ASTRO letter to CMS re: 2019 proposed budget

[Gfunk6]

https://www.astro.org/ASTRO/media/ASTRO/News and Publications/PDFs/MPFSQPPProposedRuleCommentLetter.pdf

A few points:

1. CMS has used a third-party contractor (StrategyGen) to estimate the price of various pieces of radiation equipment. This has led to highly dubious estimates as to the cost of an SBRT/SRS platform ($900k!), HDR afterloading units, IMRT treatment planning systems, and dedicated brachy vaults.

2. CMS has bundled E/M codes for various internal medicine specialties but Rad Onc seems to have been included inadvertently. Most of our visits are level 4/5 in complexity.

3. CMS is still considering the Rad Onc specific APM recommended by ASTRO - this needs to be approved as other APMs clearly do not apply to our specialty.

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[RickyScott]

I am going to continue to beat a dead horse: Again, ASTRO is lobbying for reimbursement- but stays silent on exploding residency slots, even though physician oversupply has a much greater impact on most members salaries and job prospects. If the government wants to cut technical side of radiation, I welcome it at this point. How many of us today get paid from the technical side?

 

[evilbooyaa]

They came for the technical fees, and I didn't speak up because I didn't get a cut of the technical fees.
Then they came for the professional fees, and there was no one left to speak up for me.

Somebody owns the machines. If the person/group that owns the machines isn't getting paid, it's dangerous to think where they might supplant their income from (especially in a time of oversaturation).

ASTRO is lobbying for what's in the best interest of giant hospitals and corporations. That's why you're never going to see them turn down or reverse residency expansion until this field becomes competitive to only IMGs/FMGs (again).

 

[OTN]

I am going to continue to beat a dead horse: Again, ASTRO is lobbying for reimbursement- but stays silent on exploding residency slots, even though physician oversupply has a much greater impact on most members salaries and job prospects. If the government wants to cut technical side of radiation, I welcome it at this point. How many of us today get paid from the technical side?

All of us. We are all paid to some extent (to a great extent, really) by the technical revenue generated by our treatments, whether you "see" it or not.

 

[Corgi4Prez]

I am going to continue to beat a dead horse: Again, ASTRO is lobbying for reimbursement- but stays silent on exploding residency slots, even though physician oversupply has a much greater impact on most members salaries and job prospects. If the government wants to cut technical side of radiation, I welcome it at this point. How many of us today get paid from the technical side?

First year graduate data is collected and reported each year by someone in ASTRO. Outside of changing landscape for collecting technical fees, have you seen starting salaries slide over the years where residency slots have expanded? (Genuine question by the way, there's been lots of vitriol on this forum lately).

 

[RickyScott]

They came for the technical fees, and I didn't speak up because I didn't get a cut of the technical fees.
Then they came for the professional fees, and there was no one left to speak up for me.

Somebody owns the machines. If the person/group that owns the machines isn't getting paid, it's dangerous to think where they might supplant their income from (especially in a time of oversaturation).

ASTRO is lobbying for what's in the best interest of giant hospitals and corporations. That's why you're never going to see them turn down or reverse residency expansion until this field becomes competitive to only IMGs/FMGs (again).

In most large hospitals, there is separation between technical/professional i.e urologist and the robot- hospital looses several thousand dollars per case, but the urologists still gets his fee (BTW we almost have as many radonc as urology slots.)
Why would ASTRO care once the field becomes overwhelmingly FMGs, pathology certainly didnt. I am hoping when enough of us become resentful about being forced into fellowships or jobs in the middle of nowhere, while radiation fractionation declines, sentiment on technical fees will change.

Regarding post above: you dont believe in supply/demand? Do you need randomized evidence that the doubling residency slots while increasing hypofractionation wont affect salaries or job opportunities?

 

[Corgi4Prez]

Regarding post above: you dont believe in supply/demand? Do you need randomized evidence that the doubling residency slots while increasing hypofractionation wont affect salaries or job opportunities?

Im not sure if this was directed at my question, but no I dont need randomized evidence. I was asking about data that is already being collected for other reasons. Also, everyone keeps talking about hypofractionation and there is data on that too. While I agree we will get there, it is not being adopted as quickly as people's arguments make it sound. Its not wrong to look at data that is already available when thinking about these changes to the field.

 

[RickyScott]

I am not sure about evidence, but certainly when I graduated 15 years ago, yearly,there where always jobs available in almost any city: NYC,LA,SF- (although not all paid well) Regarding hypofractionation: I dont think it has been widely adopted outside of academics, and to me that is a concern, because when it is forced upon us, there will be a lot of pain.

 

[evilbooyaa]

In most large hospitals, there is separation between technical/professional i.e urologist and the robot- hospital looses several thousand dollars per case, but the urologists still gets his fee (BTW we almost have as many radonc as urology slots.)
Why would ASTRO care once the field becomes overwhelmingly FMGs, pathology certainly didnt. I am hoping when enough of us become resentful about being forced into fellowships or jobs in the middle of nowhere, while radiation fractionation declines, sentiment on technical fees will change.

Regarding post above: you dont believe in supply/demand? Do you need randomized evidence that the doubling residency slots while increasing hypofractionation wont affect salaries or job opportunities?

The last time ASTRO closed a bunch of residencies was in the 90's when IMGs/FMGs were not uncommon in residency programs, right? I remember reading an article from that time that makes it seem like this field has not learned in anyway from its prior mistakes.

 

[Corgi4Prez]

I am not sure about evidence, but certainly when I graduated 15 years ago, yearly,there where always jobs available in almost any city: NYC,LA,SF- (although not all paid well) Regarding hypofractionation: I dont think it has been widely adopted outside of academics, and to me that is a concern, because when it is forced upon us, there will be a lot of pain.

Yeah, I agree. I think the concerns are valid, really was just curious about starting salaries since they do that survey every year.

 

[RickyScott]

The last time ASTRO closed a bunch of residencies was in the 90's when IMGs/FMGs were not uncommon in residency programs, right? I remember reading an article from that time that makes it seem like this field has not learned in anyway from its prior mistakes.

ASTRO was led by different people and economics where different. Today, you have a sprawling medical complex with a central academic department surrounded by satellites, and hospitals that are more reliant on radiation department as a source of profit (back then we were in the basement and ignored). I would argue that in the big picture, the increase in technical fees that accompanied imrt (lets go out and buy up satellites) and led to our present situation is detremental to our employment. (certainly it led to widespread consolidation and the rise of vantage/21 century etc)

 

[BobbyHeenan]

Lots of MIPS stuff in there.

The ASTRO take is in line with my experience in our group - spend lots of time and money to get a good MIPS score then see the final pay out and we barely broke even...and patient care didn't improve one bit but my time away from clinic/family sure took a hit.

 

[OTN]

I am not sure about evidence, but certainly when I graduated 15 years ago, yearly,there where always jobs available in almost any city: NYC,LA,SF- (although not all paid well) Regarding hypofractionation: I dont think it has been widely adopted outside of academics, and to me that is a concern, because when it is forced upon us, there will be a lot of pain.

Our (very large) group has moved almost exclusively to hypofractionation for breast. Huge urorads practice in town, so no opportunity for us with respect to prostate, but I have started doing prostate SBRT for low- and intermediate-risk patients.

 

[medgator]

Our (very large) group has moved almost exclusively to hypofractionation for breast. Huge urorads practice in town, so no opportunity for us with respect to prostate, but I have started doing prostate SBRT for low- and intermediate-risk patients.

I hypofx but my older partners rarely do in breast. I bet uptake of hypofx is inversely correlated with age/time out from training

 

[RickyScott]

I dont think the median salary in private/nonacademic practice has changed much since early 2000s before imrt started becoming increasingly widespread and technical revenue soared , so I am not sure why it should change with cuts to the present technical component. Salaries (and pretty much everything) are set by supply and demand. Thats why Stanford can offer 100k for 2 yr thoracic fellowship/instructor and they will have plenty of takers. Lower technical fees would incentive universities/large programs to retreat back to their main campus, and dispense with the satellites and expanding residencies. In the long game, the lower fees could benefit the field.

The fact that ASTRO will vigorously protest any move to eliminate reimbursement for protons in low risk prostate, but is complicit with residency expansion/over supply really casts them as an adversary to our professional interests. Our salaries are set by how readily replaceable we are.

 

[Irradi8or]

https://www.astro.org/ASTRO/media/ASTRO/News and Publications/PDFs/MPFSQPPProposedRuleCommentLetter.pdf

A few points:

1. CMS has used a third-party contractor (StrategyGen) to estimate the price of various pieces of radiation equipment. This has led to highly dubious estimates as to the cost of an SBRT/SRS platform ($900k!), HDR afterloading units, IMRT treatment planning systems, and dedicated brachy vaults.

2. CMS has bundled E/M codes for various internal medicine specialties but Rad Onc seems to have been included inadvertently. Most of our visits are level 4/5 in complexity.

3. CMS is still considering the Rad Onc specific APM recommended by ASTRO - this needs to be approved as other APMs clearly do not apply to our specialty.

Point #2 not quite true. Proposed E/M changes (collapsing levels 2-5 to a single blended rate of approx 3.6) are for all E/M coding throughout all of medicine. Rad Onc being included is not inadvertent. However, there was some clarification needed since additional G codes could be added to the blended E/M code depending upon visit complexity or prolonged vists (which would help to offset some of the E/M cuts we would see from our typical level 4/5 vs the lower blended rate). Rad Onc was not explicitly listed on the initial proposal as a specialty that could use these add on G codes, but it was later clarified that there were no specialty-specific restrictions for using the add on G codes. However, such G codes will add a different level of coding complexity that was unintended from the initial simplification.

 

[nguyencuong9102]

They came for the technical fees, and I didn't speak up because I didn't get a cut of the technical fees.

 

[medgator]

They came for the technical fees, and I didn't speak up because I didn't get a cut of the technical fees.

That's pretty much what ASTRO did to freestanding centers the last decade+

 

[Irradi8or]

That's pretty much what ASTRO did to freestanding centers the last decade+

The PAMPA 2015 G code freeze (I.e. for G6015) however has helped stabilize payments over the last couple of years. I'm apprehensive about what happens should the PAMPA G code freeze totally expire, and the previously discussed cuts are triggered. Even more is if we don't quite have an APM model to go to to qualify for an advanced APM.

 

[RickyScott]

That's pretty much what ASTRO did to freestanding centers the last decade+

My overall point is that technical reimbursement has much less to do with salary than supply of radiation oncologists/doubling of residency slots, which ASTRO implicitly condones. Again, how much did mean salaries in private practices increase with the windfall from imrt starting in the early 2000s? There are just about zero jobs (for several years) where I practice (3 sport team city), and if one opened up, the salary would reflect supply/demand, regardless of technical fees.

The high technical fees that started with IMRT led to vertical integration: urorads, 21 century buying up urologists, and medical oncologists, universities expanding satellites, etc. The trend is undeniably vertical integration, with ensuing employment type models where salary and mobility are set by supply. Its been years since since the number of employed docs in this field crossed over to become the majority.

ASTRO is actively working against most of our interests. It largely represents the economic interests of chairmen- who are increasingly just mid-level hospital administrators who employ the rest of us. I see the outrage of residents regarding the written boards (which is natural), but in hindsight this will be an annoying blip in their careers. ASTRO is really damaging their lifelong salaries and mobility.