electronic brachy

[Reaganite]

Looks as though noridian pulled the plug on ebx reimbursement. Think our good old derm colleagues will still be on the radiation bandwagon? . After all, we can still perform this "revolutionary, non-invasive" treatment in our offices with ir192 hdr.

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[Irradi8or]

Here's the link to the announcement, if anyone wanted more specs

 

[californiaXRT]

What does this mean practically?

 

[medgator]

It seems like "derm" rads is the biggest issue on the west coast and AZ, correct?

 

[Reaganite]

Yes, huge on the west coast. 20k per patient reimbursement. There are stories of derms sending 40 pts a month for treatment.

 

[californiaXRT]

But only Rad Oncs can do it, right? Is the issue that Dermatologists hire Rad Oncs and that's seen as a NoNo?

There needs to be a DermRads FAQ

 

[Reaganite]

Dermatologist buys machine. Hires sucker rad onc for $1000 a half day, twice a week and pumps out skin ca pts he would normally mohs since he collects over 10x more per pt. Cites single institution study of just over 100 pts done by a private practice rad onc who makes money speaking for the company making the machine as justification for doing rt over mohs.

 

[californiaXRT]

If it is non-inferior to MOHS - then why aren't rad oncs doing it themselves? I know it's probably hard to get the patients but in certain cases. Seems like a potential area for radiation to expand to.

Obviously I don't know the efficacy, but I assume it's at least on par?

 

[californiaXRT]

I mean it's not like we don't cite other smaller patient group studies for other things we do.

 

[medgator]

Sounds like there is concern from some in the Derm community regarding long term efficacy and toxicity.

http://archderm.jamanetwork.com/Mob...ccessKey=a2df7887-4e9f-4c9c-810b-3321bd7355ce

 

[medgator]

I mean it's not like we don't cite other smaller patient group studies for other things we do.

Like what? The only thing I can think of is the single targit randomized trial that some surgeons use to skip standard whole breast xrt via the the intrabeam applicator. That's also incredibly controversial given the lack of large patient numbers and long term follow up

 

[Gfunk6]

In CA, entire business models now revolve solely around e brachytherapy reimbursement for skin. Obviously it is far less complex than any form of Iridium based brachy.

All of the manufacturers of these machines are now in panic mode. Will be interesting to see how this plays out …

 

[Gfunk6]

If it is non-inferior to MOHS - then why aren't rad oncs doing it themselves? I know it's probably hard to get the patients but in certain cases. Seems like a potential area for radiation to expand to.

Money, money, money . . . MONEY!

Rad Oncs got to have it, Derms really need it. Do things, do things, do things, bad things with it.

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But seriously, it's all about referral patterns. As the perpetual "bottom feeders" of the referral hierarchy, Rad Oncs require referrals to sustain themselves. There are virtually no patients who walk through my door saying, hey I saw your fancy ad (on the interstate, on TV, on the radio, in the paper) and I want you to treat my cancer!

Skin patients have to come from Dermatologists (or PCPs to a far lesser extent). When Derms see the ridiculous revenue that you are pumping out of THEIR skin cancer patients, they buy the machine themselves, employ a Rad Onc/RTT/Physicist themselves and have at it.

Alternatively, they can buy the machine and contract Rad Oncs to provide the professional services. However, if you've ever done skin e-brachy you will understand when I say it is probably one of the most professionally unsatisfying clinical experiences. No contours, no rigorous thinking, no literature review, no bonding with patients, etc. They just show up (usually in a wheelchair or motorized scooter from a SNF) - you plop 'em on the exam table, draw a little circle around their BCC/SCC and that pretty much ends your clinical involvement.

Given the scenario above, most Rad Oncs in a practice do not wish to do e-brachy full-time which leads to problems with patient continuity. Hence, Derms try to hire a full-time Rad Onc to do it when their profit margin hits a certain point.

 

[vokey588]

Money, money, money . . . MONEY!

Rad Oncs got to have it, Derms really need it. Do things, do things, do things, bad things with it.

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But seriously, it's all about referral patterns. As the perpetual "bottom feeders" of the referral hierarchy, Rad Oncs require referrals to sustain themselves. There are virtually no patients who walk through my door saying, hey I saw your fancy ad (on the interstate, on TV, on the radio, in the paper) and I want you to treat my cancer!

Skin patients have to come from Dermatologists (or PCPs to a far lesser extent). When Derms see the ridiculous revenue that you are pumping out of THEIR skin cancer patients, they buy the machine themselves, employ a Rad Onc/RTT/Physicist themselves and have at it.

Alternatively, they can buy the machine and contract Rad Oncs to provide the professional services. However, if you've ever done skin e-brachy you will understand when I say it is probably one of the most professionally unsatisfying clinical experiences. No contours, no rigorous thinking, no literature review, no bonding with patients, etc. They just show up (usually in a wheelchair or motorized scooter from a SNF) - you plop 'em on the exam table, draw a little circle around their BCC/SCC and that pretty much ends your clinical involvement.

Given the scenario above, most Rad Oncs in a practice do not wish to do e-brachy full-time which leads to problems with patient continuity. Hence, Derms try to hire a full-time Rad Onc to do it when their profit margin hits a certain point.

It seems clear that if the Stark loophole was ever closed the dermrads and urorads business model would collapse. But what is the chance that the loophole would be closed but still allow radiation oncologists to own machines? Same goes for radiologists and their imaging machines.

 

[Gfunk6]

If Stark loophole is closed, abusive billing activity (Urorads, Dermrads) will go down but physician ownership of accelerators will go down the toilet with it.

 

[medgator]

It seems clear that if the Stark loophole was ever closed the dermrads and urorads business model would collapse. But what is the chance that the loophole would be closed but still allow radiation oncologists to own machines? Same goes for radiologists and their imaging machines.

If Stark loophole is closed, abusive billing activity (Urorads, Dermrads) will go down but physician ownership of accelerators will go down the toilet with it.

Not necessarily. Rad Oncs don't self-refer. No reason we cannot continue to own Linacs. I believe Maryland has a law against ownership of linacs by anyone besides rad onc and hospitals.

 

[Gfunk6]

Not necessarily. Rad Oncs don't self-refer. No reason we cannot continue to own Linacs. I believe Maryland has a law against ownership of linacs by anyone besides rad onc and hospitals.

Technically, yes. However the magnitude of financial risk is greatly magnified. When your referring MDs have no skin in the game, referral patterns can and will change.

Ownership of accelerators by Rad Oncs will probably be reduced to a few rural areas. Hospitals can and will take over.

 

[medgator]

Technically, yes. However the magnitude of financial risk is greatly magnified. When your referring MDs have no skin in the game, referral patterns can and will change.

Ownership of accelerators by Rad Oncs will probably be reduced to a few rural areas. Hospitals can and will take over.

Until formerly hospital-employed physicians and those who has no love for the hospital refer to the free-standing centers out of spite. It happens.

 

[Reaganite]

I agree with Gfunk. Closing the in office exemption isn't the way to go. It's one of the few things that's allowing some of us in private practice to fluorish. Otherwise, the hospitals will buy out all of our referring physians. That being said, the dermrads thing was getting out of control. This isn't urorads where it takes several urology groups (often all the urologists in an area) to fill a center with 20-30 patients. With the derm ventures, you have solo derms who see 100+ skin cancers a month. We're under enough scrutiny as it is. Imagine if this had gone national.

 

[medgator]

I agree with Gfunk. Closing the in office exemption isn't the way to go. It's one of the few things that's allowing some of us in private practice to fluorish. Otherwise, the hospitals will buy out all of our referring physians. That being said, the dermrads thing was getting out of control. This isn't urorads where it takes several urology groups (often all the urologists in an area) to fill a center with 20-30 patients. With the derm ventures, you have solo derms who see 100+ skin cancers a month. We're under enough scrutiny as it is. Imagine if this had gone national.

Despite ASTRO's daily email bombardment and wildest dreams, the IOAE ship sailed long ago. I don't see it closing. The derm rads thing sure does sound like a mess though.

 

[vokey588]

Did some googling on the topic and found it interesting to read about the alarm some dermatologists have about this emerging treatment.
Dermatology Times

"Dermatologists who instead seek to guard their NMSC turf one day could find that “most skin cancers are being treated by radiation therapy — not in the dermatologist’s office, but in the radiation oncologist’s office or comprehensive cancer center,” Dr. Werschler says."

 

[thesauce]

Potentially stupid question, but who or what is Noridian Medicare? Is this just a single insurer?

 

[Gfunk6]

Potentially stupid question, but who or what is Noridian Medicare? Is this just a single insurer?

Noridian administers Medicare on the West Coast. The idea goes like this:

1. Doctors perform procedures, consults, reimbursable activity
2. Medicare pays doctors
3. Federal government goes bankrupt

As you may know, Medicare does not require pre-authorization like other insurers. Therefore, if you ask for inappropriate IMRT, they will likely not catch it. To avoid fraud, Medicare audits claims after they are paid out and goes after physicians who are suspected of fraudulent billing patterns. Of course, the Feds are a bloated bureaucracy and auditors get paid the same whether they identify fraud or not.

Therefore, Medicare contracts with companies like Noridian to administer/audit Medicare claims. If Noridian identifies a case of billing fraud and proves it, they are allowed to keep a portion of the fine that physicians/hospitals have to pay. Hence, they are financially incentivized to identify and aggressively go after Medicare fraud.

Similarly, they can set policies based on what they see as pervasively fraudulent billing activity (e.g. e-brachy is not worth what Medicare is paying for it).

This link provides a good summary of what Noridian does for Medicare: https://med.noridianmedicare.com/web/jea/cert-reviews/mr

 

[Haybrant]

So as opposed to 20k for a treatment, what does code 17999 reimburse for the procedure?

 

[Gfunk6]

So as opposed to 20k for a treatment, what does code 17999 reimburse for the procedure?

Well, I think the jury is still out. We need more specific guidance about what we can and can't bill. But a superficial glance shows that technical reimbursement by fraction has dropped big-time; $2,376 (0182T) per fraction to $28.40 (17999).

 

[radiaterMike]

The AADs position ...

https://www.aad.org/members/publica...-therapy-and-electronic-surface-brachytherapy

 

[vokey588]

Well, I think the jury is still out. We need more specific guidance about what we can and can't bill. But a superficial glance shows that technical reimbursement by fraction has dropped big-time; $2,376 (0182T) per fraction to $28.40 (17999).

Wow that is really going to hurt for those practices

 

[Neuronix]

I'm shocked that none of these dermatology articles cite the only randomized radiation vs. surgery trial that has ever been conducted for BCC/SCC (BCC in this case). The radiation used was mostly brachytherapy, though by old fashioned techniques, and the trial had some flaws. You could easily make the point that radiation has been shown to be inferior in the past, and this new technology has not been studied in randomized fashion to update the field. This seems to me like a financial and emotional argument from all sides.

If you make that argument, then you still do have to worry about the elderly person wheeled in from the nursing home with a BCC/SCC who is too frail for the surgeons to touch. If the skin cancer is some tiny little thing, observation may be indicated. But sometimes these do grow to be ulcerative, bleeding, bulky, painful, etc, and sometimes these frail elderly people live on for years and need treatment. So why should they suffer? This is a good therapy for them even if cosmesis and control may not be as good. The problem is that $28.40 a fraction isn't even enough to pay for the treatment. Back to linear accelerator generated treatments I guess...

 

[Gfunk6]

Dermrads has about one more month to get it while the getting is good, then things will collapse.

Noridian has become aware that some physicians are using high dose rate brachytherapy for treatment of non-melanoma skin cancers and billing that service with the Category III CPT Code 0182T. The Category III CPT Code 0182T was carrier-priced by Noridian several years ago based on pricing inputs related to this service when used to treat breast cancer. Consequently, this code is not appropriate for use when treating much less complicated tumors such as non-melanoma skin cancers.
Effective June 8, 2015, when treating non-melanoma skin cancers with surface brachytherapy, code the service with CPT Code 17999 and place the appropriate destruction code for the lesion location and size from the CPT Code series 17261-17286 in Item 19 of the CMS-1500 claim form or the electronic equivalent. Claims without this information will be denied as unprocessable. Do not report or bill to anyone for any radiation planning, dosimetry, simulations, or physician management services (CPT codes 77261-77370, 77427-77499).

Reimbursement goes from about $4,000 per fraction to $200 per fraction.

There's gonna be a lot of expensive "modern art" pieces if you want one for your home or office.

 

[xrthopeful]

Why do you take so much pleasure in it though? Will you laugh as much when/if radiation onc reimbursements take such a hit?

 

[medgator]

Why do you take so much pleasure in it though? Will you laugh as much when/if radiation onc reimbursements take such a hit?

Ummm why do you equate the situation of inappropriate overuse of a treatment by a different specialty to that of primary radiation oncology?

Derms were pulling a urorads situation and overusing a specific modality of treatment with questionable long term follow up by using codes developed for treatment of breast cancer, which is more complicated.

You can thank urorads for the recent push to split out prostate into a simpler imrt code in the future

 

[radiaterMike]

The future is now

 

[Member223232]

my takeaway is that the days of high reimbursement levels from exploiting billing loopholes or other shenanigans are over. Unless you provide real value to your patients, insurance companies or the government are going to come after you, maybe not today, maybe not tomorrow but eventually. Those of us who are oncologist first should rejoice, those people who view their jobs as pill mills of radiation have been given their due notice....

 

[seper]

well said

 

[thesauce]

my takeaway is that the days of high reimbursement levels from exploiting billing loopholes or other shenanigans are over. Unless you provide real value to your patients, insurance companies or the government are going to come after you, maybe not today, maybe not tomorrow but eventually. Those of us who are oncologist first should rejoice, those people who view their jobs as pill mills of radiation have been given their due notice....

I'm not sure why that's your take-away. They got away with it for quite a while and made millions before they got shut down. It's a cat and mouse game that has been happening in medicine for decades and I see no reason why it won't continue to happen.

 

[medgator]

Job description made me LOL....

Unique Opportunity For Radiation Oncologist To Treat Skin Cancer Patients in Boca Raton

No complicated radiation treatments and no complicated terminally ill cancer patients.

No complicated medical care, imaging, or coordination of care.

You will be treating basal cell or squamous cell skin cancers only using superficial radiation (50KV to 100KV) to treat skin cancer. No Linear Accelerators. No tumor boards. No coordination of care between surgeons and other specialties.

This is where excess rad onc residents are probably going to end up before the job market goes completely dead....

After all, you still have to look at axial imaging to be a competent urorads doc...

 

[nkmiami]

Thats why choosing wisely is such a misnomer. ASTRO is really encouraging the opposite with the residency expansion by putting radoncs in these kind of dubious positions. In combination with tremendous rate increases in academic systems, where is ASTRO leading the field- check this out from mednet the other day- so the Mayo clinic charges 60k for bone stereo? Who is abusing the system, the derm rads or the Mayo clinic?

Are there any contraindications where you would not offer SBRT for an oligometastatic bone lesion from breast cancer?
Is the dose fractionation used in BR-001 (10Gyx3) appropriate for all osseous locations, for example humeral head metastases?

New answer February 2, 2018
Many things are learned "the hard way". I have zapped a LOT of b...
Kenneth Olivier, Mayo Clinic
"The other major toxicity from SBRT in the oligometastatic setting is financial. Medicare doesn't approve SBRT for bone mets (although you can GammaKnife innumerable CNS mets, but I digress), and they won't preapprove it so you won't know it's not covered until your patient gets a bill for 60k (rough price of 3 fx SBRT). That's a hell of a toxicity. Private insurers are a bit hit and miss."

What the author fails to acknowledge is that the financial toxicity is present, even if the insurer picks up the bill.

 

[OTN]

Job description made me LOL....

Unique Opportunity For Radiation Oncologist To Treat Skin Cancer Patients in Boca Raton





This is where excess rad onc residents are probably going to end up before the job market goes completely dead....

After all, you still have to look at axial imaging to be a competent urorads doc...

Seems to me like they're looking for someone at the end of their career. Not unreasonable description when you look at it that way. Live in Boca Raton, treat a few skin cancers, maybe play a little golf, fish a bit...could be worse.