ACO's and Radiation Oncology

[FFunk]

---

Members do not see this ad.

During the job search in private practice rad onc, this recurrent question comes up: Who is better prepared for the advent of Accountable Care Organizations (ACOs) when the health care reform bill is carried out around 2013-2014? Hospital-based (professional-fee-only) practices, or free-standing cancer centers (professional and technical-fee)? How about company-owned practices (national company owns the machines and contracts service out to MDs)?

Any thoughts???

 

[Gfunk6]

There are two things that appear to be coming with regards to CMS reform that are germane to Rad Onc:

1. Professional and technical fees will continue to drop (or, at best, stay stable) over the coming years; however pro fees will tend to drop at a steeper rate and will ultimately become a smaller percentage of the total pot of reimbursement

2a. Change from fee-for-service to fee-for-disease; So let's say a pt came in with prostate cancer. Instead of better reimbursement for maximum fractionation (1.8 Gy x 44), you are simply given a lump sum to do how you please. Presumably this will lead to more hypofractionation (e.g. Cleveland Clinic protocol for prostate cancer) due to removal of incentivization for fractions.

2b. As a corollary to above; Rad Onc and Med Onc will require financial integration as many diseases require concurrent chemoXRT for cure


Therefore, IMO, the following types of practice will be best prepared to weather the coming storm:

a. Physicians who collect both pro and technical fees (e.g. they own the machines) will be far better off. Technical fees, as alluded above, will remain relatively unscathed from CMS and will continue to be the future money-maker. Pro-only groups will have to see more and more patients to compensate for an ever-shrinking pool of revenue.

b. Combined Med Onc and Rad Onc practices that can easily implement the fee-for-disease reimbursement model; this model is not often found in free-standing cancer centers but is the norm in academic and community hospitals

c. Physician-employees are the future of medicine, unfortunately. These folks will still maintain a decent pay (> $300K) but will find it difficult to increase their salary with seniority outside of clinical volume bonuses. The loss of financial autonomy is also a bummer.

 

[deleted4401]

Do you have a reference or a link to this information, GFunk?

It doesn't make sense to me, not that CMS ever makes any sense. If CMS wanted to save money, I'd think the way to go would be to lower the technical component. That would have much more greater effect on cost cutting.

Anyway, from my limited perspective, I'd think if I was planning on leaving my practice, I'd be looking for a hospital-based practice where I was employed by the hospital, and had captive med-oncs/surg-oncs/urologists. It would be considerably less money, but probably far more stable in the long run.

-S

 

[Gfunk6]

Do you have a reference or a link to this information, GFunk?

Nope, just word of mouth from numerous hospital administrators, attendings, and health policy specialists. I guess one way this cut disparity could be logically defended is that technical fees represents the main source of hospital profit whereas pro fees are generally the physician's profit. If you cut the latter more than the former, I guess it shows where your priorities lie.

In the future, when we are all physician employees, the line between pro and technical fees will be rendered meaningless anyway.

Until that time, I would recommend new grads try to stay on the gravy train for as long as it lasts. In other words, if you are going private practice, seek employment at a free standing center > professional-only group > physician employee. Besides, as I alluded above, there is not a whole lot of upward mobility in physician employee salary so even if you go down that path mid-career, you won't have missed much.

 

[subatomicdoc]

Until that time, I would recommend new grads try to stay on the gravy train for as long as it lasts. In other words, if you are going private practice, seek employment at a free standing center > professional-only group > physician employee. Besides, as I alluded above, there is not a whole lot of upward mobility in physician employee salary so even if you go down that path mid-career, you won't have missed much.

I see your point, but agree only if salary is the dominant factor in decision-making about job or all other aspects of two jobs are equal. There are many factors to consider, not the least being satisfaction with the quality of care you can provide and the colleagues with whom you work. There's more to QoL than salary.

 

[Gfunk6]

There's more to QoL than salary.

👍
Touche. I feel stupid for not adding in that caveat.

 

[deleted4401]

There is also an additional type where the group gets a global percentage of revenue rather than just professional or professional + technical. That's how we do it, and I think many other practices have deals like that. Gives you a small portion of the technical without having to invest in it, at least directly.
-S

 

[OTN]

There are two things that appear to be coming with regards to CMS reform that are germane to Rad Onc:

1. Professional and technical fees will continue to drop (or, at best, stay stable) over the coming years; however pro fees will tend to drop at a steeper rate and will ultimately become a smaller percentage of the total pot of reimbursement

2a. Change from fee-for-service to fee-for-disease; So let's say a pt came in with prostate cancer. Instead of better reimbursement for maximum fractionation (1.8 Gy x 44), you are simply given a lump sum to do how you please. Presumably this will lead to more hypofractionation (e.g. Cleveland Clinic protocol for prostate cancer) due to removal of incentivization for fractions.

2b. As a corollary to above; Rad Onc and Med Onc will require financial integration as many diseases require concurrent chemoXRT for cure


Therefore, IMO, the following types of practice will be best prepared to weather the coming storm:

a. Physicians who collect both pro and technical fees (e.g. they own the machines) will be far better off. Technical fees, as alluded above, will remain relatively unscathed from CMS and will continue to be the future money-maker. Pro-only groups will have to see more and more patients to compensate for an ever-shrinking pool of revenue.

b. Combined Med Onc and Rad Onc practices that can easily implement the fee-for-disease reimbursement model; this model is not often found in free-standing cancer centers but is the norm in academic and community hospitals

c. Physician-employees are the future of medicine, unfortunately. These folks will still maintain a decent pay (> $300K) but will find it difficult to increase their salary with seniority outside of clinical volume bonuses. The loss of financial autonomy is also a bummer.

I've actually heard the opposite when it comes to the technical/professional fees dropping- that is, I've heard more drop in the technical than professional component. Probably just underscores the point that we really have a tough time predicting the future of this stuff.

When I was looking for a private practice job, given the financial uncertainty surrounding a lot of this, I didn't think it would be the best decision to join a "3 years to partner with a large buy in but we own the machines" kind of a group. Just my two cents.

 

[Gfunk6]

I've actually heard the opposite when it comes to the technical/professional fees dropping- that is, I've heard more drop in the technical than professional component. Probably just underscores the point that we really have a tough time predicting the future of this stuff.

Very interesting. I guess this really underscores subatomicdoc's point well in that you should really go to a practice that will make you happy.

 

[medgator]

Very interesting. I guess this really underscores subatomicdoc's point well in that you should really go to a practice that will make you happy.

I've heard IMRT technical codes are really front and center, esp since reaching $1 billion in charges the last couple of years, making it a line item in the congressional budget. It was brought up at ASTRO that these same codes had $0 in billing just a decade ago.

http://online.wsj.com/article/SB10001424052748703904804575631222900534954.html

In 2008, the last year for which data is available, Medicare spent an estimated $1 billion or more on IMRT, largely for the treatment of prostate cancer.

Honestly, technical cuts would probably hurt urorads centers the most considering if that statement is true.

 

[FFunk]

Yeah, 2 years ago, the whole utilization ratio issue threatened IMRT reimbursement almost by 65%, although it didn't materialize, it showed some preliminary signs that technical fee may be on the top of CMS list of cuts.

 

[T99]

I am a 3rd year MS who is interested in Rad/RadOnc and I recently came across this letter from ASTRO to CMS in response to ACO regulations released by Medicare. One of the points raised by them concerning referrals to RadOncs or lack thereof concerns me regarding the mess these new regulations are going to create in near future. I would really appreciate it if anyone (especially people like GFunk6) who are more knowledgeable can share their insight into this issue of ACO's and future of RadOnc.​

You can find the letter here, if you wish to read through other points raised by ASTRO:
http://www.astro.org/PublicPolicy/CommentLettersTestimonyAndReports/documents/ACOletter.pdf​

ASTRO was disappointed that the proposal did not address the integration of specialists in the ACO environment in greater detail. We fear that this absence will limit the success that can be achieved by the Medicare ACO program. The Medicare Medical Home model focuses on increasing the capacity of primary care providers to coordinate the care of Medicare beneficiaries. ASTRO believes ACOs need to go beyond the medical home concept and create a clinical, administrative, and financial structure that links primary and specialty care. Only a model that links the two can result in improving care to beneficiaries, developing a more stable practice environment for providers, and creating savings for the Medicare program and taxpayers. The absence of a clear vision and practical guidelines on the role and integration of specialists makes it less likely that ACOs will be able to achieve these important goals. A central concern for ASTRO is that the proposal may create incentives for delaying specialty care which could potentially lead to harm in patient care, such as in delay in diagnosis and treatment of serious diseases including cancer. For instance, a patient who presents with hemoptysis may be managed under the primary care physician in this ACO model. Without clear guidelines on the coordination between primary and specialty care,there potentially is an incentive for the primary care physician to control this patient's care until there is further clinical deterioration rather than referring the patient to a pulmonologist in a timely manner. This could possibly lead to delay in diagnosis (and treatment) of this patient's lung cancer. Delays in diagnosis of such serious illnesses such as lung cancer can have significant impact on the patient's treatment options and prognosis.We are similarly concerned that this model would provide incentives for primary care physicians to consider other methods before referring to radiation oncologists for the use of radiation treatments to palliate the severe pain often experienced by cancer patients. ​

 

[Gfunk6]

I don't think how anybody really knows how ACOs are going to ultimately work. Given the disproportional income disparity in favor of specialists for years, I think Medicare is rightfully trying to put power back in the hands of PCPs.

From what I understand, it would be prudent to position yourself where you are working closely with other oncological specialites because when the reimbursement eventually shifts from fee-for-service to fee-for-disease, it will be better for you logistically and financially.

Also, you should take press releases from medical societies (ASTRO included) with a healthy grain of salt. To preserve their specialty, they will often blow things out of proportion or offer "the worst case scenario" to prove their point. The current model of medicine has taken decades to evolve and if it changes, it will take a similarly long time to do so. I wouldn't worry about it changing overnight with the stroke of a pen.

 

[Sheldor]

I don't think how anybody really knows how ACOs are going to ultimately work. Given the disproportional income disparity in favor of specialists for years, I think Medicare is rightfully trying to put power back in the hands of PCPs.

From what I understand, it would be prudent to position yourself where you are working closely with other oncological specialites because when the reimbursement eventually shifts from fee-for-service to fee-for-disease, it will be better for you logistically and financially.

Also, you should take press releases from medical societies (ASTRO included) with a healthy grain of salt. To preserve their specialty, they will often blow things out of proportion or offer "the worst case scenario" to prove their point. The current model of medicine has taken decades to evolve and if it changes, it will take a similarly long time to do so. I wouldn't worry about it changing overnight with the stroke of a pen.

Has there been any talk as to who, in the fee-for-disease model, will decide who gets what? Will this turn in to physicians fighting amongst each other for who should get what? I really hope not...

 

[BraggPeak]

If Obama doesn't win in 2012 (he's in no way a shoe-in), significant healthcare reform will be delayed at least 4 years. In any case, changes in reimbursement are coming irrespective of which part is in power.

Given the upcoming changes, do you think there is more incentive to now go into academics (ie. salary disparity may decrease between private practice and academics, and in a few years as you become more senior you can have more time for non-clinical duties if you so desire)?

 

[medgator]

Has there been any talk as to who, in the fee-for-disease model, will decide who gets what? Will this turn in to physicians fighting amongst each other for who should get what? I really hope not...

In a way, that's how the medicare $$$ pot is now.