ASTRO Town Hall Discussion (Poll % on site)

[thecarbonionangle]

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Oh... this is telehealth. Not direct virtual supervision per se. They sort of dovetail but mostly not.

Yeah but for example places like MSK would love to do tele for surrounding states (NY, CT,NJ, etc etc) and if telesupervision is widely kosher they will expand on this, i suspect.

I imagine a place like NYP center doing tele all over, could easily supervise remote areas and funnel patients to protons PRN.

 

[medgator]

Agreed, telesupervision will be worse for RadOncs than anything we've seen before.

Hasn't this been the law of the land since 2020?

 

[NotJasonBeckta]

I have no clue what started the need for the letter. And I also don't know who actually has the ear of CMS. Seemingly the people that are most involved (again, maybe this is just conjecture based on social media) are ASTRO, Ron, Jordan/Bridge, and ACRO.

I would argue no other "outsider" (separate from ASTRO or some big letter organization) knows the history (not immediately related to the letter, just the history of supervision) on this issue better than Jason Bekta though.

*best Lurch impression*

"You rang?"

I genuinely don't believe there's a singular narrative/"red thread" that brought us to this point.

However, what's happening now is exactly what I expected would have happened in 2020 if the pandemic hadn't taken place.

What's lost in this conversation is the relatively "newness" of the Supervision rules themselves. So, taking a very high-level view of the timeline over the last 30 years, here's my best guess:

1) The majority of the people in traditional/establishment "leadership" positions today are in the 55 to 75-year-old age range. These people did their RadOnc residencies in the late 80's and the 1990's. At that time, there were severe concerns about oversupply as well, and RadOnc was very uncompetitive. Unlike today, programs responded by significantly reducing spots.

2) CMS introduced supervision rules for freestanding centers in the late 90s/early 2000s. There were more practices billing freestanding radiotherapy than today, but it doesn't appear to have caused a huge uproar like it does now. However, this could just be an artifact of the immature internet and lack of digital "stuff"/archives.

3) Early 2000s, IMRT, gravy train. RadOnc jumped into hyperspace by accident, not through planned/coordinated leadership.

4) In 2007-2009, the political landscape focused on Healthcare. The ACA ("Obamacare") was passed. This was the time of the "UroRads Troubles" and the attempt at using Stark Law to fend them off.

5) CMS issued a "clarification" in 2009 that the Supervision rules applied to hospital outpatient departments too. Everyone lost their minds. Very upset. CMS stuck to their guns and, by 2010/2011, Direct Supervision for hospital outpatient departments was clearly the law of the land.

6) The political focus on Healthcare created, in part, the "Radiation Boom" series in the New York Times. We had the high-profile MIMA (Todd) whistleblower case. Then, in 2012, we had the SGR publication making claims about how "expensive" radiotherapy was. The SGR metrics were discontinued shortly thereafter because the government realized it was dumb. Sadly, the damage was done.

7) From 2012-2015 there was intense interest in cutting/bundling radiotherapy reimbursement concurrently with the pop culture concerns about safety. ASTRO and other entities adopted a defense strategy which, in retrospect, was highly ineffective.

8) In the culture of RadOnc, all of these became dogmatically tied together. Supervision/safety/whistleblower, and then those pieces got wrapped into the reimbursement defense. Specifically today, we see the "understanding" that the OTV code was "preserved" as part of the supervision/safety/whistleblower dogma.

9) The bundling happened in 2015. Then there was a brief period of quiet. Then CMMI came out with the RO-APM proposal. Supervision and other issues took a backseat. RO-APM became the all-consuming battle.

10) Starting in 2012/2013 with the "Pendulum" aka "Bloodbath" article, the concerns about oversupply started to return. These concerns were ignored and derided.

11) ...to the detriment of everyone. We all know what happened starting in 2018.

12) The direct-to-general switch was announced in November 2019, ASTRO reacted in December 2019, it took place in January 2020.

13) Pandemic happened while RadOnc became the least desirable specialty in medicine.

14) Also, we've been in a ~14 year campaign for hypofrac/omission. Don't get me wrong, I think in many cases this is good for patients. However, it's extremely unbalanced, in that the optics of doing this appears, to the outside world, that even the radiation doctors want to get rid of radiation.

So throughout this time we've had the 22-year tenure of the now-retiring ASTRO CEO. We've had the same rotating cast of people in "leadership" positions. Where they work and their obvious biases have been discussed at length on SDN.

As I am fond of pointing out on social media and podcasts, ASTRO went on a whirlwind tour over the last ~18 months of making "unforced errors". They were on the cusp of rehabilitating their reputation during the year Eichler was ASTRO president and the Workforce Taskforce was announced.

Sadly, it turned into an unmitigated disaster.

Longwinded, I know, but it sets the stage for my hypothesis as to "why".

The current 22-year ASTRO/RadOnc era has been dominated by reaction, not action.

It was coincidence the era started with the rise in IMRT. UroRads? Reaction. Supervision and whistleblower? Reaction. New York Times? Reaction. SGR and cries of "costly radiation"? Reaction. Bundling of codes? Reaction. RO-APM? Reaction. Concerns of job market? Boards? Crash of competitiveness?

All reaction.

With the permanent tabling of RO-APM, and the country's focus on the pandemic, we've been in a period of minimal external threats to the specialty. However, the specialty is at a very low point.

The Workforce bungling, ROCR surprise, Direct Supervision necromancy...this is ASTRO taking action, unprompted. They know we're at a low point. They know something needs to be done.

They lack the skills or experience to get it done.

Because we're clearly coming to a point where CMS needs to decide whether or not Virtual Direct becomes permanent, ASTRO decided they need to throw their hat in the ring.

Because RadOnc is a bunch of W2 employees with very dogmatic views of the world, Bridge, a curious startup with a guy who struggles to maintain strong optics on social media, became a real point of fear for people.

I'm personally agnostic about Bridge. I think it has the same chances of success as any small business/startup in a highly regulated space. Startups in medicine...struggle.

Until the current echo chamber of establishment leadership steps aside or retires, I absolutely expect further "unforced errors", until/unless another external threat occurs for them to react to.

 

[elementaryschooleconomics]

*best Lurch impression*

"You rang?"

I genuinely don't believe there's a singular narrative/"red thread" that brought us to this point.

However, what's happening now is exactly what I expected would have happened in 2020 if the pandemic hadn't taken place.

What's lost in this conversation is the relatively "newness" of the Supervision rules themselves. So, taking a very high-level view of the timeline over the last 30 years, here's my best guess:

1) The majority of the people in traditional/establishment "leadership" positions today are in the 55 to 75-year-old age range. These people did their RadOnc residencies in the late 80's and the 1990's. At that time, there were severe concerns about oversupply as well, and RadOnc was very uncompetitive. Unlike today, programs responded by significantly reducing spots.

2) CMS introduced supervision rules for freestanding centers in the late 90s/early 2000s. There were more practices billing freestanding radiotherapy than today, but it doesn't appear to have caused a huge uproar like it does now. However, this could just be an artifact of the immature internet and lack of digital "stuff"/archives.

3) Early 2000s, IMRT, gravy train. RadOnc jumped into hyperspace by accident, not through planned/coordinated leadership.

4) In 2007-2009, the political landscape focused on Healthcare. The ACA ("Obamacare") was passed. This was the time of the "UroRads Troubles" and the attempt at using Stark Law to fend them off.

5) CMS issued a "clarification" in 2009 that the Supervision rules applied to hospital outpatient departments too. Everyone lost their minds. Very upset. CMS stuck to their guns and, by 2010/2011, Direct Supervision for hospital outpatient departments was clearly the law of the land.

6) The political focus on Healthcare created, in part, the "Radiation Boom" series in the New York Times. We had the high-profile MIMA (Todd) whistleblower case. Then, in 2012, we had the SGR publication making claims about how "expensive" radiotherapy was. The SGR metrics were discontinued shortly thereafter because the government realized it was dumb. Sadly, the damage was done.

7) From 2012-2015 there was intense interest in cutting/bundling radiotherapy reimbursement concurrently with the pop culture concerns about safety. ASTRO and other entities adopted a defense strategy which, in retrospect, was highly ineffective.

8) In the culture of RadOnc, all of these became dogmatically tied together. Supervision/safety/whistleblower, and then those pieces got wrapped into the reimbursement defense. Specifically today, we see the "understanding" that the OTV code was "preserved" as part of the supervision/safety/whistleblower dogma.

9) The bundling happened in 2015. Then there was a brief period of quiet. Then CMMI came out with the RO-APM proposal. Supervision and other issues took a backseat. RO-APM became the all-consuming battle.

10) Starting in 2012/2013 with the "Pendulum" aka "Bloodbath" article, the concerns about oversupply started to return. These concerns were ignored and derided.

11) ...to the detriment of everyone. We all know what happened starting in 2018.

12) The direct-to-general switch was announced in November 2019, ASTRO reacted in December 2019, it took place in January 2020.

13) Pandemic happened while RadOnc became the least desirable specialty in medicine.

14) Also, we've been in a ~14 year campaign for hypofrac/omission. Don't get me wrong, I think in many cases this is good for patients. However, it's extremely unbalanced, in that the optics of doing this appears, to the outside world, that even the radiation doctors want to get rid of radiation.

So throughout this time we've had the 22-year tenure of the now-retiring ASTRO CEO. We've had the same rotating cast of people in "leadership" positions. Where they work and their obvious biases have been discussed at length on SDN.

As I am fond of pointing out on social media and podcasts, ASTRO went on a whirlwind tour over the last ~18 months of making "unforced errors". They were on the cusp of rehabilitating their reputation during the year Eichler was ASTRO president and the Workforce Taskforce was announced.

Sadly, it turned into an unmitigated disaster.

Longwinded, I know, but it sets the stage for my hypothesis as to "why".

The current 22-year ASTRO/RadOnc era has been dominated by reaction, not action.

It was coincidence the era started with the rise in IMRT. UroRads? Reaction. Supervision and whistleblower? Reaction. New York Times? Reaction. SGR and cries of "costly radiation"? Reaction. Bundling of codes? Reaction. RO-APM? Reaction. Concerns of job market? Boards? Crash of competitiveness?

All reaction.

With the permanent tabling of RO-APM, and the country's focus on the pandemic, we've been in a period of minimal external threats to the specialty. However, the specialty is at a very low point.

The Workforce bungling, ROCR surprise, Direct Supervision necromancy...this is ASTRO taking action, unprompted. They know we're at a low point. They know something needs to be done.

They lack the skills or experience to get it done.

Because we're clearly coming to a point where CMS needs to decide whether or not Virtual Direct becomes permanent, ASTRO decided they need to throw their hat in the ring.

Because RadOnc is a bunch of W2 employees with very dogmatic views of the world, Bridge, a curious startup with a guy who struggles to maintain strong optics on social media, became a real point of fear for people.

I'm personally agnostic about Bridge. I think it has the same chances of success as any small business/startup in a highly regulated space. Startups in medicine...struggle.

Until the current echo chamber of establishment leadership steps aside or retires, I absolutely expect further "unforced errors", until/unless another external threat occurs for them to react to.

If I had a magic wand and became ASTRO, I would do one thing:

A massive, thundering, pro-radiation PR campaign.

Pull in Varian and Elekta, MIM, Radformation, Civco - even my mortal enemy, the Goo Guys.

For the next 3-5 years, all we should hear about is the safety, efficacy, and VALUE that radiotherapy brings to the table.

And it needs to be done SO THE ACTUAL REST OF THE WORLD SEES IT.

Because the Spring edition of "ASTRO News" came out this week.

It's dedicated to benign radiotherapy. Including arthritis.

Does anyone know that?

I'm not a member so I don't get any emails. I follow ASTRO's website and social media presence closely, though.

You can find it on the website if you go specifically looking for it.

But...this is a very positive, important thing they did.

Don't they want anyone to know about it?

 

[medgator]

Not widely utilized, yet

Not what I've heard when it comes to a significant chunk of centers over at GenesisCare.

My point is that people have the freedom to abuse it now in all likelihood and I just don't think we are seeing that to any large degree.

 

[TheWallnerus]

Not widely utilized, yet

People were just waiting for ASTRO to say "Don't do it" (it=telesupervision) before anyone attempted widespread use 😉

Very Minority Report, pre-crime stuff on ASTRO's part.

 

[RickyScott]

can a radonc be ceo of ASTRO?
from 2022 form 990

 

[NotMattSpraker]

can a radonc be ceo of ASTRO?
from 2022 form 990
View attachment 385297

This is an interesting topic. We just interviewed Cliff Hudis, CEO of ASCO, on the podcast. It is all about organizational management and his career doing those roles. I hope you enjoy it.

We asked him about this specifically and ultimately decided to broaden the question to ask more generally about physician versus non physician leaders in organized medicine.

ASCO mandates an all-MD board of directors with representation from Rad Onc as well as an international MD board member. I personally think the company is run super well; to me this has to be part of it.

He gives kind of a balanced answer that I think is fair, there is some upside to having non-physicians in these roles and a highly successful non-physician healthcare leader is likely to have better management skills than some physician who is president of a society because he "put in his time".

Anyway, this is one of the things on my short list that would pique my interest in ASTRO again... if they hired an MD CEO. I think there is virtually no chance this happens, but hey. They latest town hall was a real town hall. Anything is possible.

 

[Chartreuse Wombat]

Previous ASTRO CEO chosen because of relationship with American Hospital Association and Big Medicine. Some considered it a lateral move at the time.

 

[evilbooyaa]

I have no clue what started the need for the letter. And I also don't know who actually has the ear of CMS. Seemingly the people that are most involved (again, maybe this is just conjecture based on social media) are ASTRO, Ron, Jordan/Bridge, and ACRO.

I would argue no other "outsider" (separate from ASTRO or some big letter organization) knows the history (not immediately related to the letter, just the history of supervision) on this issue better than Jason Bekta though.

I think the people who ACTUALLY have the ear of CMS aren't going to publicly broadcast their hopes/desires, hoping to get someone to agree with them. If ASTRO actually had the ear of CMS, this would be a back-channel conversation, not an official letter.

 

[BobbyHeenan]

I think the people who ACTUALLY have the ear of CMS aren't going to publicly broadcast their hopes/desires, hoping to get someone to agree with them. If ASTRO actually had the ear of CMS, this would be a back-channel conversation, not an official letter.

This may be right.

I think the inertia of virtual supervision is just too strong to create some unique cut out for rad onc (though I'd personally like to see 80% direct in person...what I want matters none). In my hospital I have pulm/cc running ICU's at our sister rural hospitals via monitors. Neuro intensivists seeing stroke patients virtually, etc.

As others have said in this thread, the underlying unifying voice of our leaders should be our value and worth and expanding role of radiation. Whether that be via video screen or in person.

 

[RickyScott]

I just don’t see how there is a workable mechanism for a percent of supervision presence from cms’ perspective. And they are not going to have complicated carve out for radonc. also very likely that the cms burueocracts think Dave Adler and Astro are a bunch of losers.

 

[BobbyHeenan]

I just don’t see how there is a workable mechanism for a percent of supervision presence from cms’ perspective.

yeah, that's an issue. I'm not putting some app on my phone either.
But the "threat" of an audit may be enough to keep away virtual vultures.
Some medicare LCD's have some X% in person requirement in place now, so they must have some language about how that is tracked?

 

[metallica81788]

I like the 60-80% idea BUT anytime you bring up these percentages - how are they tracked?
I'd rather spend 5 days in clinic than be lorded over by a clock punching mechanism

 

[radoncle]

As others have said in this thread, the underlying unifying voice of our leaders should be our value and worth and expanding role of radiation. Whether that be via video screen or in person

Agreed, and our worth does not lay in babysitting linacs.

 

[OTN]

This may be right.

I think the inertia of virtual supervision is just too strong to create some unique cut out for rad onc (though I'd personally like to see 80% direct in person...what I want matters none). In my hospital I have pulm/cc running ICU's at our sister rural hospitals via monitors. Neuro intensivists seeing stroke patients virtually, etc.

As others have said in this thread, the underlying unifying voice of our leaders should be our value and worth and expanding role of radiation. Whether that be via video screen or in person.

This is the main issue as I see it. I do enough SBRT/HDR so I'm always going to have to be in clinic, and as a result this discussion isn't going to personally effect me. However, requesting a return to direct supervision when all of medicine is headed in the other direction seems misguided.

 

[elementaryschooleconomics]

I like the 60-80% idea BUT anytime you bring up these percentages - how are they tracked?
I'd rather spend 5 days in clinic than be lorded over by a clock punching mechanism

The answer is the same for both Direct Supervision or 80% on-site:

Whistleblowers.

Because let's say you're following Direct Supervision rules. Let's say the design of your hospital is that the main clinic/treatment area with the linac is in its own distinct area. The physician offices are 50 feet down the hall, nearby but in a distinct area.

Let's say there are some small exam rooms in the treatment area, but there's a bigger "multi-disciplinary clinic" where you see most of your patients.

Unless you're in the treatment area, or someone comes to your office to find you - how do they know you're there?

What if your tumor board is on the third floor?

What if that tumor board is at 3PM and your linac generally treats till 4PM? And tumor board meets on the 3rd floor, which is also where the walkway to the parking deck is?

If tumor board gets out at 3:30PM, are you going back down to your office for 30 minutes?

(I know, I know - some of you losers would)

Everyone should go read the actual court documents from the existing RadOnc whistleblower cases. Because the question your asking is central to those cases.

That's why there's almost ALWAYS some other component.

In the MIMA/Todd case, for example, it required the whistleblower documenting when the infamous RadOnc was CLEARLY not physically on campus, and this was able to be corroborated (traveling to give an industry talk). But that wasn't enough then, and wouldn't be enough now. Because MIMA created the very first remote offline review (IGRT) using smartphones (before everyone knew the term "smartphone"), the government pulled the cell phone records and "proved" that the images were not actually reviewed because no cellular data had been used...not accounting for the fact that Wi-Fi exists.

And therein lies the problem for ALL OF THIS.

It's why Ronny D's business is soaring. It's why he and his company give talks everywhere.

This system only functions based on honor and fear.

Direct Supervision has NEVER stipulated what type of doctor needed to be "immediately available". The government refuses whistleblower cases all the time, the case needs to be strong and also have a sizeable payout on the table. I can't think of any RadOnc whistleblower cases with less than $500,000 at stake, but usually, it's over $1 million.

Or, for 21C - way, WAY more than $1 million.

While it's possible some hospitals would make their RadOncs punch a clock...I don't think that is the likely scenario in most places. If, for no other reason, than inertia and expense. It's not normal for hospitals to do that, and this would be a big shift in direction. Then you would either have to build out the hospital's existing timecard system to include RadOncs and some tracking mechanism, and have someone to review the data, etc etc etc. The cost wouldn't be zero.

But even if the became a minimum of 80% on site, and there was a whistleblower case, and the government agreed to pursue it...

Well, 80% of...what? Time the linac is on? Time the doctor is performing clinical tasks, including chart review and notes and contouring? Those aren't static values. Especially when you need to determine a time period. If it's 80% per week, and some RadOnc is on site 95-100% of the time most of the year, but has a week in February and a week in October where there were family emergencies and they were only on site 50% of the time - did they follow the law or break it?

And if it goes by day of the week, so 4 out of 5 days on site - that metric is uneven nationally if one hospital has 9 on beam while another has 59.

Anyway, my point, as always, is none of these systems are perfect. There are loopholes in all of them.

And it doesn't matter anyway because ASTRO is a joke to CMS, Virtual Direct will be permanent.

 

[TheWallnerus]

ASTRO publicly posted the town hall recording.

Supervision Town Hall Recording - American Society for Radiation Oncology (ASTRO) - American Society for Radiation Oncology (ASTRO)

Attended by more than 200 participants, ASTRO’s Supervision Town Hall covered CMS’ supervision policy and provided attendees with an opportunity to share insights regarding the impact supervision has on their practice. View the recording.

www.astro.org

HIGHLIGHTS:
18:30 .... @Rad Onc SK says we are in a supervision nirvana, and it must end
22:50 .... virtual supervision will change the workforce
58:50 .... CMS's virtual supervision has put the entire specialty of rad onc in danger

OK.

While it's possible some hospitals would make their RadOncs punch a clock...

FWIW at a small rural hospital I was at for a good period of time, I as the solo rad onc was certainly required to sign in and out (on a sheet of paper), daily, with notated times. Because an attorney told the CEO this was required of the rad onc (but no other doctor in the hospital).

 

[deleted1180461]

I just don’t see how there is a workable mechanism for a percent of supervision presence from cms’ perspective. And they are not going to have complicated carve out for radonc. also very likely that the cms burueocracts think Dave Adler and Astro are a bunch of losers.

If the theory is that this is all being done to preserve technical reimbursement, why would CMS NOT continue virtual/general? They need to reduce expenditures. If they can get away with keeping direct supervision at bay and use that to justify cutting, why would they not do it? Shouldn't the burden be on ASTRO to explain why the supervision level is not what justifies the reimbursement (since it's obviously not) rather than just fight for direct supervision, which is basically admitting that reimbursement SHOULD BE tied to supervision level?

 

[thecarbonionangle]

One cynical way to look at this, is ASTRO is doing this so they can avoid doing anything about expansion and oversupply. They love the cheap labour warm bodies. They will not let them go. The breadlines will be here by time they choose to address it.

 

[NotMattSpraker]

Previous ASTRO CEO chosen because of relationship with American Hospital Association and Big Medicine. Some considered it a lateral move at the time.

Yea. My take away from our discussion is that do not be so confident to believe that just because you are a good physician means you will be a good leader, negotiator, lobbyist, etc.

However, Id just counter with the fact that there are so. many. people in these roles in the US that have never set foot in a clinic. Thats a huge problem. If you read this board for 3 seconds, you see multiple times that ASTRO decided to "stick up for" the hospital over the physician.

If you read history, there are many examples where physicians (i.e. the AMA) lobbied for themselves over their patients, but in 2024 the pendulum has swung way too far toward focus on business aspects and away from clinical care.

In a time when radiation oncology has tons of consolidation, non-competes, workforce concerns and an increasingly scarce private practice environment, hire an MD! The hospitals have plenty of support in our field.

 

[RO28]

If I had a magic wand and became ASTRO, I would do one thing:

A massive, thundering, pro-radiation PR campaign.

Pull in Varian and Elekta, MIM, Radformation, Civco - even my mortal enemy, the Goo Guys.

For the next 3-5 years, all we should hear about is the safety, efficacy, and VALUE that radiotherapy brings to the table.

And it needs to be done SO THE ACTUAL REST OF THE WORLD SEES IT.

Because the Spring edition of "ASTRO News" came out this week.

It's dedicated to benign radiotherapy. Including arthritis.

Does anyone know that?

I'm not a member so I don't get any emails. I follow ASTRO's website and social media presence closely, though.

You can find it on the website if you go specifically looking for it.

But...this is a very positive, important thing they did.

Don't they want anyone to know about it?

Ok so i just thumbed through this because I remain a member (ducks) and its really well done. It has evidence, practical advice and coding information.

if someone from ASTRO leadership is reading this, figure out a way to get that ASTRO news more widely disseminated.

 

[BobbyHeenan]

ASTRO publicly posted the town hall recording.

Supervision Town Hall Recording - American Society for Radiation Oncology (ASTRO) - American Society for Radiation Oncology (ASTRO)

Attended by more than 200 participants, ASTRO’s Supervision Town Hall covered CMS’ supervision policy and provided attendees with an opportunity to share insights regarding the impact supervision has on their practice. View the recording.

www.astro.org

HIGHLIGHTS:
18:30 .... @Rad Onc SK says we are in a supervision nirvana, and it must end
22:50 .... virtual supervision will change the workforce
58:50 .... CMS's virtual supervision has put the entire specialty of rad onc in danger

OK.


FWIW at a small rural hospital I was at for a good period of time, I as the solo rad onc was certainly required to sign in and out (on a sheet of paper), daily, with notated times. Because an attorney told the CEO this was required of the rad onc (but no other doctor in the hospital).

I watched it all.

Good for them for posting.

My biggest red flag was how surprised they were about how much feedback /reaction they got from this letter. Seems extremely out of touch.

Otherwise, they explained some things fairly well.

 

[NotMattSpraker]

Ok so i just thumbed through this because I remain a member (ducks) and its really well done. It has evidence, practical advice and coding information.

if someone from ASTRO leadership is reading this, figure out a way to get that ASTRO news more widely disseminated.

If ASTRONews starts coming in the mail with Oncology Today and the Cleveland Clinic Hawaii CME Conference O' The Month post card Im gonna lose it.

 

[TheWallnerus]

One cynical way to look at this, is ASTRO is doing this so they can avoid doing anything about expansion and oversupply. They love the cheap labour warm bodies. They will not let them go. The breadlines will be here by time they choose to address it.

Plausible deniability

“Look guys. WE TRIED. Don’t blame us things are shee-tay. We threw out a life preserver and you ungratefuls threw it back at us.”

 

[Mandelin Rain]

Jordan Johnson rocking a Pablo Escobar painting in his office was something.

 

[communitydoc13]

This system only functions based on honor and fear.

Everything works on honor and fear. Without these, there is no social contract of any sort.

And it doesn't matter anyway because ASTRO is a joke to CMS, Virtual Direct will be permanent.

I agree that ASTRO has limited influence on CMS. But ASTRO, at present, has a fairly large impact on radonc culture and the establishment of standards that are not "legally based" but are often clinically implemented.

ASTRO is not going to bring a case against anyone. But, if your admin values your physical presence, they could reference ASTRO guidance to help set work expectations. They could even make a bit of a legal argument, stating that while CMS allows for virtual direct for billable services, the de-facto standard of care is really established through professional consensus, and at least one professional society has gone on the record establishing in-person direct supervision as standard. Fortunately or unfortunately

The point being...ASTRO doesn't need CMS to make an impact on real practice expectations or even on the perceived threat of legal action.

Per the NIH...The standard of care is a legal term, not a medical term. Basically, it refers to the degree of care a prudent and reasonable person would exercise under the circumstances.

The widespread adoption of virtual direct is what will protect virtual services legally, and it will change the workforce landscape incredibly (undeniable). In an environment where virtual becomes standard practice, it will be harder and harder for the individual rural radonc (or any radonc or doc period) to demonstrate value over virtual alternatives branded under larger institutions.

Doc X is willing to come in three days/week in person and work their tail off for us. He costs 850K/year. But the XYZ network has offered us branded, virtual services with in-person service provided by a shared APP...cost is 750K/year plus I get to put the XYZ logo up.

 

[drowsy12]

The widespread adoption of virtual direct is what will protect virtual services legally, and it will change the workforce landscape incredibly (undeniable).

lot of folks here denying!

 

[elementaryschooleconomics]

lot of folks here denying!

...what?

Literally no one is denying that.

Of course it will.

 

[elementaryschooleconomics]

Everything works on honor and fear. Without these, there is no social contract of any sort.

I agree that ASTRO has limited influence on CMS. But ASTRO, at present, has a fairly large impact on radonc culture and the establishment of standards that are not "legally based" but are often clinically implemented.

ASTRO is not going to bring a case against anyone. But, if your admin values your physical presence, they could reference ASTRO guidance to help set work expectations. They could even make a bit of a legal argument, stating that while CMS allows for virtual direct for billable services, the de-facto standard of care is really established through professional consensus, and at least one professional society has gone on the record establishing in-person direct supervision as standard. Fortunately or unfortunately

The point being...ASTRO doesn't need CMS to make an impact on real practice expectations or even on the perceived threat of legal action.

Per the NIH...The standard of care is a legal term, not a medical term. Basically, it refers to the degree of care a prudent and reasonable person would exercise under the circumstances.

The widespread adoption of virtual direct is what will protect virtual services legally, and it will change the workforce landscape incredibly (undeniable). In an environment where virtual becomes standard practice, it will be harder and harder for the individual rural radonc (or any radonc or doc period) to demonstrate value over virtual alternatives branded under larger institutions.

Doc X is willing to come in three days/week in person and work their tail off for us. He costs 850K/year. But the XYZ network has offered us branded, virtual services with in-person service provided by a shared APP...cost is 750K/year plus I get to put the XYZ logo up.

Well, this is directly related to a bigger concern/point I have on several topics, not just supervision.

I think a version of this future is coming no matter what.

I think that, instead of preparing the field of Radiation Oncology for this future, ASTRO is trying to desperately hold onto the past. Or, in the case of supervision, bring back the increasingly distant past.

This has basically never worked in the history of markets/capitalism/society/etc, whatever you want to call it.

Even if ASTRO "succeeds", it won't matter. A version of this future is coming, likely faster than we know.

 

[communitydoc13]

This has basically never worked in the history of markets/capitalism/society/etc, whatever you want to call it.

Bay Pilots.

Of course they were on the ship that rammed the Francis Scott Key bridge (A rare event, I'm sure the shipping company is happy the Bay Pilot was on board!)

To an outsider, the in-person presence of Bay Pilots seemingly superfluous for years (development of high end GPS technology).

Teachers...of higher education. Let everyone learn orgo from the best prof at MIT.

It's not clear to me that insisting on a physical, human presence is not in fact an ethical salvo against the technological encroachment on human values.

 

[drowsy12]

...what?

Literally no one is denying that.

Of course it will.

okay.

there have been many posts saying that people are overreacting and that things have been this way since 2019 and nothing has happened so why do we care now?

we may have different definitions of literally no one.

 

[elementaryschooleconomics]

okay.

there have been many posts saying that people are overreacting and that things have been this way since 2019 and nothing has happened so why do we care now?

we may have different definitions of literally no one.

Perhaps?

The way this is being framed is that this is some kind of change, as in, we will be moving into a world where Virtual Direct/General is "the norm". As in, the "threat" is in the future.

I see it as the change happened on January 1st, 2020, and then again in March/April 2020.

The consequences on any industry/workforce began many years ago. This is our status quo.

There were three options for ASTRO, really:

1) Do nothing
2) Acknowledge our legislative reality and craft a future-facing strategy for the field
3) Acknowledge our legislative reality and attempt to turn back the clock (uniquely, as it turns out)

Of the 3, the one they chose is the worst. Now we have to spend time and energy on this instead of something even mildly productive.

 

[Ray D. Ayshun]

This discussion exemplifies the QOL issue I've tried to verbalize: we're having a drawn out discussion that centers around the importance to our specialty of being sure we're expected to do something we all know we don't need to do.

 

[elementaryschooleconomics]

It is crazy to think that just because things haven't been significantly abused in the past 4-5 years (while we were recovering from a pandemic mind you), that it will never happen. Virtual supervision without RadOncs on site will drastically increase the supply side and do nothing for the demand side, this will drive down the worth of physicians and employers will be psyched about it. It won't matter if it's worse for patients theoretically or actually.

The only way that it would possibly be able to be overcome is to not even be RadOncs anymore, but to become clinical oncs to raise our demand enough to offset the massive shift in supply demand that would surely lead to unemployment for many and plummet pay for a lot of RadOncs.

This is literally elementary economics.

I think the abuse has already happened. That's my point. I don't think any of this matters.

Again, look at the voices active in this conversation. All the dirt this kicked up came from doctors mostly not at the 100 institutions with residency programs.

Meanwhile, ASTRO stands alone.

Where is SCAROP? Specifically, why haven't we heard from HROP, Anderson, Mayo, City of Hope, Moffitt, Sloan, UCSF, Penn...and on and on and on, voicing their support either way?

The only thing this does is rekindles the abuse of whistleblower cases and QoL for RadOncs "everywhere else", as in, not for the monster institutions trying to gobble up all the geography they can.

The outcome of this debate doesn't matter to the real boogeymen.

At all.

 

[drowsy12]

I think the abuse has already happened.

Interesting. What do you mean? The rise of BRIDGE or something else?

 

[RickyScott]

It is crazy to think that just because things haven't been significantly abused in the past 4-5 years (while we were recovering from a pandemic mind you), that it will never happen. Virtual supervision without RadOncs on site will drastically increase the supply side and do nothing for the demand side, this will drive down the worth of physicians and employers will be psyched about it. It won't matter if it's worse for patients theoretically or actually.

The only way that it would possibly be able to be overcome is to not even be RadOncs anymore, but to become clinical oncs to raise our demand enough to offset the massive shift in supply demand that would surely lead to unemployment for many and plummet pay for a lot of RadOncs.

This is literally elementary economics.

the threat of supervision changes and hypofract/ommission has been vocally raised since at least 2018. Asto/scarop response has been to gas light.

 

[TheWallnerus]

Perhaps?

The way this is being framed is that this is some kind of change, as in, we will be moving into a world where Virtual Direct/General is "the norm". As in, the "threat" is in the future.

I see it as the change happened on January 1st, 2020, and then again in March/April 2020.

The consequences on any industry/workforce began many years ago. This is our status quo.

There were three options for ASTRO, really:

1) Do nothing
2) Acknowledge our legislative reality and craft a future-facing strategy for the field
3) Acknowledge our legislative reality and attempt to turn back the clock (uniquely, as it turns out)

Of the 3, the one they chose is the worst. Now we have to spend time and energy on this instead of something even mildly productive.

ASTRO struggled mightily and loudly against the Jan 2020 change (permanent general in hospital) and Jan 2021 change (NPs could supervise IGRT in hospitals). (ASTRO supported virtual supervision in all sites of service in light of COVID.)

Now, it is attempting to struggle again, years later, in light of perhaps supervision changing “again” in 2025. If we think about it, this re-protestation is likely to have the same success rate as curative attempt reirradiation. Except with this tumor, many other doctors are vigorously trying to keep the recurrent tumor from being touched much less retreated.

 

[elementaryschooleconomics]

Stuff like this is what I'm talking about:

There's only ONE WAY this can happen. And that's if your institution is an unstoppable juggernaut, a cross between a mob boss and the Terminator.

And just to be even more confusing/nuanced: I actually think Penn/CHOP do great medicine! I'd go there! I'd send my family there!

But does Penn, or its peers, care AT ALL about this in terms of the levers and loopholes they will exploit to maximize profit?

No.

Will the behavior of Penn, Anderson, Mayo, Sloan - will it have an effect on our workforce?

Yes.

Supervision is the WRONG BATTLE.

 

[drowsy12]

f we think about it, this re-protestation is likely to have the same success rate as curative attempt reirradiation.

interesting analogy. so it will work sometimes. you just gave them the green flag of support of their attempts haha.

 

[drowsy12]

Stuff like this is what I'm talking about:

View attachment 385332

There's only ONE WAY this can happen. And that's if your institution is an unstoppable juggernaut, a cross between a mob boss and the Terminator.

And just to be even more confusing/nuanced: I actually think Penn/CHOP do great medicine! I'd go there! I'd send my family there!

But does Penn, or its peers, care AT ALL about this in terms of the levers and loopholes they will exploit to maximize profit?

No.

Will the behavior of Penn, Anderson, Mayo, Sloan - will it have an effect on our workforce?

Yes.

Supervision is the WRONG BATTLE.

I am confused by the constant muddying of the waters. You're bringing up wildly different things. Some of which are in ASTRO's purview and some of which are not.

ASTRO can give their opinion on supervision. It has the direct potential, as you admit, to really hurt the livelihood of current members. big time. Maybe you are right that it will have zero impact on CMS' view. I tend to agree.

But if you think CMS doesn't care about ASTRO's opinion, then I will tell you who REALLY doesn't give a damn. that's the corporate medical complex in the USA.

'Will the behavior of Penn, Anderson, Mayo, Sloan - will it have an effect on our workforce?'

Yeah - pretty clearly they are leading to more jobs and more dollars going to rad onc departments overall. For better or worse.

The discussion of the overall societal impact rising costs of medicine is a totally different topic, and I don't think any of us want to go too far down this rabbit hole.

 

[drowsy12]

I don't understand the points people are trying to make here.

What should ASTRO be doing? If they can't support supervision (which is beneficial to the large majority of us), what could they possibly support that people will listen to that will help the majority of RadOncs?

And why are there people here hoping for the worst possible outcome that will completely destroy the field?

yep.

I really find it very confusing.

 

[elementaryschooleconomics]

Stuff like this is what I'm talking about:

View attachment 385332

There's only ONE WAY this can happen. And that's if your institution is an unstoppable juggernaut, a cross between a mob boss and the Terminator.

And just to be even more confusing/nuanced: I actually think Penn/CHOP do great medicine! I'd go there! I'd send my family there!

But does Penn, or its peers, care AT ALL about this in terms of the levers and loopholes they will exploit to maximize profit?

No.

Will the behavior of Penn, Anderson, Mayo, Sloan - will it have an effect on our workforce?

Yes.

Supervision is the WRONG BATTLE.

Further, from a story that broke yesterday:

For those that don't know, Mayo offers the "MCCN":

They have, for years, offered this:

I'm sure we've all seen the rise in eConsults, independent of this.

The discussion of the overall societal impact rising costs of medicine is a totally different topic, and I don't think any of us want to go too far down this rabbit hole.

You're kidding, right?

You HAVE TO GO DOWN THIS RABBIT HOLE. This is all related.

I understand the easy logic here about "Direct Supervision means a RadOnc has to physically be present means more jobs".

That's not real. That's an illusion.

Do I think there's a chance that, if Virtual Direct is made permanent in 2025, there could be a handful of fewer jobs available in 2025-2030?

Maybe. I genuinely don't know.

But to see drastic changes to our workforce in a rapid timeline, one of two things need to happen:

1) Staffing of existing linacs needs to change.
2) New linacs need to be built.

#2 is basically off the table. Outside of Florida (lol), the CoN process is a huge roadblock to linac expansion.

Further, the capital-rich days of the last few years is gone. Interest rates are high. Purse strings are tight. Reimbursement is down. You're not going to see a flood of new linacs because...well that's not something that has ever happened, really.

For #1: Hospitals HATE CHANGE. There are a lot of downstream effects to a place that is used to having an on-site RadOnc for 30 years just...not having an onsite RadOnc anymore.

@drowsy12 - what do you mean "rise of Bridge"??? Does Bridge even have a clinical site yet? Maybe one is what I've heard? The probability they fail is quite high regardless of regulation.

I don't understand the points people are trying to make here.

What should ASTRO be doing? If they can't support supervision (which is beneficial to the large majority of us), what could they possibly support that people will listen to that will help the majority of RadOncs?

And why are there people here hoping for the worst possible outcome that will completely destroy the field?

Relentless.

Unstoppable.

Advocacy.

Blanket all media with pro-radiotherapy ads. Stories in print and digital. Television. Blogs. Podcasts.

Hire effective lobbyists.

ACRO already has one. Liberty Partners are beasts. Look what they did for 21C.

ROCR and Supervision are tilting windmills. The playbook already exists.

Lobby. PR. Lobby. PR. Lobby. PR.

 

[drowsy12]

@drowsy12 - what do you mean "rise of Bridge"??? Does Bridge even have a clinical site yet? Maybe one is what I've heard? The probability they fail is quite high regardless of regulation.

I meant only their emergence/existence. Otherwise I questioned you - what is the abuse that exists now, I was replying to your post

 

[TheWallnerus]

I am confused by the constant muddying of the waters. You're bringing up wildly different things. Some of which are in ASTRO's purview and some of which are not.

I don't understand the points people are trying to make here.

What should ASTRO be doing? If they can't support supervision (which is beneficial to the large majority of us), what could they possibly support that people will listen to that will help the majority of RadOncs?

And why are there people here hoping for the worst possible outcome that will completely destroy the field?

Relentless.

Unstoppable.

Advocacy.

Blanket all media with pro-radiotherapy ads. Stories in print and digital. Television. Blogs. Podcasts.

Hire effective lobbyists.

God, grant me the serenity to accept the things I cannot change
The courage to change the things I can
And the wisdom to know the difference

 

[drowsy12]

I don't understand the points people are trying to make here.

What should ASTRO be doing? If they can't support supervision (which is beneficial to the large majority of us), what could they possibly support that people will listen to that will help the majority of RadOncs?

And why are there people here hoping for the worst possible outcome that will completely destroy the field?

I think there are are a lot of folks here who only want to talk about one thing, and that is that large hospital systems make a lot of money.

I have many posts here about this topic and the rise of corporate medicine and its impact on medicine as a whole and rad onc specifically.

but it does make these conversations difficult. see this page. Ultimately, no one has answered or really even addressed your question.

 

[communitydoc13]

Where is SCAROP? Specifically, why haven't we heard from HROP, Anderson, Mayo, City of Hope, Moffitt, Sloan, UCSF, Penn...and on and on and on, voicing their support either way?

These entities are too big to fail...on so many fronts.

They are protected regarding legal jeopardy due their size, status and legal teams. Mayo could literally say, "this has become our institutional standard after much deliberation" and it provides some level of legal protection.

They are likely tacitly for virtual supervision as it is another tool for their network expansion. They almost certainly are confident that virtual direct is here to stay. They likely have multiple service lines that are extending far into the community using virtual direct.

I actually think ASTRO is trying to protect jobs and centers. (Maybe I'm crazy).

They should be doing other things though, as mentioned above. Scope of practice needs to increase for radoncs. This means harder work but more valuable work.

There ain't no free lunch.

 

[Bequerel]

I don't understand the points people are trying to make here.

What should ASTRO be doing? If they can't support supervision (which is beneficial to the large majority of us), what could they possibly support that people will listen to that will help the majority of RadOncs?

And why are there people here hoping for the worst possible outcome that will completely destroy the field?

They should support residency contraction. Until they address that issue..I can’t take them seriously.

I think people aren’t upset that they supported supervision..I think people are upset about they way they went about it. Any good leader would have a town hall then write a letter to DC that supports the views of the majority of the group not the other way around.

 

[Ray D. Ayshun]

ACRO already has one. Liberty Partners are beasts. Look what they did for 21C.

I guess this explains why the nearby Genesis nightmares are ACRO-certified.

 

[elementaryschooleconomics]

They should be doing other things though, as mentioned above. Scope of practice needs to increase for radoncs. This means harder work but more valuable work.

There ain't no free lunch.

Bingo.

From earlier either in this thread...or another thread...who even knows, but:

Part of the reason I work more hours than what might be considered "average" for RadOnc is I immediately got involved in things other than "EBRT for Oncology".

Everyone, everywhere, should be doing the same.

Like yesterday.