ASTRO: Murses/Midhusbands Can Now Supervise Radiation

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TheWallnerus

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In the words of one of the great poets "Everybody's runnin', but half of them ain't lookin'; it's goin' on in the kitchen, but I don't know what's cookin'." I didn't see this one on the stovetop let me just be the first to admit. The murses and midhusbands can now supervise the radiotherapying completely. I'm reading it in black & white from ASTRO:

"In the 2021 MPFS final rule, CMS is finalizing policy revisions related to the scope of practice for physician fee schedule services that would allow [nurse practitioners, certified nurse specialists, physician assistants, certified nurse midhusbands/midwives] to provide the appropriate level of supervision assigned to [IGRT], to the extent authorized under State law and scope of practice. In accordance with statute, these [non-physician practitioners] would be working either under physician supervision or in collaboration with a physician. According to CMS, this flexibility is designed to increase the capacity and availability of practitioners who can supervise [IGRT], which would alleviate some of the demand on physicians as the only source to perform this specific function.

ASTRO provided CMS with comments expressing concern about patient safety related to this policy. ASTRO has long expressed that the existing supervision levels associated with IGRT services (i.e., codes G6001 (previously 76950), 77014, G6002 (previously 77421), and 76965) should remain in place and require the physician’s presence and participation due to the irreversible nature of radiation therapy. Despite these concerns, the Agency did not feel compelled to change the scope of practice policy for 2021."


My how the specialty of therapeutic radiology, my beloved specialty, has changed in just the last couple of years. I was having some of the minions here do some Googling and the Student Doctor's page on this appears right near the top. (I love time capsuling. It makes me feel young.) Here's what people were saying in 2019 when supervision changed direct to general:

"Bottom line, you want to be as busy as possible with consults, planning and otvs, and you don't need to be physically present for the daily professional igrt charges is how I interpret it. THis is my understanding."

"From my first glance this seems like a seismic shift in language from CMS on this issue - which used to be kind of gray - seeming to give more of an endorsement to mid level coverage. I have this exact scenario - hospital based pro group - and it presents a major change potentially for our group and our multiple hospital based centers."

"'That’s it folks - we are ****ed. Those 150 kids in the match this year should get out while they still can.' You know, it's hard to say that's hyperbole, because I don't see how this ends well for anyone getting out of training now.... We may need <100 graduating residents from here on out assuming CMS follows through with the plan to change things from Direct to General supervision in hospital based RO."

"If that includes freestanding one day, we'll need even less. You won't need locums if you have another partner around, even if they are in a different center, geographically."

Later, ASTRO came out and said (regarding IGRT) that the changes were "more limited than they appear." Toss all that dissembling out the window because CMS just comes right back and is like "Yeah, sorry, they are not limited."

Fortunately I can report based on my ears on the ground and spies that there is still some pretty reliable and predictable ignoring of reality for the time-being. Ignoring reality is of course most therapeutic radiology leaders' favorite pastime. Let's hope it stays this way. For your sake.

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ASTRO ALSO nearly simultaneous requested that the relaxed rule be applied to free standing clinics as well when the pandemic hit.

Literally requested that the practices they, themselves deemed a "threat to patient safety" like two months before be more broadly applied.
 
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In the words of one of the great poets "Everybody's runnin', but half of them ain't lookin'; it's goin' on in the kitchen, but I don't know what's cookin'." I didn't see this one on the stovetop let me just be the first to admit. The murses and midhusbands can now supervise the radiotherapying completely. I'm reading it in black & white from ASTRO:

"In the 2021 MPFS final rule, CMS is finalizing policy revisions related to the scope of practice for physician fee schedule services that would allow [nurse practitioners, certified nurse specialists, physician assistants, certified nurse midhusbands/midwives] to provide the appropriate level of supervision assigned to [IGRT], to the extent authorized under State law and scope of practice. In accordance with statute, these [non-physician practitioners] would be working either under physician supervision or in collaboration with a physician. According to CMS, this flexibility is designed to increase the capacity and availability of practitioners who can supervise [IGRT], which would alleviate some of the demand on physicians as the only source to perform this specific function.

ASTRO provided CMS with comments expressing concern about patient safety related to this policy. ASTRO has long expressed that the existing supervision levels associated with IGRT services (i.e., codes G6001 (previously 76950), 77014, G6002 (previously 77421), and 76965) should remain in place and require the physician’s presence and participation due to the irreversible nature of radiation therapy. Despite these concerns, the Agency did not feel compelled to change the scope of practice policy for 2021."


My how the specialty of therapeutic radiology, my beloved specialty, has changed in just the last couple of years. I was having some of the minions here do some Googling and the Student Doctor's page on this appears right near the top. (I love time capsuling. It makes me feel young.) Here's what people were saying in 2019 when supervision changed direct to general:

"Bottom line, you want to be as busy as possible with consults, planning and otvs, and you don't need to be physically present for the daily professional igrt charges is how I interpret it. THis is my understanding."

"From my first glance this seems like a seismic shift in language from CMS on this issue - which used to be kind of gray - seeming to give more of an endorsement to mid level coverage. I have this exact scenario - hospital based pro group - and it presents a major change potentially for our group and our multiple hospital based centers."

"'That’s it folks - we are ****ed. Those 150 kids in the match this year should get out while they still can.' You know, it's hard to say that's hyperbole, because I don't see how this ends well for anyone getting out of training now.... We may need <100 graduating residents from here on out assuming CMS follows through with the plan to change things from Direct to General supervision in hospital based RO."

"If that includes freestanding one day, we'll need even less. You won't need locums if you have another partner around, even if they are in a different center, geographically."

Later, ASTRO came out and said (regarding IGRT) that the changes were "more limited than they appear." Toss all that dissembling out the window because CMS just comes right back and is like "Yeah, sorry, they are not limited."

Fortunately I can report based on my ears on the ground and spies that there is still some pretty reliable and predictable ignoring of reality for the time-being. Ignoring reality is of course most therapeutic radiology leaders' favorite pastime. Let's hope it stays this way. For your sake.

that is awful but unfortunately a growing trend in medicine

California passed NP scope of practice bill recently = end of PCP

Physicians need to step up and recognize their worth

I just can’t get over that I have to spend 4 yrs med school & 5 years residency to be “eligible” to say femur properly aligned

while others can just “learn on the fly”
 
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ASTRO ALSO nearly simultaneous requested that the relaxed rule be applied to free standing clinics as well when the pandemic hit.

Literally requested that the practices they, themselves deemed a "threat to patient safety" like two months before be more broadly applied.
Wallner's safety first, patient safety second! Safety is no accident.
 
In the words of one of the great poets "Everybody's runnin', but half of them ain't lookin'; it's goin' on in the kitchen, but I don't know what's cookin'." I didn't see this one on the stovetop let me just be the first to admit. The murses and midhusbands can now supervise the radiotherapying completely. I'm reading it in black & white from ASTRO:

"In the 2021 MPFS final rule, CMS is finalizing policy revisions related to the scope of practice for physician fee schedule services that would allow [nurse practitioners, certified nurse specialists, physician assistants, certified nurse midhusbands/midwives] to provide the appropriate level of supervision assigned to [IGRT], to the extent authorized under State law and scope of practice. In accordance with statute, these [non-physician practitioners] would be working either under physician supervision or in collaboration with a physician. According to CMS, this flexibility is designed to increase the capacity and availability of practitioners who can supervise [IGRT], which would alleviate some of the demand on physicians as the only source to perform this specific function.

ASTRO provided CMS with comments expressing concern about patient safety related to this policy. ASTRO has long expressed that the existing supervision levels associated with IGRT services (i.e., codes G6001 (previously 76950), 77014, G6002 (previously 77421), and 76965) should remain in place and require the physician’s presence and participation due to the irreversible nature of radiation therapy. Despite these concerns, the Agency did not feel compelled to change the scope of practice policy for 2021."


My how the specialty of therapeutic radiology, my beloved specialty, has changed in just the last couple of years. I was having some of the minions here do some Googling and the Student Doctor's page on this appears right near the top. (I love time capsuling. It makes me feel young.) Here's what people were saying in 2019 when supervision changed direct to general:

"Bottom line, you want to be as busy as possible with consults, planning and otvs, and you don't need to be physically present for the daily professional igrt charges is how I interpret it. THis is my understanding."

"From my first glance this seems like a seismic shift in language from CMS on this issue - which used to be kind of gray - seeming to give more of an endorsement to mid level coverage. I have this exact scenario - hospital based pro group - and it presents a major change potentially for our group and our multiple hospital based centers."

"'That’s it folks - we are ****ed. Those 150 kids in the match this year should get out while they still can.' You know, it's hard to say that's hyperbole, because I don't see how this ends well for anyone getting out of training now.... We may need <100 graduating residents from here on out assuming CMS follows through with the plan to change things from Direct to General supervision in hospital based RO."

"If that includes freestanding one day, we'll need even less. You won't need locums if you have another partner around, even if they are in a different center, geographically."

Later, ASTRO came out and said (regarding IGRT) that the changes were "more limited than they appear." Toss all that dissembling out the window because CMS just comes right back and is like "Yeah, sorry, they are not limited."

Fortunately I can report based on my ears on the ground and spies that there is still some pretty reliable and predictable ignoring of reality for the time-being. Ignoring reality is of course most therapeutic radiology leaders' favorite pastime. Let's hope it stays this way. For your sake.
Is this for hospital based practices or both hospital and freestanding practices? I thought hospital based practices had already been changed to general supervision. Are they now considering changing the rules for freestanding as well? I can’t keep up.
 
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Is this for hospital based practices or both hospital and freestanding practices? I thought hospital based practices had already been changed to general supervision. Are they now considering changing the rules for freestanding as well? I can’t keep up.

1) In 2020, CMS changed all outpatient hospital therapies from direct to general.
2) In a unique twist, ASTRO claimed that image guided radiation therapy was not therapy (they have a nice history of this... e.g., they claimed that intensity modulated radiotherapy was not actually intensity modulated radiotherapy before) and was instead a diagnostic test! So instead of doing daily IGRT, patients get daily diagnostic tests? (https://www.astro.org/ASTRO/media/ASTRO/Daily Practice/PDFs/2020SupervisionGuidance.pdf)
3. In response, CMS one year later has said "No, even diagnostic tests... which means IGRT... can have non-physician supervision."
4. Superseding all this, even in freestanding centers, is the ability to have virtual, non-present supervision (due to COVID PHE) at least until Dec 31, 2021.
 
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Yes, this is a seismic shift and it is ludicrous to have graduating classes almost double the size of 10 years prior.

There really isn’t even anything to argue or opine about anymore - we have predatory leadership running out the clock on their own lucrative careers grinding the new team into the ground, while pumping out more new team members to provide cheap labor for the end of their reign. Field has many people who do compassionate, wonderful things for patients - but these same people would throw a new rad onc under the bus to pad their retirement without a second thought.
 
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I don't see this going away. The genie is out of the bottle.
If you look at ASTRO's initial take on direct-to-general in late 2019 and early 2020, time after time they would say something to the effect "We have reached out to 'the agency' *multiple times* for clarification." CMS said radiation was general and then ASTRO went back a hundred (exaggerating) times to get some gaslight-y technicalities nailed down where it really wasn't general. It was supervision only Schrödinger's cat could understand. But I would've loved to hear those discussions. In my mind, I think they went something like when a parent tells a child that they now have the freedom to do something they didn't before and an irksome sibling (let's call him ASTRO) cries "Yeah, but Dad... remember when you said" this, this, and this, blah, blah, blah. So later Dad just throws his hands up in the air and is like "Kids just do whatever the hell you want!" And then ASTRO-bro is again like "But Dad!" And Dad goes "for the love of God go away."
 
1) In 2020, CMS changed all outpatient hospital therapies from direct to general.
2) In a unique twist, ASTRO claimed that image guided radiation therapy was not therapy (they have a nice history of this... e.g., they claimed that intensity modulated radiotherapy was not actually intensity modulated radiotherapy before) and was instead a diagnostic test! So instead of doing daily IGRT, patients get daily diagnostic tests? (https://www.astro.org/ASTRO/media/ASTRO/Daily Practice/PDFs/2020SupervisionGuidance.pdf)
3. In response, CMS one year later has said "No, even diagnostic tests... which means IGRT... can have non-physician supervision."
4. Superseding all this, even in freestanding centers, is the ability to have virtual, non-present supervision (due to COVID PHE) at least until Dec 31, 2021.
Yes, I know of freestanding practices who are monitoring their patients through zoom with the docs going home after finishing patient visits.

I was wondering if remote monitoring would be a temporary or permanent change. But now it sounds like even in freestanding facilities only an NP will be needed? What a hit to the job market - another one. I have always found it odd that med oncs don’t necessarily need to be present to monitor infusion reactions but we need to be around for radiation treatments. It seems like we should both be around if patients are getting care.
 
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If you look at ASTRO's initial take on direct-to-general in late 2019 and early 2020, time after time they would say something to the effect "We have reached out to 'the agency' *multiple times* for clarification." CMS said radiation was general and then ASTRO went back a hundred (exaggerating) times to get some gaslight-y technicalities nailed down where it really wasn't general. It was supervision only Schrödinger's cat could understand. But I would've loved to hear those discussions. In my mind, I think they went something like when a parent tells a child that they now have the freedom to do something they didn't before and an irksome sibling (let's call him ASTRO) cries "Yeah, but Dad... remember when you said" this, this, and this, blah, blah, blah. So later Dad just throws his hands up in the air and is like "Kids just do whatever the hell you want!" And then ASTRO-bro is again like "But Dad!" And Dad goes "for the love of God go away."
ASTRO ignored the general supervision loophole at rural/critical access hospitals for over a decade. They had zero credibility when it came time to talk to CMS about their views. Just another day of amateur hour at ASTRO
 
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1+,

For a historical perspective (for those who are new to this thingy)...

- Back some 11-12 years ago, the fiasco from Melbourne FL happened...Some MDs were NOT even in the USA, they
were out of the country!

- The issue went all the way up Medicare, Congressional hearings back in those days...

- Not to defend for ASTRO, but in 2011 or so (forgot the exact year) ASTRO went the "knee-jerk" reflex way in terms of supervision.
I have friends in rural Kansas, rural Penn etc. complaining about this supervision rule, making it very difficult to care for their patients.

- ASTRO, being run mostly academic with enough coverage, ignores the solo (whether urban or rural) practice issues.
Then a few years later (maybe 2012-2013 or so), revised a bit with CAH (Critical Access Hospital) guidelines.
There are quite a few "White Papers" on this issue.

- CMS, in the mean time, has the data whether or not it is safe doing it the CAH's way. Once CMS has the CAH data, they say "screw ASTRO, this is what we think is right". Now ASTRO loses credibility.

- ASTRO should have had adequate presentation from critical access hosp and solo practices from the beginning...

Guess who calls the shot? It is CMS...
 
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1+,

For a historical perspective (for those who are new to this thingy)...

- Back some 11-12 years ago, the fiasco from Melbourne FL happened...Some MDs were NOT even in the USA, they
were out of the country!

- The issue went all the way up Medicare, Congressional hearings back in those days...

- Not to defend for ASTRO, but in 2011 or so (forgot the exact year) ASTRO went the "knee-jerk" reflex way in terms of supervision.
I have friends in rural Kansas, rural Penn etc. complaining about this supervision rule, making it very difficult to care for their patients.

- ASTRO, being run mostly academic with enough coverage, ignores the solo (whether urban or rural) practice issues.
Then a few years later (maybe 2012-2013 or so), revised a bit with CAH (Critical Access Hospital) guidelines.
There are quite a few "White Papers" on this issue.

- CMS, in the mean time, has the data whether or not it is safe doing it the CAH's way. Once CMS has the CAH data, they say "screw ASTRO, this is what we think is right". Now ASTRO loses credibility.

- ASTRO should have had adequate presentation from critical access hosp and solo practices from the beginning...

Guess who calls the shot? It is CMS...
Pretty sure that a radonc was in fact present, But images were approved remotely by billing doc remotely, which is quite common today. I am not going to answer if I have done the exact same.
 
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Pretty sure that a radonc was in fact present, But images were approved remotely by billing doc remotely, which is quite common today. I am not going to answer if I have done the exact same.

one of my recent employers forbade checking CBCT and plans while on vacay/CME time; another one allowed
 
anyone know if the certification groups have also changed their stance, ACR for example still stipulated the need for physician on site for all treatments, any clue if they also changed that
 
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Nope,

ACR accreditation still sings the same song as ASTRO, for now.
 
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Nope,

ACR accreditation still sings the same song as ASTRO, for now.
Genuine question.. why does ACR/Astro whatever accreditation matter? I’ve been through the ACR accreditation process and we’ve been accredited but I still don’t fully understand what the benefit was of having gone through it. The patients, at least in my area, have no clue about ACR. I’m pretty sure there’s no financial incentive. I don’t believe it reduces liability. I can’t say that it has affected our quality in any tangible way. What is the point? Just wondering. Same goes for CoC accreditation, ACS, whatever else the hospital chooses to fixate upon..
 
Genuine question.. why does ACR/Astro whatever accreditation matter? I’ve been through the ACR accreditation process and we’ve been accredited but I still don’t fully understand what the benefit was of having gone through it. The patients, at least in my area, have no clue about ACR. I’m pretty sure there’s no financial incentive. I don’t believe it reduces liability. I can’t say that it has affected our quality in any tangible way. What is the point? Just wondering. Same goes for CoC accreditation, ACS, whatever else the hospital chooses to fixate upon..
Probably good if you've got competition in the area
 
My understanding for diagnostic radiology Medicare Part B reimbursement requires ACR accreditation.
 
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I am in a competitive area. I have not found that ACR accreditation affects referral patterns or volumes at all.
None of it does. CoC has some value, IMO. It makes you actually examine your cancer program and improve it, but it's a lot of work.

Not sure any patient cares, but it sounds good. I'm fairly certain no patient cares one bit about ASTRO/ACRO/ACR accreditation for rad onc.
 
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It is almost like an ABR written/oral exam.

By the time you finish PGY-5, you should be competent enough to practise independent radonc even without
taking the ABR written/oral exam.
Does passing the ABR make you a better doc? No.

However, if you are a weak resident, the ABR pressure is good bc it forces you to read/study to become better.

Do referring MDs care if you are certified by ABR? No.

Sorry about my analogy, but it is something you guys/girls can relate to...
 
It is almost like an ABR written/oral exam.

By the time you finish PGY-5, you should be competent enough to practise independent radonc even without
taking the ABR written/oral exam.
Does passing the ABR make you a better doc? No.

However, if you are a weak resident, the ABR pressure is good bc it forces you to read/study to become better.

Do referring MDs care if you are certified by ABR? No.

Sorry about my analogy, but it is something you guys/girls can relate to...
Hospitals and (some) insurance companies do though... Not quite the same thing imo
 
Genuine question.. why does ACR/Astro whatever accreditation matter? I’ve been through the ACR accreditation process and we’ve been accredited but I still don’t fully understand what the benefit was of having gone through it. The patients, at least in my area, have no clue about ACR. I’m pretty sure there’s no financial incentive. I don’t believe it reduces liability. I can’t say that it has affected our quality in any tangible way. What is the point? Just wondering. Same goes for CoC accreditation, ACS, whatever else the hospital chooses to fixate upon..

Have heard that some form of accreditation may be required for certain contracts like the VA.
 
Some ~ ten (10) years ago, yes ACR accreditation required for VA contract bc of the VA prostate brachy fiasco in Philly.
Now, no need for ACR accreditation ever since VA goes to Health Net...
 
Some ~ ten (10) years ago, yes ACR accreditation required for VA contract bc of the VA prostate brachy fiasco in Philly.
Now, no need for ACR accreditation ever since VA goes to Health Net...
The va authorizations we get do mention requesting an acr accredited facility on the document... I'll take a closer look next time i see one
 
I have seen VA pts being treated in rural Kansas hospitals with no ACR accreditation.
 
There is a difference between treating VA patients through a community care referral (open to anyone) and having a contractual agreement with them to be their primary radiation oncology service line provider. I had heard that accreditation is required for the latter but cannot say I have personally vetted this.
 
Wasn't there something in APM about getting a 5% bonus if being a center of quality? Or the other way around - if not a center of excellence, then 5% less reimbursement? I thought I heard someone tell me one of those.

If not, I'm sure quality metrics will some how be tied into RO reimbursements at some point like Medicare and ACR accreditation for diagnostics. Gov't loves looking at quality metrics! I remember during my VA rotation that they were all about metrics!
 
1+,

For a historical perspective (for those who are new to this thingy)...

- Back some 11-12 years ago, the fiasco from Melbourne FL happened...Some MDs were NOT even in the USA, they
were out of the country!

- The issue went all the way up Medicare, Congressional hearings back in those days...

- Not to defend for ASTRO, but in 2011 or so (forgot the exact year) ASTRO went the "knee-jerk" reflex way in terms of supervision.
I have friends in rural Kansas, rural Penn etc. complaining about this supervision rule, making it very difficult to care for their patients.

- ASTRO, being run mostly academic with enough coverage, ignores the solo (whether urban or rural) practice issues.
Then a few years later (maybe 2012-2013 or so), revised a bit with CAH (Critical Access Hospital) guidelines.
There are quite a few "White Papers" on this issue.

- CMS, in the mean time, has the data whether or not it is safe doing it the CAH's way. Once CMS has the CAH data, they say "screw ASTRO, this is what we think is right". Now ASTRO loses credibility.

- ASTRO should have had adequate presentation from critical access hosp and solo practices from the beginning...

Guess who calls the shot? It is CMS...

Maybe someone who posts here all the time knows a bit more about that incident 11-12 years ago?
 
That incident 11-12 years ago went all the way up The Dept of Justice.
This serves as a warning for facilities abusing IMRT...

---

 
That incident 11-12 years ago went all the way up The Dept of Justice.
This serves as a warning for facilities abusing IMRT...

---

Abusing IMRT. That sounds horrible. Is that like abusing alcohol. Child abuse? Can IMRT get free counselling? Will IMRT get its own TV special one day? Maybe it's like treating every single patient that walks in the door at a proton center with proton therapy no matter the diagnosis. I hear that protons have formed a support group. They're fed up and not gonna take our s**t anymore.
 
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Abusing IMRT. That sounds horrible. Is that like abusing alcohol. Child abuse? Can IMRT get free counselling? Will IMRT get its own TV special one day? Maybe it's like treating every single patient that walks in the door at a proton center with proton therapy no matter the diagnosis. I hear that protons have formed a support group. They're fed up and not gonna take our s**t anymore.
Or treating every single patient at 5-10 x CMS prices.
 
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