ASTRO adversary or advocate

[RickyScott]

I think this needs its own thread.

Increasingly, I am concluding that ASTRO is my adversary. i am speaking in general terms and I know there are exceptions, but for the most part, the leadership is encouraging an oversupply of the job market while the field shifts towards hypofractionation. This is accompanied by a "choosing wisely" initiative that serves as a fig leaf while this group extorts insurances with the worlds highest medical costs to go with PPS exemptions at the main and satellite locations.
I recently had a patient whose insurance paid out over 90,000$ for hypofractionated prostate IMRT at MDACC (which is still able to mismanage its finances) Metropolitan areas that soon will have multiple proton centers (with one being NCCN) include Philadelphia, MIami,DC/balitmore, NY, others. Some even claim they charge IMRT rates for protons with the caveat that IMRT rates are still insane at these places. They are making the calculation that at IMRT rates they charge, protons are still viable.And of course, many like MSKCC (generalization) take no medicaid or limit access to obamacare.

Which brings me back to the irresponsible oversupply of residents- they are entering a job market where there will be incredible pressure to overutilize resources, because if you dont meet your rvus, we can quickly find someone who will, perhaps one of the fellows in palliative care, SBRT or another core competency- that they have no business offering a "fellowship" in.

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Members don't see this ad.

 

[OTN]

I strongly, strongly agree. I let my ASTRO membership lapse this year and will not be renewing. The "leadership" of this field should be ashamed of what they've done.

 

[medgator]

ACRO annual meeting is Feb 1-3, 2018 in Ft Lauderdale, 9 free SAM credits included with meeting

Annual Meeting - American College of Radiation Oncology

 

[RickyScott]

sorry, need to rant some more about this Leadership who uses political clout/ monopolistic pricing of their institutes to get tremendous reimbursement, while offering up the rest of us to "choose wisely"

340B program is ending next year... except for NCCN/PPS exempt centers. For me that means, the PPS exempt and NCCN centers in Florida will purchase drugs at 80%, even though they dont take medicaid or indigent patients.

Who is choosing wisely/unwisely- someone like me who treats prostate to 79/1.8 and the hospital receives 25k technical, (we also gives out 15% free care, including cancer drugs) ... or the nearby PPS exempt academic instituition who may hypofractionate, charge 60k+, takes no free care/medicaid/and not even managed medicare?

 

[Irradi8or]

sorry, need to rant some more about this Leadership who uses political clout/ monopolistic pricing of their institutes to get tremendous reimbursement, while offering up the rest of us to "choose wisely"

340B program is ending next year... except for NCCN/PPS exempt centers. For me that means, the PPS exempt and NCCN centers in Florida will purchase drugs at 80%, even though they dont take medicaid or indigent patients.

Just to add some data to this statement, look at the insane increases in 2018 to HOPPS payments for the PPS exempt centers. As someone who trained at a top PPS exempt cancer center, this emphasis on "value" really is just a continued way for the large centers to make more and the community practitioners to consolidate and leave even less cost effective solutions available for patients.

 

[medgator]

Just to add some data to this statement, look at the insane increases in 2018 to HOPPS payments for the PPS exempt centers. As someone who trained at a top PPS exempt cancer center, this emphasis on "value" really is just a continued way for the large centers to make more and the community practitioners to consolidate and leave even less cost effective solutions available for patients.

View attachment 227351

Yet somehow MDACC, getting the biggest boost of all while the rest of us are thrilled that we are seeing 0-1% changes, managed to lose money.

Amazing.

Too Big to Fail? Anderson in trouble

 

[Irradi8or]

Yet somehow MDACC, getting the biggest boost of all while the rest of us are thrilled that we are seeing 0-1% changes, managed to lose money.

Amazing.

Too Big to Fail? Anderson in trouble

Indeed - need more transparency and accountability for the PPS exempt centers. These are tax payer dollars funneling into these centers.

 

[Chartreuse Wombat]

Just to add some data to this statement, look at the insane increases in 2018 to HOPPS payments for the PPS exempt centers. As someone who trained at a top PPS exempt cancer center, this emphasis on "value" really is just a continued way for the large centers to make more and the community practitioners to consolidate and leave even less cost effective solutions available for patients.

View attachment 227351

Reference please

 

[deleted18755]

sorry, need to rant some more about this Leadership who uses political clout/ monopolistic pricing of their institutes to get tremendous reimbursement, while offering up the rest of us to "choose wisely"

340B program is ending next year... except for NCCN/PPS exempt centers. For me that means, the PPS exempt and NCCN centers in Florida will purchase drugs at 80%, even though they dont take medicaid or indigent patients.

Who is choosing wisely/unwisely- someone like me who treats prostate to 79/1.8 and the hospital receives 25k technical, (we also gives out 15% free care, including cancer drugs) ... or the nearby PPS exempt academic instituition who may hypofractionate, charge 60k+, takes no free care/medicaid/and not even managed medicare?

Can somebody provide a reference or briefly explain what it means to be a NCCN/PPS exempt center (how does a center acquire this status and then what does it allow them to do, etc) and maybe a list of them if it's readily available. Same thing for 340B. I have an understanding of the latter but not the former and although I'm in private practice kind of in the middle of nowhere this is very relevant for the entire field so I would like to educate myself. I'm sure I'm not the only one and they obviously don't teach this stuff in residency. You guys seem to have a very good understanding and I'm sure many of us would appreciate learning. Thanks

 

[Irradi8or]

Reference please

2018 OPPS Final Rule Summary

List of PPS-Exempt Cancer Hospitals

 

[Chartreuse Wombat]

2018 OPPS Final Rule Summary

List of PPS-Exempt Cancer Hospitals

This is acute inpatient services according to the website. Is this germane to radiation oncology billing?

 

[Irradi8or]

This is acute inpatient services according to the website. Is this germane to radiation oncology billing?

Hi CW - yes, it is. Once you delve into the details of the PPS-exempt centers, you see that they are exempt from inpatient DRGs, get a substantial boost to the hospital outpatient services as well, among several other advantages.

Here's a group called the ADCC that is an alliance of the PPS-exempt centers:

http://www.adcc.org/sites/default/files/ADCC_Facts_On_Dedicated_Cancer_Centers.pdf

 

[Chartreuse Wombat]

Hi CW - yes, it is. Once you delve into the details of the PPS-exempt centers, you see that they are exempt from inpatient DRGs, get a substantial boost to the hospital outpatient services as well, among several other advantages.

Here's a group called the ADCC that is an alliance of the PPS-exempt centers:

http://www.adcc.org/sites/default/files/ADCC_Facts_On_Dedicated_Cancer_Centers.pdf

Thanks. What a perverse system we inhabit.

 

[xrt123]

To add to the perversion there was a scare for PPS centers that if they expanded and were billing from a new address they would not get their PPS status at the new building. I am not sure how this played out after but I remember there being lobbying to prevent this by our center so they could build more satellite centers and still get the large profit margins.

 

[PruritisAni]

To add to the perversion there was a scare for PPS centers that if they expanded and were billing from a new address they would not get their PPS status at the new building. I am not sure how this played out after but I remember there being lobbying to prevent this by our center so they could build more satellite centers and still get the large profit margins.

Currently, (pre)existing satellites bill/collect at main center prices. If I recall correctly, any new (free standing, non-comprehensive/lacking essentially the full gamut of service at the main facility - ie inpatients) center (acquired or built) will no longer be under the PPS-umbrella.

The people (and more importantly congress) is recognizing this is a significant cost for little value and in all likelihood, in the next 10ish years we will have site-neural reimbursement schedules. Private payors are starting this trend, govt will follow suit in time...

 

[Fpg1245]

It is pretty perverse. Let’s say they leveled the playing field tomorrow. No more privileged centers. Maybe some other groups do a bit better. At the end of the day, I think we’re just putting everyone in the same sinking boat. I certainly hope that would spur more aggressive lobbying for better reimbursement especially from the people on that list but I’m pretty skeptical on that being successful. With tax reform passed unless other measures are taken, the govt will be looking for entitlement cuts to deal with deficit. Now the pain will be shared a little more evenly. All pain no gain.

 

[medgator]

Currently, (pre)existing satellites bill/collect at main center prices. If I recall correctly, any new (free standing, non-comprehensive/lacking essentially the full gamut of service at the main facility - ie inpatients) center (acquired or built) will no longer be under the PPS-umbrella.

The people (and more importantly congress) is recognizing this is a significant cost for little value and in all likelihood, in the next 10ish years we will have site-neural reimbursement schedules. Private payors are starting this trend, govt will follow suit in time...

I believe that CMS passed a rule for centers for either this year, or maybe last year, that hospital acquired free-standing centers still had to bill at lower free-standing rates, not hospital rates.

Can't wait til we see site-neutral payments (and I am sure ASTRO is dreading that day).

 

[OTN]

Given that we're delivering the identical service, why we don't already have site-neutral payments is beyond me. I love the irony of academic centers developing the Choose Wisely campaign and publishing hypofractionation data for cost-effectiveness over and over instead of publishing real research to push the field forward/improve survival rates, while in the background bilking government payers for as much as they can and fighting tooth and nail to keep their subsidies. Bravo.

 

[Chartreuse Wombat]

Below is a link to a brief summary about prices in the US health care system. It does touch on the issue of drug pricing in 340B hospitals.

The Importance of Relative Prices in Health Care Spending

 

[RickyScott]

that is a great and timely article. (unjustified) Price increases are apparently behind .5 trillion dollars in health care expense over the past 15 years. In our field, when a dominant center is able to achieve exorbitant rates because of reputation, monopoly, pps exemption etc, the next logical step is to purchase other hospitals xrt departments, build satellites and gain even more pricing power, as well as buy a proton center or 2 to defend your empire. Upenn now apparently has over 600 patients on treatment/day!
ASTRO leadership is at the heart of this corrupt system of insane rates and pumping out residents for the satellites. That is why I am so disgusted when they ask others charging 1/3 of their rates to "choose wisely," when it is their greed that is destroying our health care system.

 

[nkmiami]

Hypofractionation as a competitive advantage.
Do you foresee a scenario where increased utilization of hypofractionation results in radiation only being financially sustainable for systems that can negotiate high rates/receive preferential CMS reimbursement? Macroscopically this would mean shifting pts from cheaper community/oupt centers to large more expensive tertiary systems. In essence, this is the elimination of competition with biased payment systems that the article is referring to with 340B reimbursement that perversly ends up costing the system more money.

 

[medgator]

Hypofractionation as a competitive advantage.
Do you foresee a scenario where increased utilization of hypofractionation results in radiation only being financially sustainable for systems that can negotiate high rates/receive preferential CMS reimbursement? Macroscopically this would mean shifting pts from cheaper community/oupt centers to large more expensive tertiary systems. In essence, this is the elimination of competition with biased payment systems that the article is referring to with 340B reimbursement that perversly ends up costing the system more money.

Has already been happening for years with differing payments to hospital-owned vs freestanding radiation centers.

This is just a more blatant example.

There is a reason why freestanding centers end up getting preferred contracts with certain insurers... they are the cheaper option for those insurers that do their homework.

 

[Chartreuse Wombat]

340B breaking news!
Hospital Associations Will Appeal Court Decision Allowing Cuts in Payments to 340B Hospitals - Washington Highlights - Government Affairs - AAMC

 

[medgator]

ny times article on this. Again, "its the prices, stupid." We really need more transparency on prices in this field. Honestly, the choosing wisely campaign is wothless at best, but actually downright malicious, without "prices," given the huge spread that exists in radiation.
Why the U.S. Spends So Much More Than Other Nations on Health Care

Both parties refuse to deal with this highly important issue.

That being said, it really is nonsensical to hear republicans talk about having a free market approach to healthcare yet not push for this one bit. It would solve many problems as soon as it was implemented, but I imagine the pharma and insurance lobby own both parties enough to ensure this will never happen

 

[medgator]

My physicist went to ASTRO this year and mentioned how attendance was down for the meeting this year and that some of the exhibitors were frustrated.

Is this true? Personally I may go next year to get some SAM credits and catch up with people after a several year hiatus, but thinking about cancelling my membership after my first re cert after that.