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If you do a sim with 1 cm slice thickness when treating a 0.5 cm lesion, you May be able to get it on only on slice. Then you could just treat a 2 dimensional target right?
Are We Winning Yet
Started by TheWallnerus
Of course! After all Loma Linda has been doing it for years to treat clival chordomas. The only cost is some late temporal lobe necrosis.
Kavadi out with a letter publicly stating two centers have closed. Privately they have heard concerns of many more centers that may/will close and an unamed number of physicians have already lost their jobs. Any word from the doubters who know a lot of people? Waiting for a word from the people in the know!
The breadlines are coming. In Kavadi’s words, this is “frankly a crisis”.
Enjoy the SOAP this coming year, folks!
The breadlines are coming. In Kavadi’s words, this is “frankly a crisis”.
Enjoy the SOAP this coming year, folks!
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Feature, not a bug (at least as it pertains to Medicare PFS/freestanding centers)
As warren buffet said, "Be fearful when others are greedy, and greedy when others are fearful."
How can I find this letter?
Dear Colleagues,
The first quarter of 2026 has brought significant financial instability and uncertainty for many in our field. The 2026 payment rules for both the Hospital Outpatient Prospective Payment System (OPPS) and, especially, the Medicare Physician Fee Schedule (MPFS) introduced numerous fundamental changes. While the full impact of these changes may take months or even longer to fully understand, the struggles faced by radiation oncologists and cancer centers are real and immediate — and merit immediate action.
It is important that we review the history of how we arrived at this point, examine the current impact of these changes, and clearly outline ASTRO’s path forward.
How We Arrived Here
Radiation oncology experienced a substantial increase in billed charges between 2002 and 2014, primarily driven by the increased clinical appropriateness of intensity modulated radiation therapy (IMRT) in a larger number of cases. In 2014, the Centers for Medicare and Medicaid Services (CMS) declared that technical delivery charges were overvalued and requested a new approach. The AMA Current Procedural Terminology (CPT) Editorial Panel and RVS Update Committee (RUC) developed a new methodology, but unfortunately, it was rejected by CMS. Consequently, temporary G codes for delivery in the freestanding setting were created.
In 2015, the Patient Access and Medicare Protection Act (PAMPA) legislation then introduced a rate freeze for several years to facilitate the implementation of a new payment model. ASTRO played a significant role in the rate freeze. We diligently collaborated with the Center for Medicare and Medicaid Innovation (CMMI) to create a viable alternative payment model (coined the RO Model) intended to bring stability, predictability, and modest cost savings. However, when it became evident that CMS was pursuing extensive cuts rather than stability, we withdrew our support. After CMS placed the RO Model on an indefinite hold, their cuts resumed.
"...the struggles faced by radiation oncologists and cancer centers are real and immediate — and merit immediate action." |
The 2026 Revaluation: Positives and Negatives
In 2025, the radiation treatment delivery and image guidance codes saw major changes. These changes reflect advances in technology and care delivery, which dramatically impact how these services are valued. ASTRO was actively engaged in the CPT and RUC processes, advocating for radiation oncology’s unique needs to be accounted for in these discussions. While the specific details of the CPT and RUC process remain confidential, several noteworthy outcomes emerged from this revaluation.
The Positive:
- MPFS has consistently faced the challenge of accurately capturing practice expenses for our specialty. There was a substantial risk that we would be categorized under diagnostic imaging, leading to significant reductions in our practice expense reimbursement. We were heartened to see CMS acknowledge that practice expense for equipment and specialized staff is not different between OPPS and MPFS. This led to MPFS technical payments being linked to hospital ambulatory payment classifications (APCs).
- The 2026 MPFS rule has many components that work in varying ways, resulting in an inability to make apples-to-apples comparisons year over year.
- Collapsing into three treatment delivery codes and bundling image guided radiation therapy (IGRT) makes appropriate APC designation for the codes under OPPS of paramount importance since MPFS technical payments are now linked to OPPS. ASTRO continues to believe that 77407 was placed in the wrong OPPS APC, resulting in significant undervaluation of the code. Reimbursement for IMRT treatment for prostate cancer, the “typical” case for 77407, has decreased by 14%. This is a profound change.
- The definition of 77412 is quite specific and hence its utilization is far less frequent in practice than was predicted. CMS originally had it at 45%, but it was reduced to 35% in the final rule after public feedback. In many practices, including my own, utilization of that code has been less than 15%.
- CMS estimated that overall MPFS would see an aggregate cut of 1%. To many of us, this was quite difficult to reconcile with what was being presented. The professional codes saw an overall increase, but the technical codes, which make a much higher percentage of total charges, saw significant cuts. Hence, -1% was always suspect. Both hospitals and freestanding centers are seeing major cuts on the technical side.
In the first two months of this year, we heard major concerns from our members. This resulted in a survey of impact of the 2026 payment rules that was sent to members across the country. The findings are as follows:
- While hospitals are seriously impacted, the impact is felt most significantly by doctors at freestanding, independent practices and those in rural areas.
- In the freestanding setting, two-thirds reported decreases of 10% or more. This is not a minor adjustment. It is a destabilizing shock.
- Many doctors report that health insurance companies were unprepared for the transition (i.e., could not process the new codes), introducing additional delays, holds and denials. One respondent said processing time has doubled for many of their patients.
- Half of the survey respondents said advanced radiation treatments are frequently denied by insurance companies, causing unnecessary delays and anxiety for patients. Denials are especially common at freestanding centers.
- Private payers and benefit managers are exacerbating the tenuous situation with additional prior authorization requirements, downcoding even when documentation exists, and failing to update payment rates appropriately. Continued payer behavior such as this will have dire consequences.
ASTRO’s Ongoing Actions
Here are the steps ASTRO has taken thus far, and what we intend to do moving forward:
- Providing regular membership updates via ASTROgram, ROhub, podcasts, and other communications channels
- Met with CMS staff to stress the crisis-level impact the coding and reimbursement changes are having on RO practices and submitted written comments to CMS leadership with policy solutions to help remedy the situation
- Lobbying Congress on how this crisis will impact patients’ access to radiation therapy, particularly in rural and underserved areas
- Heavily advocating with payers nationwide to ensure appropriate implementation and reimbursement rates for the revised codes
- Created a new Payer Support and Resolution Center as a one-stop shop to keep members apprised of updates related to the revised delivery codes and report payer issues to ASTRO staff
- Contacted Medicaid Directors in every state to notify them of the need to update their respective fee schedules and billing systems
- Hosting a Town Hall on May 6
Reimbursement concerns are not unusual in our field, but this time it is truly different. It is frankly a crisis. Center closures, physician layoffs, and the inability to meet payroll have created an existential threat to the viability of some practices. That impact affects access to care, technology maintenance and upgrades, and innovation.
CMS identified IMRT as potentially misvalued in 2012. They have cut reimbursement already by over 25% — cuts that were unjustified, as we have repeatedly stated. Having already absorbed those reductions, there is absolutely no justification for what is happening now. Ultimately our patients lose.
Because of this, ASTRO’s Advocacy Day on April 27-28 is especially critical. Please join us now and in the weeks and months to come as we make our voices heard. I am calling upon you to act by petitioning CMS Administrator Mehmet Oz, MD, directly.
Act Now |
Best regards,
Vivek S. Kavadi, MD, MBA, FASTRO
ASTRO CEO
There are going to be some great fire sales on freestanding centers for the hospitals systems.
They really should have instructed us to talk to the payors about the crosswalk. Michigan payors are going to fix this and make it retroactive for Jan 1, but it took a lot of work and ****ting our pants to get us there. Those new codes weren't new and had values to them that were far lower than the previous tx delivery codes. No one checked this. UGH. I think those centers could have actually held on if they had capital reserves / cash on hand, b/c there are centers that are actually doing somewhat better (personal communication), b/c they proactively managed the rates for 77402/77407/77412 in late 2025. They are sitting pretty. Less than 5% of centers I imagine took this approach. I know I'm a broken record on this, but saying it was going to be a 1% hit and not looking at numbers and actual reimbursement was incompetence. We modeled it out and we are a bit lower than predicted (b/c of commercial payor snafu mentioned above), but essentially a small practice was able to figure this out, but ASTRO's crack team believed the 1% number? Proactively contacting the payors should have been number one thing for us to do and it should have come from Keole/Rewari/Kavadi/Yashar/Mantz. These folks simply do not have the knowledge and action-oriented mindset to get us through these types of changes.
In 2025 internet connections at my house saw major changes. Technology advances allowed me to move from dialup to high speed fiber broadband. I began to actively engage in online activity. While the specific details of that activity remain confidential, I now have syphilis.
Thanks for sharing the letter.
Its unfortunate, I know at least one person that wanted to do advocacy day but was turned away. I applied to be at the town hall to hear more but seems like I have to be approved to attend. 🤷♂️
You have to wonder if they have the political clout anyway. ROCR was going around CMS and I strongly suspect CMS does not like working with ASTRO. Ive asked a few times what is plan B and how are discussions going with CMS? I really want to know the answer since ROCR is modeled at a 0% chance of passing. No one talks about it.
If you work for a large hospital network, you could consider talking to your leadership to find out if they are talking to CMS or payors. Mine has been a lot more transparent than ASTRO and Id guess they have more influence as well.
Its unfortunate, I know at least one person that wanted to do advocacy day but was turned away. I applied to be at the town hall to hear more but seems like I have to be approved to attend. 🤷♂️
You have to wonder if they have the political clout anyway. ROCR was going around CMS and I strongly suspect CMS does not like working with ASTRO. Ive asked a few times what is plan B and how are discussions going with CMS? I really want to know the answer since ROCR is modeled at a 0% chance of passing. No one talks about it.
If you work for a large hospital network, you could consider talking to your leadership to find out if they are talking to CMS or payors. Mine has been a lot more transparent than ASTRO and Id guess they have more influence as well.
Enticing more and more residents into a specialty where its clinics are shutting down and doctors being laid off seems really mean spirited
As per my Buffet quote, I think it's reasonable to ask which way this will go. These closures/the threat isn't a product if our services being made redundant by some other thing. Rather, it's self-imposed and hopefully performative, much like last year's "Liberation day." Don't you wish you'd sold all your bonds and dumped money into an international index fund last April? C'mon, I don't get the impression from the people I meet everyday that prolonged and large scale rural rad onc clinic closures are gonna be tolerated by the population....
This is why im not super impressed when a chair says we wont fill with SOAP. It is a low bar. They will just fill with warm bodies or whoever they have to take to fill. Say even they do not have to do any of this and standards remain high, does Rochester and similar programs need two a year? nobody asks the question for obvious reasons. Everyone has a great program that needs 2-5 a year. The reality is we should be cutting slots significantly. Nobody wants to hear this.
There are programs still trying to expand! I know for a fact this is the case.
Nothing can be said to academic centers about this. They simply do not care. They are insulated from reality.
Doesn't matter. Their focus is currently on going to case rates so we become 5 fraction technicians focusing on throughput and efficiency rather than iterative improvement and tech/capital driven innovation.
Nothing can be said to academic centers about this. They simply do not care. They are insulated from reality.
Doesn't matter. Their focus is currently on going to case rates so we become 5 fraction technicians focusing on throughput and efficiency rather than iterative improvement and tech/capital driven innovation.
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Another way people are expanding is by adding a sneaky military spot or a research one (Duke). Stop expanding! Cut your slots NOW.
Where I used to work, unfilled positions would be filled by taking someone outside of the match after soap, create an extra spot the following year, or take a clinical fellow.
They signed the “no soap pledge” too. I’d love to have another article measuring the compliance of the no soap pledge when it comes to just getting around it, but I imagine that some of these sneaky tactics are hard to measure.
Oh yeah i forgot about the “clinical fellow”, usually someone who already completed residency in a place like India.
The military spots are sneaky, they absolutely get clinical jobs at civilian hospitals in desirable coastal areas.
Research residents or Holman, yeah they end up practicing clinically by and large.
Clinical fellow/IMG spots are a bit predatory and are also a way to fudge the numbers. All those angles are bad.
Research residents or Holman, yeah they end up practicing clinically by and large.
Clinical fellow/IMG spots are a bit predatory and are also a way to fudge the numbers. All those angles are bad.
"You have to wonder if they have the political clout anyway."
I think it is abundantly obvious and has been for two decades for those paying attention, that theclowns at ASTRO have has no clout, full stop.
Addendum: Someone should write a book of how PAMPA came to be
I think it is abundantly obvious and has been for two decades for those paying attention, that the
Addendum: Someone should write a book of how PAMPA came to be
Consider checking your facts - military trainees owe 12 years of service without location choice after completing residency
They aren’t in the job hunt with their coresidents
Radiation Clinic in Greenville, Mississippi, May Close in Latest Blow to Rural Health Care
The Alliance Cancer Center radiation clinic in Greenville, Mississippi, may close on June 1.
www.mississippifreepress.org
Wow - condescending AND wrong. Most have heavy influence on where they end up and the amount of time they owe depends on their path. MANY only owe a few years and then go out to PP. Want me to give you some names of people that served less than 4 years after residency then went to PP?
what is the point of your post or the original post though, regardless of whether it's 4 years or 10 years?
St
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I work at a large healthcare system with hospital-based and free-standing sites, and we saw a net 10% reduction in revenue, with some of the free-standing sites seeing at 25% drop in revenue. ASTRO messed this up big time. This has very significant implications for the job market, and i dont think academic folks and residents understand the long-term consequences if this is not mitigated
why exactly 2026 CMS code change caused drop in freestanding revenue?
Loss of technical igrt revenue for freestanding is a biggie
Mass membership resignations are needed imho
But spoiler alert it’s not going to be mitigated
And once the patient is dead it doesn’t matter if you restore the power to the ventilator… the freestanding sites that are gonna shut down will never come back. However I have thought of renaming my clinic “The Spirit Airlines Cancer Center.”
A lot of cost cutting targets available. Most systems have too many physicists (and often techs) and physicians can remotely cover satellites. A 15 year old trilogy is 98%, -maybe more with add ons- as capable as a 3 mill true beam.
Many linacs have 12-14 pts on beam. As Wallnerus has previously pointed out, most centers are just not busy, (Pareto distribution). Consolidation awaits.
I replied to YOUR post. Are you back-peddling?
Let me help you out: you should because it was objectively wrong.
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Once you can't buy a service contrast for a machine, though, it's worthless.
I've heard they're not cheap, though, and now here we are back again with the same issue.
After the SOAP years a few years ago, academics launched a heavy misinformation campaign using then residents (now attendings who wanted a job) to tell people that rad onc was back and all the concerns were fake news. Some of these people are still at it. This was followed by a narrative that times have never been better. The current crop of residents were brought in under this misinformation and lies. Reality has a way to punch you in the mouth.
Rad onc residents are lied to by people they admire. They are misled and don’t have a full understanding. Some may fully understand to some extent but dont care because they want a job and their chair is asking them to help.
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does Astro still offer a “masterclass” seminar in leadership at the annual meeting?
I would trust ASTRO leadership as much as I’d trust the Titanic as a ship
the titanic was by all accounts a fine ship. It was mismanagement and poor leadership that made it infamous FWIW.
As the rad onc reimbursement goes down the salaries keep going up! Paying a locums company up to $1000 a day and the locums $3200 a day to treat ~20 people… this center is going to have to pay maybe 2/3 of its daily reimbursement for locums. If they’re a low volume center they could maybe have to pay all their daily reimbursement! That possibly means centers now have to take on negative profit margins to get a locums.
Good point. The recruiter didn’t say.
The uncomfortable reality is that radiation oncology is not clinically dying, but the community/freestanding economic model is under severe pressure.
The field still matters. Radiation will be needed for the foreseeable future. SBRT, SRS, breast, prostate, lung, CNS, palliation, oligomets, etc. are not going away.
But survival of the modality is not the same thing as health of the specialty.
The problems are structural:
1. Fixed costs are brutal. Machines, vaults, service contracts, software, imaging, QA infrastructure, physics, dosimetry, therapists, nursing, auth staff — the overhead is enormous before a single patient is treated. Some of this is legitimate and safety-critical. Some of it is also an over-specialized staffing model that is very hard to streamline, for the usual Upton Sinclair reason: it is hard to get a man to understand something when his salary depends on him not understanding it.
2. Reimbursement keeps compressing and becoming less predictable. The 2026 recode did not create the problem by itself. It exposed the fragility. Whether the national Medicare impact averages out to modest changes or not, the practical reality for many centers is payer implementation chaos, bundling, code confusion, cash-flow disruption, and a shrinking margin for error.
3. Rad onc has an economic innovation problem. The field absolutely innovates: SBRT, SRS, adaptive RT, MR-guidance, motion management, AI planning, better image guidance, etc. But much of our innovation improves value while reducing billable treatment volume. Med onc innovation often creates new reimbursable spend. Rad onc innovation often means fewer fractions, fewer visits, tighter margins, less toxicity, and less revenue per course. That is great for patients, but it is economically self-cannibalizing. Protons and heavy ions are too expensive to save the field at scale.
4. We usually do not own the patient. We are often a terminal referral specialty. Urology owns prostate. Med onc owns systemic therapy and the longitudinal cancer identity. Surgeons own the initial pathway. Pulm/GI often own diagnosis. Outside select niches — prostate SBRT, CNS/SRS, palliation, oligomets, certain breast/lung programs — we generally receive episodes of care, not the patient relationship.
5. ASTRO has not acted like the ruthless specialty-defense organization the moment requires. Yes, ASTRO does reimbursement advocacy. Yes, there are comment letters, coding guidance, payer engagement, etc. But the issue is intensity and institutional priority. While community/freestanding RO needed aggressive advocacy on reimbursement, payer behavior, access, and survival of the non-hospital practice model, ASTRO was also platforming Ibram X. Kendi at ASTRO20 for “A Conversation About Race.” That session did not cause our problems, obviously. But it was a perfect symbol of ASTRO’s institutional instincts: highly responsive to academic prestige and cultural branding, far less effective at defending the actual economic viability of the specialty outside protected hospital systems.
Long term, the durable survivors are large academic centers, especially those insulated by hospital economics, institutional subsidy, residents/fellows, brand gravity, and favorable facility economics, plus large health systems in major metros that control referrals and can absorb inefficiency inside a broader cancer-service-line machine.
Private practice will still exist, and people in good private groups can still make an excellent living. But that requires the right combination of capital, payer mix, geography, timing, machine utilization, referral credibility, operational discipline, risk tolerance, partner alignment, and luck. Most people do not have that combination.
The centers most exposed are rural and marginal community/freestanding centers without enough volume, system protection, payer leverage, or referral control. They may be clinically necessary, but clinical necessity does not pay for a LINAC, therapists, physics, dosimetry, auth staff, software, QA, management, and service contracts when reimbursement falls and fractionation drops.
So no, radiation oncology is not “going away.”
But the old comfortable economic model is going away. The future is bifurcation: protected academic/health-system nodes on one side, highly efficient and well-positioned private groups on the other, and a lot of vulnerable community capacity getting squeezed in between.
That is not a healthy specialty. That is a specialty where the winners can still do very well while the overall structure deteriorates.
The field still matters. Radiation will be needed for the foreseeable future. SBRT, SRS, breast, prostate, lung, CNS, palliation, oligomets, etc. are not going away.
But survival of the modality is not the same thing as health of the specialty.
The problems are structural:
1. Fixed costs are brutal. Machines, vaults, service contracts, software, imaging, QA infrastructure, physics, dosimetry, therapists, nursing, auth staff — the overhead is enormous before a single patient is treated. Some of this is legitimate and safety-critical. Some of it is also an over-specialized staffing model that is very hard to streamline, for the usual Upton Sinclair reason: it is hard to get a man to understand something when his salary depends on him not understanding it.
2. Reimbursement keeps compressing and becoming less predictable. The 2026 recode did not create the problem by itself. It exposed the fragility. Whether the national Medicare impact averages out to modest changes or not, the practical reality for many centers is payer implementation chaos, bundling, code confusion, cash-flow disruption, and a shrinking margin for error.
3. Rad onc has an economic innovation problem. The field absolutely innovates: SBRT, SRS, adaptive RT, MR-guidance, motion management, AI planning, better image guidance, etc. But much of our innovation improves value while reducing billable treatment volume. Med onc innovation often creates new reimbursable spend. Rad onc innovation often means fewer fractions, fewer visits, tighter margins, less toxicity, and less revenue per course. That is great for patients, but it is economically self-cannibalizing. Protons and heavy ions are too expensive to save the field at scale.
4. We usually do not own the patient. We are often a terminal referral specialty. Urology owns prostate. Med onc owns systemic therapy and the longitudinal cancer identity. Surgeons own the initial pathway. Pulm/GI often own diagnosis. Outside select niches — prostate SBRT, CNS/SRS, palliation, oligomets, certain breast/lung programs — we generally receive episodes of care, not the patient relationship.
5. ASTRO has not acted like the ruthless specialty-defense organization the moment requires. Yes, ASTRO does reimbursement advocacy. Yes, there are comment letters, coding guidance, payer engagement, etc. But the issue is intensity and institutional priority. While community/freestanding RO needed aggressive advocacy on reimbursement, payer behavior, access, and survival of the non-hospital practice model, ASTRO was also platforming Ibram X. Kendi at ASTRO20 for “A Conversation About Race.” That session did not cause our problems, obviously. But it was a perfect symbol of ASTRO’s institutional instincts: highly responsive to academic prestige and cultural branding, far less effective at defending the actual economic viability of the specialty outside protected hospital systems.
Long term, the durable survivors are large academic centers, especially those insulated by hospital economics, institutional subsidy, residents/fellows, brand gravity, and favorable facility economics, plus large health systems in major metros that control referrals and can absorb inefficiency inside a broader cancer-service-line machine.
Private practice will still exist, and people in good private groups can still make an excellent living. But that requires the right combination of capital, payer mix, geography, timing, machine utilization, referral credibility, operational discipline, risk tolerance, partner alignment, and luck. Most people do not have that combination.
The centers most exposed are rural and marginal community/freestanding centers without enough volume, system protection, payer leverage, or referral control. They may be clinically necessary, but clinical necessity does not pay for a LINAC, therapists, physics, dosimetry, auth staff, software, QA, management, and service contracts when reimbursement falls and fractionation drops.
So no, radiation oncology is not “going away.”
But the old comfortable economic model is going away. The future is bifurcation: protected academic/health-system nodes on one side, highly efficient and well-positioned private groups on the other, and a lot of vulnerable community capacity getting squeezed in between.
That is not a healthy specialty. That is a specialty where the winners can still do very well while the overall structure deteriorates.
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Well said. Historically high reimbursements drove overexpansion of both university systems and resident numbers as well as enabled survival of low volume clinics. The Problem has been made even worse by technology and a toxic and arrogant culture spearheaded by Astro focused on reducing fractions and footprint of the specialty in oncology.
In an employed model, our compensation and job prospects should not be defined by reimbursement, but largely by supply and demand. Even, with reimbursement cuts, I am still bringing in much more revenue than orthopedic, urology and neurosurgeons as well as gyn onc, but obviously compensation and job opportunities are very different.
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I think this looks bad for the field. When your flagship, feather in the hat rad onc clinic is deadbeat dadding it, there's going to be blowback. I really think the significant cut in IGRT revenue (was never bundled in hospital protons, only hospital IMRT), w/ no lifeboat 77412-similar upsell to claw back profit margin, is going to be many places' thousandth cut.
www.arkansasonline.com
EDIT: If your proton center goes on the fritz for two months and can't treat anyone... gosh, as the treating MD, what do you do? What do you tell people? "Protons are definitely best, but cancer won't just cure itself... IMRT it is!"
Proton Center faces Thursday deadline to pay $900,000 owed to UAMS | Arkansas Democrat Gazette
LITTLE ROCK -- The state's only proton therapy center is facing the potential termination of its service agreement with the University of Arkansas for Medical Sciences if the center doesn't meet almost $900,000 in unpaid obligations by May 28.
www.arkansasonline.com
EDIT: If your proton center goes on the fritz for two months and can't treat anyone... gosh, as the treating MD, what do you do? What do you tell people? "Protons are definitely best, but cancer won't just cure itself... IMRT it is!"
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It blunts appetite for innovation in industry
It affects payor interactions where they don’t see need to pay for innovation over time
It eventually could have blowback on the workforce long term
I see a lot of ways it affects every rad onc. Maybe not today but eventually. A rising tide lifts all ships. Rad onc has a lot of low tides right now.
