ASTRO ROCR Town Hall

[Gfunk6]

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I've been on for most of this town hall. A few key points that ASTRO reiterated:

* ROCR is way better than the old Radiation Oncolgy Model that was previosly proposed.
* ROCR is not perfect by any means, but because we had to please a lot of people this is the best we could do.
* We are all screwed if this doesn't pass - doubly so for freestanding centers.
* The quality metrics that were rolled into ROCR (e.g. be certified by APEX, ACR, etc.) are much better that the old MIPS requirement that were largely meaningless.

Thoughts?

 

[TheWallnerus]

I've been on for most of this town hall. A few key points that ASTRO reiterated:

* ROCR is way better than the old Radiation Oncolgy Model that was previosly proposed.
* ROCR is not perfect by any means, but because we had to please a lot of people this is the best we could do.
* We are all screwed if this doesn't pass - doubly so for freestanding centers.
* The quality metrics that were rolled into ROCR (e.g. be certified by APEX, ACR, etc.) are much better that the old MIPS requirement that were largely meaningless.

Thoughts?

I suppose whether a medical student should choose to go into rad onc or not essentially totally hinges on whether congress passes ROCR. I mean, we are “all screwed” or aren’t we, ASTRO?

 

[RickyScott]

Even if ROCR were fantastic, circumventing cms via congress with reimbursement rules for a niche specialty would set a horrible precedent for the rest of medicine. I just can’t see how it could ever pass.

 

[Chartreuse Wombat]

Even if ROCR were fantastic, circumventing cms via congress with reimbursement rules for a niche specialty would set a horrible precedent for the rest of medicine. I just can’t see how it could ever pass.

I am very skeptical of any claims by ASTRO that they have the political clout to bring this about. This is not on the radar of most politicians.

 

[RickyScott]

I am very skeptical of any claims by ASTRO that they have the political clout to bring this about. This is not on the radar of most politicians.

But even if Astro were competent and had clout, wouldn’t this open the doors for every specialty to try pork barrelling?
Btw: the previous grifting Astro ceo probably knew a s storm was on the horizon, and promptly retired.

 

[communitydoc13]

wouldn’t this open the doors for every specialty to try pork barrelling

There is definitely input from the AMA, and Wallner talked about the efforts to establish coding standards for our field 40 years ago.

I think the move from this HHS head will be to not welcome input from providers at all.

RFK Jr. wants to change how Medicare pays doctors

Robert F. Kennedy Jr., President-elect Donald Trump's pick to lead HHS, is reportedly exploring a proposal that would minimize the role played by the American Medical Association in determining what Medicare pays for medical services. Here's what you need to know.

www.advisory.com

Buckle up.

 

[DebtRising]

I don’t understand how payments per patient instead of payment per services prevents further cuts. They can just cut the per patient rate until practices cut as many corners as possible to stay afloat?

It made more sense when APM had us targeted arbitrarily.

In 2020 total CMS spending on radiation services was $4.3 billion. In 2020 total CMS spending on Keytruda only was $3.6 billion. Both can be verified through simple searches. Just keytruda. Need ROCR for immunotherapy. Urorads replaced by Immunopal.

 

[NotMattSpraker]

I suppose whether a medical student should choose to go into rad onc or not essentially totally hinges on whether congress passes ROCR. I mean, we are “all screwed” or aren’t we, ASTRO?

Great point.

Not surprising but disappointed at how this went.

We will have adaptive codes now with some double dip billing weirdness icing on top. This is a big deal for the field, we've never had adaptive codes. Submitted without public comment, then announced. Nice.

 

[thesauce]

I suppose whether a medical student should choose to go into rad onc or not essentially totally hinges on whether congress passes ROCR. I mean, we are “all screwed” or aren’t we, ASTRO?

Right. If it doesn’t pass, then all training programs must immediately shut down. We need to hold Astro to that.

 

[thesauce]

Great point.

Not surprising but disappointed at how this went.

We will have adaptive codes now with some double dip billing weirdness icing on top. This is a big deal for the field, we've never had adaptive codes. Submitted without public comment, then announced. Nice.

I must have missed this. What was announced re: adaptive?

 

[OTN]

It is such an ASTRO thing to spend political capital, energy, and effort to fight for a code which has no good clinical data to back it up but is loved by the neophiles at academic institutions.

 

[medgator]

It is such an ASTRO thing to spend political capital, energy, and effort to fight for a code which has no good clinical data to back it up but is loved by the neophiles at academic institutions.

Just like fighting against physician ownership of linacs a decade ago. Very ASTRO

 

[drowsy12]

Breaking news: ROCR Act of 2025 reintroduced in Congress​

Yesterday, Sens. Thom Tillis (R-N.C.), and Gary Peters (D-Mich.) introduced the ASTRO-led Radiation Oncology Case Rate (ROCR) Value Based Payment Program Act (S. 1031), which would protect access to high quality cancer care and improve outcomes for patients nationwide. A bipartisan companion bill led by Reps. Brian Fitzpatrick (R-Pa.), Jimmy Panetta (D-Calif.), John Joyce, MD (R-Pa.) and Paul Tonko (D-N.Y.) was introduced today in the House. The ROCR Act is broadly supported by more than 80 organizations and is designed to stabilize payments after Medicare reimbursement cuts to radiation oncology of 25% since 2013. ASTRO applauds the bipartisan leadership of radiation oncology’s Senate and House champions. Read more in ASTRO’s release and the section-by-section summary.

Key features of the ROCR Act of 2025 include:

• Patient specific episode-based payments that align financial incentives with guideline-driven care supported by science
• Encouraging the adoption of evidence-based shorter treatments when they are clinically determined to be in the patient's best interest, minimizing physical and financial burdens on patients
• Strengthening quality and safety standards by incentivizing practice accreditation and supporting new technologies for patient care
• Targeted support to tackle transportation barriers that keep patients from completing their radiation treatments
• Unifying technical payments across hospital and freestanding/community practice settings

What you can do:

1. Contact your representative and senators to cosponsor the ROCR Act today to advance it through Congress this year.
2. Join the more than 80 organizations representing small and large hospital systems, independent clinics, patient advocates, health professionals and technology companies that support ROCR by filling out the ROCR Support Form.

If you missed last night's ROCR Town Hall, a recording is available to members (login required) on the ASTRO website.

 

[thesauce]

Good know. I'll reach out to my representative again to oppose this.

 

[TheWallnerus]

#OffTheirROCR

 

[Gfunk6]

Other than proton exemption, which I also oppose, I'm curious to understand what else you guys have against this bill?

 

[medgator]

Other than proton exemption, which I also oppose, I'm curious to understand what else you guys have against this bill?

No site neutrality right? I think brachy is carved out but not sure that's enough to help that modality which is sorely in need of it

 

[Fpg1245]

Good know. I'll reach out to my representative again to oppose this.

Unlike most other specialty led initiatives I can’t use the template and submit directly

Also the brachy carve out is marginal compared to the glaring exemptions.

 

[TheWallnerus]

Other than proton exemption, which I also oppose, I'm curious to understand what else you guys have against this bill?

It’s a good example of a deal with the devil, mostly

 

[drowsy12]

It’s a good example of a deal with the devil, mostly

Did you call Thom Tillis?

 

[thesauce]

Other than proton exemption, which I also oppose, I'm curious to understand what else you guys have against this bill?

That's a huge one. Also the centers that created the bill are excluded from it.

 

[medgator]

That's a huge one. Also the centers that created the bill are excluded from it.

Yeah PPS exempt continued to be exempt

 

[OTN]

Yeah PPS exempt continued to be exempt

If it were such a good deal and so critical to the future of the specialty, why would the architects of ROCR exclude themselves from the program?

 

[drowsy12]

A. Equating the architects of the ROCR with 13 (is it 13, I don’t even know. Something like that) PPS exempt cancer centers at large is just not accurate.

B. If it helps everyone else who cares if groups that already have their own rules continue to have their own rules?


I would like to see more discussion of the new policy itself. This is a massive and seemingly likely change coming that will effect us all. If SDN can’t discuss this then they shouldn’t be considered a premiere discussion hub for rad oncs.

It seems to me pointless and fruitless to continue to focus so much attention on minority of working rad oncs when the rest of us are going to be affected by this?

PPS exemption is a totally separate topic and is not going away right now. Bottom line. It’s been around for like 40 years!

I also have no problem with adaptive codes. Seems short sighted to be upset about it? I’m young in my career. Maybe older folks won’t be around long enough to benefit?

Rad onc has never ever stayed the same and im open minded about what the future will entail, even outside of the academic sphere in terms of technology. It seems very likely that adaptation of some sort will become common.

 

[CurbYourExpectations]

Have only peripherally paid attention to the ROCR stuff. Safe to assume having patients get an average of 30-35 fractions is more lucrative than the ROCR payment distribution? It seemed like the large busy PP group in the East were proponents of switching to ROCR.

 

[RickyScott]

I am aware of many satellites, small clinics that have around 20 pts on treatment. With rocr, this will come down by 25-50% and these clinics will only be open for several hours. A Lot of radoncs will become part time or supervise multiple clinical. It will kill the job market.

If my rvus don’t drop, but I am done at 12, the hospital will make me part time, and the job market will allow them to get away with it.
Also any department within 30 miles of a proton center will be an acquisition target since the center will now be more valuable as a feeder to the proton center than its present owners.

 

[drowsy12]

I am aware of many satellites, small clinics that have around 20 pts on treatment. With rocr, this will come down by 25-50% and these clinics will only be open for several hours. Lot of radoncs will become part time or supervise multiple clinical. It will kill the job market.

If my rvus don’t drop, but I am done at 12, the hospital will make me part time, and the job market will allow them to get away with it.

so in this ridiculous hypothetical, you would willingly convert all your patient schedules to as short as possible when there's a threat (?) of that forcing you to go part time?

come on, man.

 

[thesauce]

so in this ridiculous hypothetical, you would willingly convert all your patient schedules to as short as possible when there's a threat (?) of that forcing you to go part time?

come on, man.

It’s the only way to compete. Every center will decrease fractions and you’ll be the odd one out still giving 28 fx for prostate.

If you work for a hospital system, word will get out and you’ll be forced into conformity. I’ve seen this in a lot of hospital systems such as Providence.

Not to mention that incentivizing the most toxic courses is probably the stupidest thing we could do as a field. But at least we’ll save some money on rad tech labor costs 🙂

 

[RickyScott]

I don’t think 5 fraction partial breast or prostate is any more toxic. I use them judiciously for obvious reasons. Out satellite load is in the high teens to low 20s at a satellite, and we finish before 2

 

[madchemist89]

Does anyone have an opposition letter that we could use to send to our representative?

 

[Tumorinator]

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No site neutrality right? I think brachy is carved out but not sure that's enough to help that modality which is sorely in need of it

ROCR is site-neutral. It’s a lifeline for freestanding that would slow consolidation

 

[Fpg1245]

This is already happening in major metro markets in the northeast. It’s a race to the bottom.

 

[Tumorinator]

Caveat being that ROCR generally pays accredited practices a little more

 

[RickyScott]

Caveat being that ROCR generally pays accredited practices a little more

Have you head of insurance companies? They pay rates negotiated by the health system responsible for the extreme differences in reimbursement that drives consolidation, and rocr will not touch this. If anything, by excluding protons, rocr will encourage proton centers to acquire nearby satellites as those nearby centers will be more valuable to the organizations with protons vs their present operators.

 

[A_DeMichele]

which centers are carved out, again?

 

[RickyScott]

which centers are carved out, again?

Protons and pps exempt centers

 

[thesauce]

Does anyone have an opposition letter that we could use to send to our representative?

Yes. PM me.

 

[RickyScott]

Yes. PM me.

Why not just make it available as its own thread ?

 

[Tumorinator]

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Have you head of insurance companies? They pay rates negotiated by the health system responsible for the extreme differences in reimbursement that drives consolidation, and rocr will not touch this. If anything, by excluding protons, rocr will encourage proton centers to acquire nearby satellites as those nearby centers will be more valuable to the organizations with protons vs their present operators.

Insurance rates are often negotiated using Medicare rates as the starting point (eg [emoji[emoji[emoji6]][emoji[emoji6][emoji6]]][emoji[emoji[emoji6][emoji6]][emoji[emoji[emoji6]][emoji[emoji6]]]][emoji[emoji[emoji6]][emoji[emoji6]]]% of Medicare), and site neutral CMS payments would have positive downstream effects with insurers for freestanding sites. I don’t like the proton exclusion either (or the PPS one)

 

[SneakyBooger]

Not to mention that incentivizing the most toxic courses is probably the stupidest thing we could do as a field. But at least we’ll save some money on rad tech labor costs 🙂

PACE-A recently reported 6.6% rate of incontinence at 2 yrs with SBRT for prostate. Incontinence was defined as wearing at least 1 pad per day.

That is way too high compared to standard fractionation.

 

[RickyScott]

PACE-A recently reported 6.6% rate of incontinence at 2 yrs with SBRT for prostate. Incontinence was defined as wearing at least 1 pad per day.

That is way too high compared to standard fractionation.

I definitely see more side effects with sbrt. Reminds me of when we were told short course rectal xrt is equivalent, fine; but it wasn’t.

 

[drowsy12]

Reminds me of when we were told short course rectal xrt is equivalent, fine; but it wasn’t.

yeah this is a really weird/strange/unfortunate way at looking at the rectal cancer short course data.

Wish you the best.

 

[thesauce]

yeah this is a really weird/strange/unfortunate way at looking at the data.

Wish you the best.

Well since you seem to be a little bit better at this, can you please tell us why you believe that prostate SBRT with an incontinence rate of 7% is good?

 

[RickyScott]

Well since you seem to be a little bit better at this, can you please tell us why you believe that prostate SBRT with an incontinence rate of 7% is good?

2 of my first 10 pts have severe dyruria 3 months out.

 

[Doctorer]

yeah this is a really weird/strange/unfortunate way at looking at the rectal cancer short course data.

Wish you the best.

Maybe his glib comment lacked some nuance, but it's not too far off from the truth.

Good luck!

 

[drowsy12]

Maybe his glib comment lacked some nuance, but it's not too far off from the truth.

Good luck!

Fair enough. Not worth arguing.

 

[medgator]

yeah this is a really weird/strange/unfortunate way at looking at the rectal cancer short course data.

Wish you the best.

Opra study showed worse control outcomes with short course did it not?

 

[RickyScott]

Opra study showed worse control outcomes with short course did it not?

some pts end up in the er with acute proctitis 2 weeks later

 

[OTN]

I haven't noticed an increase in incontinence in my SBRT patients- my experience has more been in line with PACE-B rather than PACE-A. Data does show that fractionated radiation also causes incontinence as well, and at least in that prospective dataset it seems to be closer to PACE-B results, though the fractionated study doesn't break it down exactly like the PACE data does.

SBRT does cause a spike in urinary toxicity for the 6 weeks after completion of treatment, just like brachytherapy. However, in my experience the symptoms reliably return to baseline/what I would expect with fractionated treatment.

Very, very few GI symptoms in either the short- or long-term. I do not advocate for the SpaceOAR, do not place it, but I'm perfectly fine treating with it in place if someone else wants to light that candle.

 

[thesauce]

I haven't noticed an increase in incontinence in my SBRT patients- my experience has more been in line with PACE-B rather than PACE-A. Data does show that fractionated radiation also causes incontinence as well, and at least in that prospective dataset it seems to be closer to PACE-B results, though the fractionated study doesn't break it down exactly like the PACE data does.

SBRT does cause a spike in urinary toxicity for the 6 weeks after completion of treatment, just like brachytherapy. However, in my experience the symptoms reliably return to baseline/what I would expect with fractionated treatment.

Very, very few GI symptoms in either the short- or long-term. I do not advocate for the SpaceOAR, do not place it, but I'm perfectly fine treating with it in place if someone else wants to light that candle.

I've seen some very severe complications from SBRT requiring multiple procedures and even surgeries.

But the acute effects that are higher (which we can all agree on) are completely unnecessary when they have the alternative of standard frac with which these issues are essentially non-existent. Better they come a few more times and skip the toxicity altogether and are happy and tell their friends what a great option RT is. Instead they say how much better it would be with protons since they are comparing it with SBRT, when it was only the fractionation that made a difference.

Convenience as the primary oncologic endpoint (which is almost every trial run in the last 10 years) has gotten entirely out of hand. One of these days (if we survive as a field) we'll get back to actually trying to improve REAL oncologic outcomes.