Be careful what you wish for . . .

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Gfunk6

And to think . . . I hesitated
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ASTRO has been pushing very hard on the legislative front to 'close the self-referral loophole.' They assured us that this was only to curb urorads and not to prevent Rad Oncs from owning their own equipment. Some have argued that this is a slippery slope argument and legislators will simply assume that physicians should not own any medical equipment due to the danger of 'over-utilization' which would fit nicely with the model of all doctors being employed and safely under the boot heel of bureaucrats.

Will guess what? It's starting to happen.

Case in point: http://leginfo.legislature.ca.gov/faces/billNavClient.xhtml?bill_id=201320140SB1215

This is a bill proposed in the CA legislature that would essentially bar any physicians from owning (or profiting from or using) their own imaging equipment and radiation equipment.

YAY, the policy makers cry we are reducing costs! No, not really. When I see a treat/scan a patient at one of my centers it is at a lower rate (60-80%) then what the hospitals bill AND the patient doesn't have to drive 30 miles more every time they need an MRI or receive 2.0 Gy of radiation.

So who really makes off like bandits? Hospitals and administrators - this is a dream come true for them.

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When I see a treat/scan a patient at one of my centers it is at a lower rate (60-80%) then what the hospitals bill AND the patient doesn't have to drive 30 miles more every time they need an MRI or receive 2.0 Gy of radiation.

So who really makes off like bandits? Hospitals and administrators - this is a dream come true for them.

Freestanding RT centers have been getting killed the last few years while hospital-based RT centers have been moving up in terms of medicare reimbursement. Consolidation into the hospital will end up removing competition and increasing prices because there will be no freestanding alternative for patients to go to and there will be a lower number of centers to provide services overall.

Remember, ASTRO is primarily headed by academic hospital-based rad oncs, who probably won't mind seeing their freestanding competition bleed a little. They are even bold enough to suggest that they've helped to prevent cuts to freestanding centers (contrary to the facts) the last few years per the recent email sent out a couple of days ago:

ASTRO is completely committed to sustaining fair payments for radiation oncology, particularly for freestanding radiation oncology centers that have faced significant cumulative cuts in recent years. We recognize that many freestanding centers increasingly are struggling under severe cost pressures. As you know, it was ASTRO that led the advocacy charge and invested significant resources to protect cancer patient access to community-based radiation therapy services by fighting against proposed freestanding center cuts in 2009, 2012, and most recently in 2013. ASTRO is actively working to protect radiation therapy codes in a way that we hope will bring greater stability to payments. Still, we are well aware that the future for the specialty is uncertain and challenging. Unfortunately, there is no magic bullet to solve our problems.

It continues to make no sense for hospital-based and freestanding-based radiation therapy services to be billed at different rates. Doing the same services in the hospital costs the healthcare system more overall.

And it's not just a radiation therapy issue, it applies to pretty much any ancillary service that can be administered in the hospital vs outpatient/freestanding setting. Our diagnostic rads, med onc and medical/surgical specialists deal with these same issues too. Hopefully one day we will see "site neutral" payments for ancillary services, but I am not holding my breath.
 
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ASTRO has been pushing very hard on the legislative front to 'close the self-referral loophole.' They assured us that this was only to curb urorads and not to prevent Rad Oncs from owning their own equipment. Some have argued that this is a slippery slope argument and legislators will simply assume that physicians should not own any medical equipment due to the danger of 'over-utilization' which would fit nicely with the model of all doctors being employed and safely under the boot heel of bureaucrats.

Will guess what? It's starting to happen.

Case in point: http://leginfo.legislature.ca.gov/faces/billNavClient.xhtml?bill_id=201320140SB1215

This is a bill proposed in the CA legislature that would essentially bar any physicians from owning (or profiting from or using) their own imaging equipment and radiation equipment.

YAY, the policy makers cry we are reducing costs! No, not really. When I see a treat/scan a patient at one of my centers it is at a lower rate (60-80%) then what the hospitals bill AND the patient doesn't have to drive 30 miles more every time they need an MRI or receive 2.0 Gy of radiation.

So who really makes off like bandits? Hospitals and administrators - this is a dream come true for them.

The thing I've never understood about this is, SOMEONE will profit from machines. Why are hospitals any more trustworthy? I don't know what the solution is, but inconveniencing patients AND helping them to receive worse care just doesn't make sense.

There is no reason that a Radiation Oncologist shouldn't be able to own the equipment necessary for them to perform their job. In my mind, this is the same as telling ENT's they can't own their laryngoscopes. Or telling OB/Gyn/s they can't own their own U/S equipment. Just seems so ridiculous.
 
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In my honest personal opinion, hospital based centers on average deliver better care than freestanding independent clinics. So this push to consolidate care by the government serves society well.
 
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In my honest personal opinion, hospital based centers on average deliver better care than freestanding independent clinics. So this push to consolidate care by the government serves society well.

I have never received radiation therapy, but my personal experience with nearly every other specialty begs to differ. For my family and I, we pay a larger co-pay to go to private practice for nearly everything because the experience is SO much better.
 
ASTRO has been pushing very hard on the legislative front to 'close the self-referral loophole.' They assured us that this was only to curb urorads and not to prevent Rad Oncs from owning their own equipment. Some have argued that this is a slippery slope argument and legislators will simply assume that physicians should not own any medical equipment due to the danger of 'over-utilization' which would fit nicely with the model of all doctors being employed and safely under the boot heel of bureaucrats.

Will guess what? It's starting to happen.

Case in point: http://leginfo.legislature.ca.gov/faces/billNavClient.xhtml?bill_id=201320140SB1215

This is a bill proposed in the CA legislature that would essentially bar any physicians from owning (or profiting from or using) their own imaging equipment and radiation equipment.

YAY, the policy makers cry we are reducing costs! No, not really. When I see a treat/scan a patient at one of my centers it is at a lower rate (60-80%) then what the hospitals bill AND the patient doesn't have to drive 30 miles more every time they need an MRI or receive 2.0 Gy of radiation.

So who really makes off like bandits? Hospitals and administrators - this is a dream come true for them.

I realize that nobody has a crystal ball, but what will happen to the groups that currently own their linear accelerators? Will they be "grand-fathered in" and still be able to collect the technical fee? I can see how they can potentially prevent future RadOncs from purchasing their own equipment, but I think that they would have a difficult time telling them that they have to sell their Linacs or s0mehow no longer collect the technical fees. Thoughts?
 
Gfunk6, that bill doesn't seem to prevent rad oncs from being owners of rad onc equipment -- we don't refer patients for RT, they are referred to us to get RT (we prescribe and deliver RT); am I reading the bill wrong? It would seem to prevent most in-practice referrals from med oncs to rad oncs when they co-own the equipment, though.
 
I will say one thing that goes against free standing centers vs. hospital, there are costs in having to practice in a hospital setting that are not in seen a free standing center based on state and federal regulations. its kind of like the argument that Er's are making against urgent cares, you can't expect the same reimbursement rate for the same job when there is lot more required behind the scenes. Further, while not always the case, where I practice, the free standing centers don't have the availability of social workers, oncologic pysch services, dieticians, etc. These are not mandated but certainly add to the cost of cancer care in a way that is beneficial to patients while the private centers i know of in the area function as as a come in, get treated and get out kind of place. So it would make sense if ASTRO looked into this and actually determined what those costs were and then adjust rates between free standing and hospital based practices based on this rather than being arbitrary.

I think it's better to split the costs of those services out and acknowledge them for what they are rather than giving a hospital a carte blanche to have higher reimbursement for the same service because they are a hospital. The only way to address costs in medicine is to know what they are.
 
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I realize that nobody has a crystal ball, but what will happen to the groups that currently own their linear accelerators? Will they be "grand-fathered in" and still be able to collect the technical fee? I can see how they can potentially prevent future RadOncs from purchasing their own equipment, but I think that they would have a difficult time telling them that they have to sell their Linacs or s0mehow no longer collect the technical fees. Thoughts?

I doubt they've thought that far because, honestly, this legislation has virtually zero chance of passing. But at the end of the day, they can mandate whatever they want (e.g. make it prospective or retrospective).

Gfunk6, that bill doesn't seem to prevent rad oncs from being owners of rad onc equipment -- we don't refer patients for RT, they are referred to us to get RT (we prescribe and deliver RT); am I reading the bill wrong? It would seem to prevent most in-practice referrals from med oncs to rad oncs when they co-own the equipment, though.

Buying Rad Onc equipment is a risky proposition. One way to mitigate the risk is to get co-owners from different specialities. If you are in a competitive marketplace, it is financial suicide to get a bunch of only Rad Oncs together and buy the equipment. If people stop referring to you, then you are done. Share risk & share reward - this is the core of being a shareholder in a practice.

If you remove incentiviziation, then you remove motivation. This is why communism always fails.
 
ASTRO has been pushing very hard on the legislative front to 'close the self-referral loophole.' They assured us that this was only to curb urorads and not to prevent Rad Oncs from owning their own equipment. Some have argued that this is a slippery slope argument and legislators will simply assume that physicians should not own any medical equipment due to the danger of 'over-utilization' which would fit nicely with the model of all doctors being employed and safely under the boot heel of bureaucrats.

Will guess what? It's starting to happen.

Case in point: http://leginfo.legislature.ca.gov/faces/billNavClient.xhtml?bill_id=201320140SB1215

This is a bill proposed in the CA legislature that would essentially bar any physicians from owning (or profiting from or using) their own imaging equipment and radiation equipment.

YAY, the policy makers cry we are reducing costs! No, not really. When I see a treat/scan a patient at one of my centers it is at a lower rate (60-80%) then what the hospitals bill AND the patient doesn't have to drive 30 miles more every time they need an MRI or receive 2.0 Gy of radiation.

So who really makes off like bandits? Hospitals and administrators - this is a dream come true for them.

many people on this forum have been predicting this would happen for years, there are some really seasoned rad oncs on ASTRO, did they really think politicians would differentiate between urologists and rad oncs especially in this harsh climate and increasingly excessive campaign against doctors and their salaries? Heck politicians probably dont even know anything about rad onc
 
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The thing I've never understood about this is, SOMEONE will profit from machines. Why are hospitals any more trustworthy? I don't know what the solution is, but inconveniencing patients AND helping them to receive worse care just doesn't make sense.

There is no reason that a Radiation Oncologist shouldn't be able to own the equipment necessary for them to perform their job. In my mind, this is the same as telling ENT's they can't own their laryngoscopes. Or telling OB/Gyn/s they can't own their own U/S equipment. Just seems so ridiculous.

doctors are the politically safest targets, the average person will not have any sympathy for decreasing doctors salaries..there already running a very systematic media campaign the last couple of years to highlight doctors "excessive" salaries that always suggest "exploitation" by doctors..the foundation is being set for drastic cuts to medicine in future (the specialities that don't recognize this and ignore it will be hit the hardest, like path, rads and anesthesiology have already set the foundation for their ruin all by themselves, it'll only get worse for them, ASTRO is taking rad onc that direction)..hospitals, insurance companies, pharma, nurses are all united and have major lobbying powers...doctors have AMA but we all know AMA sucks and does not represent majority of doctors who themselves are too divided and fight against other specialities (primary care docs say specialists get paid too much, surgeons say radiologists aren't real doctors and that their salaries are too high for just reading films, rad oncs say urology should not exploit prostate cancer patients by using their technology, etc.)...and ASTRO's "lobbying" is nothing compared to those lobbying groups..ASTRO did extensive harm to their own field by repeatedly running to politicians, NEJM, NY Times/media, to complain about urorad reimbursement..urology will be fine in the end because they have much more variety of procedures they can do to cover the decrease in reimbursement from radiation services but rad services are the entire premise of the field of rad onc, the field had too much to lose by bringing this out into the public..
 
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I think it's better to split the costs of those services out and acknowledge them for what they are rather than giving a hospital a carte blanche to have higher reimbursement for the same service because they are a hospital. The only way to address costs in medicine is to know what they are.

This is definitely true - without understanding what the true costs are (not JUST the reimbursed costs) of providing high value cancer care, we won't know how much it simply costs to deliver care vs the margin.
 
This is definitely true - without understanding what the true costs are (not JUST the reimbursed costs) of providing high value cancer care, we won't know how much it simply costs to deliver care vs the margin.

Why do hospitals get paid more to administer the same service? Isn't that anti-competitive?
 
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Per medicare "because they incur higher costs in performing the same services" The logic of that is faulty. The reality is that they probably have better lobbyists :D

Don't you think its high time that physicians get together and commission an independent audit of the costs of hospital-administered vs physician-administered services?
 
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Now Gator, you and GFunk have been pretty strongly on the side of freestanding centers,but I think you miss some of the issues from the hospital side. I think there are definitely higher costs for hospital based centers than free standing centers at least where i am. Higher costs associated with state and federal regulations being part of a hospital, further a lot of additional cancer services (dietician, social worker, etc.) that we don't see at all or in a much less availability in private centers. Also, many of the free standing centers pass on the "self-pay" and Medicaid cases so we know where those end up. Finally, though there are some free standing centers that do many have far less in terms of clinical trials available to patients which is also a big expense. The problem is no one has put all these costs together to come up with a number; it would behoove ASTRO to figure out this number to guide policy makers.
Actually, we end up taking a Lot of the Medicaid and Medicare replacement plans and self pays more often than the hospital in our area. We do not have the luxury of an academic center within a 1.5hr radius willing to do that, so the hospital is actually picky about what it does and does not take.

It is funny you mention quality because our freestanding center in one of the counties we practice in is ACR accredited and offers srs and radioimmunotherapy while the hospital does not.

Agreed, but that's not how its done right now so you have freestanding centers doing a lot less yet asking for the same reimbursement. In terms of overall quality of oncologic care, shouldn't we reimburse more for a center that provides all those features compared to one that doesnt since that is one indicator of quality care (availability of ancillary services and social work) thats not reimbursed well as it is.

Actually when it really comes down to it, the meat of what is done in freestanding or hospital based centers is the same. A cpt code for cbct or imrt and the service delivered is fundamentally the same regardless of where it is done, not really "a lot less." Patients are not referred to your clinic or mine for nutritional or psychosocial services at the end of the day. If those services are offered, they should be recognized as such and billed separately imo

Just because certain hospital systems may offer those services doesn't 1) mean they all do or 2) justify the same basic procedures billing significantly more because of where it is done.

Disparate costs between hospitals and physicians owned practices are a huge issue in healthcare and this is the perfect place to start addressing and dealing with it. It's something that touches on literally every specialty, not just our own. We get paid less for doing the same pet/ct as well, for example. Hospitals double their billing on echocardiography when they buy up cardiologist' practices and the list goes on....

Here's a good read on the matter if you haven't read it: http://online.wsj.com/news/articles/SB10000872396390443713704577601113671007448

Personally, I'd love to see case-based, bundled reimbursement become a reality with site-neutral payments giving the hospital and outpatient centers the same flat fee. That would stop rewarding some of the bad actors in the freestanding setting who prescribe more fractions or imrt when unnecessary and also bring freestanding and hospital-based centers on to the same playing field. My understanding is that astro strongly opposes this but that it is supported by the rta
 
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A race to the bottom. Notice that the intent is to "equalize" hospital-based and freestanding reimbursement. This does not mean increasing free-standing reimbursement to match hospital reimbursement but rather reducing hospital reimbursement to match freestanding reimbursement.

While we quarrel with each other about reimbursement for doing the same work in different settings, the powers that be are going for the jugular behind the scenes.
 
I completely agree that this would lead to lower technicals for hospital-based centers rather than the other way around.

I suspect if this moves forward, there will be a reversal back to free-standing status of many of the university or hospital group associated satellites which have in recent years become "hospitals." I say this because my understanding is there are increased costs of regulatory compliance associated with "hospital" status as well as some other less significant headaches.
 
I suspect if this moves forward, there will be a reversal back to free-standing status of many of the university or hospital group associated satellites which have in recent years become "hospitals."

Considering the massive capital investments that hospitals make to create such centers and make them OSHPD compliant (as you alluded to), they will not likely 'give them up' to Rad Oncs who provide professional services. Even if the hospital is willing to sell the facility back to the ROs, it is extremely unlikely that they would be able to afford it.
 
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Considering the massive capital investments that hospitals make to create such centers and make them OSHPD compliant (as you alluded to), they will not likely 'give them up' to Rad Oncs who provide professional services. Even if the hospital is willing to sell the facility back to the ROs, it is extremely unlikely that they would be able to afford it.

Some of the private (Vantage, US Oncology etc.) and soon to be public (21st C) entities that own/co-own practices might be interested....
 
I understand the concerns of some that worry about the financial impact of closing the loophole. But that does not automatically mean all doctors will become employed if they can't own equipment. Some data suggest lower costs for hospitals working with independent rather than employed doctors, same quality. Professional fees are enough for a good living and a vibrant private practice career.
 
Some data suggest lower costs for hospitals working with independent rather than employed doctors, same quality. Professional fees are enough for a good living and a vibrant private practice career.

Sorry, I have to disagree. If you are not employed directly by a hospital and instead have some form of professional services agreement (PSA), then you are still at the whim of your administrators. At the end of the day, the hospital owns all the equipment, employs all of the staff (including your supervisor), controls all of the marketing and controls the entire referral base. With that comprehensive level of control does it really matter who is at the helm as long as they are competent? Time and time again, I've seen experienced Rad Oncs in such settings be fired in favor of hiring new, cheaper grads.

Also, professional fees are not good enough for me. I enjoy the business side of the practice. Granted the practice involves substantial risk and if it fails from a business sense, then I will only have myself to blame. However, I don't appreciate being placed into a second-tier provider status by the government when my practice provides outstanding care to our community.
 
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I understand the concerns of some that worry about the financial impact of closing the loophole. But that does not automatically mean all doctors will become employed if they can't own equipment. Some data suggest lower costs for hospitals working with independent rather than employed doctors, same quality. Professional fees are enough for a good living and a vibrant private practice career.

So you favor the ancillary revenues of practices going to hospital and hospital administrators? There will be revenue and potential profit in the ancillaries..... the question is, where can and should it go.

What about the places where there are no hospital owned centers, or hospitals even interested in providing cancer care? Should such underserved areas not have access to treatment until "hospitals" decide to provide it?
 
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Also, professional fees are not good enough for me. I enjoy the business side of the practice. Granted the practice involves substantial risk and if it fails from a business sense, then I will only have myself to blame.

Gfunk, thanks for replying. I see working with hospitals as a good business relationship and in the best interest of patients. That requires being collaborative rather than competitive in nature with administrators. That is a different business model that the one you propose, but it is more closely aligned with what I want to focus upon: quality patient care, not profit margin.

Medgator, you make a good point about underserved areas. In CON states, those decisions are often made based upon population need and access to care. In non-CON states not necessarily the case. I would be interested to know the percentage of physician-owned facilities in underserved areas. I'm not sure that just because hospitals won't build a facility in a remote location that it requires a physician-owned model.

Surely you've seen Jean Mitchell's earlier article showing poorer access to care at joint venture facilities in Florida? That was in NEJM too in 1992: http://www.nejm.org/doi/full/10.1056/NEJM199211193272106 .
 
Huh. Sorry for misspellings. They don't seem to correct in editing!
 
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Your article basically says self-referral is bad. Physician-owned practices by rad onc cannot, by definition, self-refer. Those pateints have to come from somewhere.
You can when rad onc practices start buying urology practices.
 
You can when rad onc practices start buying urology practices.
agreed. Outlaw that. No sense in outlawing rad oncs owning their own equipment though IMO. Plus there should be sensible laws regarding ownership by multi-specialty practices. Personally, I think multi-specialty (Rad Onc/Med Onc/Surgical specialists) ownership of XRT/imaging is far preferable to hospital-ownership or single-specialty non rad-onc (Urorads, Orthopod MRI mills etc.) ownership of those assets
 
agreed. Outlaw that. No sense in outlawin' rad oncs ownin' their own equipment though IMO. Plus thar should be sensible laws regardin' ownership by multi-specialty practices. Personally, me think multi-specialty (Rad Onc/Med Onc/Surgical specialists) ownership of XRT/imagin' be far preferable to hospital-ownership or single-specialty non rad-onc (Urorads, Orthopod MRI mills etc.) ownership of those assets

I agree, but in different healthcare markets different approaches may work better. In mine, partnering with hospitals works great. Why is SDN making me sound like Captain Jack Sparrow?
 
Gfunk, thanks for replying. I see working with hospitals as a good business relationship and in the best interest of patients. That requires being collaborative rather than competitive in nature with administrators. That is a different business model that the one you propose, but it is more closely aligned with what I want to focus upon: quality patient care, not profit margin.

Well, to be clear we collaborate with multiple hospitals across different health systems and do our best to 'play nice' (stay neutral). However, the local hospitals want you to be partisan in their favor and tend to take aggressive measures against you if not. Also, quality patient care and profit margin are not mutually exclusive. When push comes to shove, the former takes precedence of course.
 
I agree, but in different healthcare markets different approaches may work better. In mine, partnering with hospitals works great. Why is SDN making me sound like Captain Jack Sparrow?

I think hospital jvs probably do make sense in some places. Imo they are still more preferable than a prof only psa agreement where as gfunk alluded to, you can be disposable and there is no skin in the game for the practitioners.

At the end of the day, someone has to own the equipment and a jv with a hospital or multispecialty group makes the most sense to me
 
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