervision at all sites. Also, how would direct supervision work within the context of APM? Other than radioactive source-related stuff, it has never been illegal to treat a Medicare patient without a doctor on site. The illegal part has been the submission of a claim. So if CMS keeps supervision requirements of any kind, but plans to pay essentially case rates...how would CMS account for the days you didn't directly supervise some component of the treatment?

Maybe virtually supervise/be present for 51% of the tx course....

 

[TheWallnerus]

Maybe virtually supervise/be present for 51% of the tx course....

Under RO-APM will see a lot more of those 1-5 fx courses. For sure one fraction bone met will see its naissance. So must be there at least 5 minutes and 1 second for the 10 minute bone met treatment. For fraction 17 through 30 of lung chemoRT... ... ... .. .

 

[deleted1111261]

Chatted with Dave Adler.

Looks like they are going to review practice patterns. Any big changes will be noted, as you still have to submit the charges.
So, if all of a sudden you aren't doing any weeklies any more, that may be noted.

I've told him that if there isn't an ability to streamline practice, what is this other than a massive haircut? I.e. - if we can be more like Canadian/European sisters and brothers and do every other week OTVs or PRN (which makes more sense), if we can be off site to see inpatients or do brachy - then there are efficiencies gained. Otherwise, let's just call a spade a spade - they want to pay this specific specialty less. And, the RO-APM achieves that.

 

[TheWallnerus]

Looks like they are going to review practice patterns. Any big changes will be noted, as you still have to submit the charges.
So, if all of a sudden you aren't doing any weeklies any more, that may be noted...

let's just call a spade a spade - they want to pay this specific specialty less. And, the RO-APM achieves that.

As I understand by "noting it," CMS will use this as an excuse later to pay rad onc less. Thus there's going to be... peer pressure?... to maintain business as usual. Or maybe hired killings of rad oncs who start doing less work?

Economics, aka "The Dismal Science," predicts human behavior on the basis of "maximizing behaviors." In this regard I don't think economics has ever been proven wrong. Just like speed is distance over time, pay (P) is work (W) over time (t). Humans will seek out maximizing behaviors on the equation:

P = W/t

Decrease pay? If we can do the same amount of work but with much less expenditure of time, this psychologically feels like less of a pay cut. So follow the math/psychology: the 10 fraction bone mets will become 1, breast will transition to 5 fraction in Stage 1... these will result in less treatments AND less weeklies. Fractionation changes aside, if we will be paid the same regardless the number of weeklies we perform, why do the same amount of weeklies? There is going to be an honor system where everyone agrees "Let's not do anything different even though we're getting paid less"? Nah. It's fairy tale economics to think this will happen. Let your competitor across the street start advertising single fraction RT for prostate or breast to the all the patients... let's see if that guy's competitors listen to Dave Adler or the rational voice inside their own head.

 

[Doctorer]

I worked for a MD Anderson network site. This is a separate issue than accreditation - all of our sites were ACR certified. I am certain that most of the MDACC network sites get ACR or APEX accreditation.

That being said, I have some reservations about APEX/ACR. They are a 'minimum standard'. If you look at the wording for peer review, it's really "whatever you want to do". I'd rather promote and develop an internal program that isn't a minimum standard, but one that is thoughtful and logical. I'm not plugging our little project, but I do discuss what we did for our peer review and I think we are doing it right - certainly need to develop it further. Chart rounds is the past and the way the majority of community sites do it - it is low value and not improving quality in a meaningful way. Currently, we plan on continuing on with APEX accreditation. I'm going to deep dive into it for this go-around and if it seems high value, we will keep it.

Mudit C and I have had some conversations regarding this and though he is more radical than I am, I'd rather he come on here and state his case.

I'm not torn about supervision. Supervision should not make up for terrible decisions made by leadership. If it was truly safer to have someone on site for all treatments, it would not just be a Medicare requirement - it would be for all carriers. And it would not be just for IMRT/SBRT, it would be for all techniques, etc. We have to be logical/efficient and promote practices that improve the health of the field. Sometimes doing the right thing for patient care and the business may be harmful to career prospects of fresh grads. That's not my fault, is it?

Regarding that last part, I disagree. That’s the attitude that brought us to our current situation with the job market, and what our colleagues in some other sub specialties have done a better job of understanding. Maybe a chairman(or private practice) having to hire an extra physician isn’t a bad thing for the health of the specialty?

 

[deleted1111261]

Regarding that last part, I disagree. That’s the attitude that brought us to our current situation with the job market, and what our colleagues in some other sub specialties have done a better job of understanding. Maybe a chairman(or private practice) having to hire an extra physician isn’t a bad thing for the health of the specialty?

I wholeheartedly disagree. That is not the attitude the got us here. They have ruined / are ruining the field. This is using a bad rule to prop up the field because of terrible strategic planning and it is not something I’m okay
with.

If the labor situation gets worse, and then ASTRO/Medicare says for safety, you now need an additional doctor on site for backup in case primary doctor, for example, has to take a massive dump and doesn’t want to do it on site, should we do that, too?

If supervision is not required, altruism will not save the system. Every low volume center will stop over-staffing / linac babysitting. Right now, the wording is way too ambiguous for many people to take that leap.

Medicare needs to have clear rules and a hotline for guidance. The status quo is bizarre.

 

[medgator]

Regarding that last part, I disagree. That’s the attitude that brought us to our current situation with the job market, and what our colleagues in some other sub specialties have done a better job of understanding. Maybe a chairman(or private practice) having to hire an extra physician isn’t a bad thing for the health of the specialty?

So are supervision rules for the health of the patient or the health of the specialty?

 

[Lamount]

As I understand by "noting it," CMS will use this as an excuse later to pay rad onc less. Thus there's going to be... peer pressure?... to maintain business as usual. Or maybe hired killings of rad oncs who start doing less work?

Economics, aka "The Dismal Science," predicts human behavior on the basis of "maximizing behaviors." In this regard I don't think economics has ever been proven wrong. Just like speed is distance over time, pay (P) is work (W) over time (t). Humans will seek out maximizing behaviors on the equation:

P = W/t

Decrease pay? If we can do the same amount of work but with much less expenditure of time, this psychologically feels like less of a pay cut. So follow the math/psychology: the 10 fraction bone mets will become 1, breast will transition to 5 fraction in Stage 1... these will result in less treatments AND less weeklies. Fractionation changes aside, if we will be paid the same regardless the number of weeklies we perform, why do the same amount of weeklies? There is going to be an honor system where everyone agrees "Let's not do anything different even though we're getting paid less"? Nah. It's fairy tale economics to think this will happen. Let your competitor across the street start advertising single fraction RT for prostate or breast to the all the patients... let's see if that guy's competitors listen to Dave Adler or the rational voice inside their own head.

In my mind, there are bigger economic questions. In APM zips, will the current number of rad onc treatment slots be sustainable under the APM? Do clinics close and/or downsize? Do old-timers finally retire? Does access to care wane?

The entire premise of the APM is that we are over-treating patients, so they are now incentivizing under-treating them. I think there is a decent chance this ends up being a completely failure.

 

[TheWallnerus]

So are supervision rules for the health of the patient or the health of the specialty?

Evidently they're present so we can have society (and Medicare) spend more healthcare dollars than it would have otherwise by having falsely inflated numbers of needed physicians... not to care for patients per se, but to be warm, lung-containing paperweights.

The entire premise of the APM is that we are over-treating patients, so they are now incentivizing under-treating them.

Like Simul alluded to above, per ASTRO/Adler etc: ignore the under-tx incentivization. Continue doing everything you did before EXACTLY as you used to, even though you're getting paid less, or you gonna be in trouble.

 

[Lamount]

Evidently they're present so we can have society (and Medicare) spend more healthcare dollars than it would have otherwise by having falsely inflated numbers of needed physicians... not to care for patients per se, but to be warm, lung-containing paperweights.

Like Simul alluded to above, per ASTRO/Adler etc: ignore the under-tx incentivization. Continue doing everything you did before EXACTLY as you used to, even though you're getting paid less, or you gonna be in trouble.

I am fortunate enough to not be affected by the APM. Putting aside the issue of everyone trying to get the job done in one fraction... I think another major concern is less access for patients. There will be clinics who simply cannot afford to treat a second uncompensated course within 90 days, or cannot afford to take APM medicare patients, doctors retiring and not being replaced... and even clinic closures. I worry a lot of places are going to go out of business and a lot of people will decide it isn't worth it anymore. Maybe those big hospitals decide to refocus their resources in non-APM zips. As you know, it's not just an issue of cuts to reimbursement, but there is also requirements for EMR utilization and upgrades... and this will hit those rural clinics the hardest... leaving those patients SOL.

If CMS was smart, they would have made this optional (and a little less spartan). That way, the only places who signed on would be ones who are likely able to survive. CMS would then be able to point to their successes and say "see, it's doable!"

If clinics start closing and we start hearing stories of grandpa having to drive 300 miles to get his cancer treated... the whole APM thing may be done.

 

[Doctorer]

So are supervision rules for the health of the patient or the health of the specialty?

Why are these mutually exclusive? I think with the increase in hypofractionated treatments where there's fewer opportunities for stuff to "average out," it becomes even more important to have a physician available in the event that a CBCT needs to be checked, etc.

 

[TheWallnerus]

Why are these mutually exclusive? I think with the increase in hypofractionated treatments where there's fewer opportunities for stuff to "average out," it becomes even more important to have a physician available in the event that a CBCT needs to be checked, etc.

Is this checking CBCT with the protractor and chart paper, or via a “computer” of some sort. The former is impossible to do virtual… clinics stuck doing that need a doctor present. However, if your CBCT tech uses “computers,” the magic of the Internet can be brought to bear. Single fraction bone mets I still use the protractor but thinking of switching to “computer.”

 

[Doctorer]

Is this checking CBCT with the protractor and chart paper, or via a “computer” of some sort. The former is impossible to do virtual… clinics stuck doing that need a doctor present. However, if your CBCT tech uses “computers,” the magic of the Internet can be brought to bear. Single fraction bone mets I still use the protractor but thinking of switching to “computer.”

Call me old fashioned but I like to be at the machine/present for things like 3-5 fraction SBRTs.

 

[medgator]

Call me old fashioned but I like to be at the machine/present for things like 3-5 fraction SBRTs.

Sure, but why can't you check that cbct in real time from your office? Or home?

 

[TheWallnerus]

Call me old fashioned but I like to be at the machine/present for things like 3-5 fraction SBRTs.

Will be "old fashioned," eventually. See me in 10 years after RO-APM becomes: "this is rad onc."

 

[Doctorer]

Sure, but why can't you check that cbct in real time from your office? Or home?

Because occasionally there are issues with alignment, setup, etc, where I'm at the machine moving the couch with physics/therapy. That can't be done remotely.

Although I guess I could use Facetime!

edit: yup, exactly. Doesn't mean we should encourage activity like that. I'd say it's similar to a surgeon running multiple rooms at once. Although, on second thought, what percent does a whistleblower get again?

 

[TheWallnerus]

Because occasionally there are issues with alignment, setup, etc, where I'm at the machine moving the couch with physics/therapy. That can't be done remotely.

Although I guess I could use Facetime!

edit: yup, exactly.

 

[TheWallnerus]

f clinics start closing and we start hearing stories of grandpa having to drive 300 miles to get his cancer treated... the whole APM thing may be done.

Or it may be this back at CMS HQ

 

[Chartreuse Wombat]

I am fortunate enough to not be affected by the APM. Putting aside the issue of everyone trying to get the job done in one fraction... I think another major concern is less access for patients. There will be clinics who simply cannot afford to treat a second uncompensated course within 90 days, or cannot afford to take APM medicare patients, doctors retiring and not being replaced... and even clinic closures. I worry a lot of places are going to go out of business and a lot of people will decide it isn't worth it anymore. Maybe those big hospitals decide to refocus their resources in non-APM zips. As you know, it's not just an issue of cuts to reimbursement, but there is also requirements for EMR utilization and upgrades... and this will hit those rural clinics the hardest... leaving those patients SOL.

If CMS was smart, they would have made this optional (and a little less spartan). That way, the only places who signed on would be ones who are likely able to survive. CMS would then be able to point to their successes and say "see, it's doable!"

If clinics start closing and we start hearing stories of grandpa having to drive 300 miles to get his cancer treated... the whole APM thing may be done.

The problem is that a small minority of the "voluntary" APM reduced costs.

1) CMS looks at the equation Value=Quality/Costs

2) By all accounts Quality is hard to measure.

3) Forcing down costs guarantees increased value.

4) Many will claim that Quality suffers but refer to #2 above

Our leaders thought that they could partner with CMS.

It is telling that the person who is charged with the pricing methodology of the RO APM has a PhD in International Studies and Comparative Politics-no degrees in Economics

Our elites are horrible