ASTRO Town Hall Discussion (Poll % on site)

[TheWallnerus]

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I will admit I don't know the exact rules or terminology of this, but I have multiple friends that work in groups that are multi-site multi hospital, and one of the sites is classified as rural enough that a rad onc doc is only needed one day a week, and this has been ongoing for at least a decade. What is this called?

"Drowsy, you're out of your element!" (respectfully)

As far back as 10 years ago ~20% of all rad onc departments were allowing non-rad oncs to provide some level of supervision of radiation therapy.

I have no hard data, but I am gonna go on a limb and say not 20% of all rad onc departments "ran afoul of the law" over time, nor were 20% rural.

 

[drowsy12]

Look - if this is going to have minimal impact on the need for Rad Oncs, then I literally could not care less. That is my only level of interest in this. I hope it does not have a negative impact.

the one thing @elementaryschooleconomics and I absolutely agree on is that we are fooling ourselves in trying to predict the future.

 

[deleted1180461]

Alright then!

60% for the truly remote and 90 for everyone else!

I'm down for it.

I'm a reasonable person. I will make a deal if there is no avenue to keeping the 2019 general ruling, but the logistics of what you have just proposed are messy. Also we have to do away with the charade that's it about critical safety. If this is critical, then we need to be here 100% of the time. The FAA doesn't allow the pilots to be sleeping for 40% of the flight.

 

[Mandelin Rain]

Alright then!

60% for the truly remote and 90 for everyone else!

I'm down for it.

What about the health care desert inner city hospital with nearly 100% medicaid that no one else (including the academic center) will staff because of the payor mix and low census? That hospital is not rural. That hospital can't afford/sustain 90% staffing. Should they shut down?

It's almost like the treating doctors are the best judges of what their clinics' and patients' needs are.

 

[TheWallnerus]

Look - if this is going to have minimal impact on the need for Rad Oncs, then I literally could not care less. That is my only level of interest in this. I hope it does not have a negative impact.

the one thing @elementaryschooleconomics and I absolutely agree on is that we are fooling ourselves in trying to predict the future.

For as long as I've been a rad onc, there was no clear workforce protection under supervision rules even as they were written pre-2020.

To think otherwise means you are, or were, a not fully informed person. To think otherwise would also mean, admittedly, a deviation from ASTRO's multiple... "opinions"... through the years.

The supervision rules are more lax now, yes, but abuses etc. are still feasible even with a blanket, national return to direct. The loopholes were always there. (We haven't even addressed APP "loopholes" with a return to direct.) Just now, maybe, people are thinking for themselves. And I will say again (to paraphrase @Rad Onc SK): "Once a man has tasted nirvana, he can do a pretty good job of recreating the recipe."

 

[deleted1180461]

"Drowsy, you're out of your element!" (respectfully)

As far back as 10 years ago ~20% of all rad onc departments were allowing non-rad oncs to provide some level of supervision of radiation therapy.

I have no hard data, but I am gonna go on a limb and say not 20% of all rad onc departments "ran afoul of the law" over time, nor were 20% rural.

View attachment 385345

Raise your hand if you've supervised chemo before. 🖐️

 

[BobbyHeenan]

For as long as I've been a rad onc, there was no clear workforce protection under supervision rules even as they were written pre-2020.

To think otherwise means you are, or were, a not fully informed person. To think otherwise would also mean, admittedly, a deviation from ASTRO's multiple... "opinions"... through the years.

The supervision rules are more lax now, yes, but abuses etc. are still feasible even with a blanket, national return to direct. The loopholes were always there. (We haven't even addressed APP "loopholes" with a return to direct.) Just now, maybe, people are thinking for themselves. And I will say again (to paraphrase @Rad Onc SK): "Once a man has tasted nirvana, he can do a pretty good job of recreating the recipe."

View attachment 385347

Yeah, as you know someone astutely asked in the town hall meeting whether NP or PA could provide direct and ASTRO said basically "no, we believe that direct should be a radiation oncologist"......

But it takes it all back to what ASTRO believes and what CMS believes may be two different things.


I just hope at the end of this we get clarity.

 

[elementaryschooleconomics]

Raise your hand if you've supervised chemo before. 🖐️

Haha literally right now, in this moment.

Although maybe it's just the immuno patients...

Ah. No. It's both.

 

[deleted1180461]

Haha literally right now, in this moment.

Although maybe it's just the immuno patients...

Ah. No. It's both.

What is the stipend the hospital is giving you to take on this extra responsibility/liability? LOL

 

[RickyScott]

If Astro (scarop is part of Astro) had increased resident numbers in line with other specialties, we would be fine. Period.

 

[communitydoc13]

Raise your hand if you've supervised chemo before. 🖐️

I've supervised chemo. (There will be no re-trialing with adverse reactions).

I think some folks are getting too hung up on the particulars and the legal ramifications of small details.

Those rural clinics (as stated above) existed before 2020. There is a lot of leeway in interpreting supervision. Most places will let a doc leave for an appointment from time to time if there is a medonc down the hall (and vice-versa). All of this preceded the 2020 ruling.

It is actually more about culture than anything else (yes, there are exceptional cases).

I have no problem with a professional society advocating for in person as standard.

If you are in a city where everyone else is there 90% of the time and there is an eff-up and you've only been there 40% of the time...yeah, there is probably a little liability associated with this.

If you've negotiated an arrangement with a truly remote place to provide scarce services (relative to that place), there is going to be a lot less legal vulnerability if something goes wrong.

This is the general concept of "reasonableness". It is actually meaningful...if not very concrete.

What about the health care desert inner city hospital with nearly 100% medicaid that no one else (including the academic center) will staff because of the payor mix and low census? That hospital is not rural. That hospital can't afford/sustain 90% staffing. Should they shut down?

If it is a low census urban center, there should be some soul searching about the need for that center. A harsh take, I know, but I think it is reasonable.

If the academic places are not taking their own state's medicaid...that is unconscionable, and needs to be punished.

 

[Mandelin Rain]

If it is a low census urban center, there should be some soul searching about the need for that center. A harsh take, I know, but I think it is reasonable.

But why?

Set up the 2 hour, three transfer bus ride for the inner city poor with cancer?

Honest to God, some of yall need to see the world a bit.

 

[communitydoc13]

But why?

Set up the 2 hour, three transfer bus ride for the inner city poor with cancer?

Honest to God, some of yall need to see the world a bit.

I grew up in the city...a big, poor one. There has been major consolidation over the last 30 years, but a two hour bus ride? I used to take the bus (into my 20s). I couldn't come up with a 2 hour route if I wanted to (certainly without passing several large hospitals).

Is this hyperbole?

The other thing (as I'm sure you know) is that 10 poor patients with poor patient cancers can take more time, resources and "in person" medical care and encouragement than 30 affluent patient with breast and prostate cancers. 10 patients on beam in a poor part of the city is enough for a full time doc IMO.

5 patients on beam? There is a lower limit to reasonableness here.

Now again, the fact that there are academic places not serving the community and happy to have a negative margin center actually doing their job is the big problem IMO.

 

[elementaryschooleconomics]

What is the stipend the hospital is giving you to take on this extra responsibility/liability? LOL

I called ASCO to see if I could get a letter or something to help me make my case for a stipend

As soon as I started talking about supervision

They started laughing

"You think we care about that stuff? We have real doctor issues to deal with, go back to your little basement club, dweeb"

Then they hung up

 

[RickyScott]

“f it is a low census urban center, there should be some soul searching about the need for that center. A harsh take, I know, but I think it is reasonable.“

But why?

Set up the 2 hour, three transfer bus ride for the inner city poor with cancer?

Honest to God, some of yall need to see the world a bit.

I know docs in large metros whose volumes crashed often due to academic satellites. Is the argument that they should leave their families and move somewhere else after the requisite soul searching?

 

[communitydoc13]

I know docs in large metros whose volumes crashed often due to academic satellites. Is the argument that they should leave their families and move somewhere else?

What are we even talking about.

A hypothetical center that can only support a doc on site 2 days a week in an urban setting? But is somehow critical to the community (which is likely saturated with radoncs).

Or are we talking about urban docs wanting to work remotely when they have a 15 minute commute?

 

[pikachu]

Raise your hand if you've supervised chemo before. 🖐️

Yep

 

[Reaganite]

But I don't understand why you think it's wise for ASTRO to not speak out about one of the few things they should have an opinion on. Something that it seems most people here agree will crash the field.

I've said this before and will say it again - anyone who thinks they should have done something to stop residency expansion but does not think they should have an opinion on supervision - this does not compute to me. Please explain.

I agree that sending a letter and then trying to walk it back with a town hall after it has already been sent is silly.

I see no relationship between residency expansion and supervision. The single greatest threat to our specialty is overtraining, and I believe ASTRO is keenly aware of that. Specialties like urology are in the midst of the job boom of the century because they have kept tight control of their numbers. They are naming their price with hospitals and payors. Imagine a world where rad oncs named their price with payors and hospitals. We wouldn't need hospitals. We could negotiate high payor contracts as independent providers and open our own centers...just like the IMRT boom days. These ASTRO academic center hacks would never want us to have that kind of leverage. They spent a decade trying to squash urorads and in office for that very reason. When that failed, they just flooded the market with new grads.

Burdening a generation of radoncs with unnecessary, draconian supervision isn't the answer. I never want to go back to the days of having to hire a locum to cover my clinic so I can attend a tumor board. In the qui tam heyday I had friends reported to hospital admin for leaving the clinic to grab lunch at the hospital cafeteria. F that.

 

[Mandelin Rain]

What are we even talking about.

A hypothetical center that can only support a doc on site 2 days a week in an urban setting? But is somehow critical to the community (which is likely saturated with radoncs).

Or are we talking about urban docs wanting to work remotely when they have a 15 minute commute?

Do you live in a big city with a large inner city?

Let me tell you, they are not saturated with rad oncs, let alone primary care clinics, pharmacies, grocery stores, parks, whatever.

The hospitals all moved and/or transitioned services to the burbs where the private insurance is long ago.

And yes, I’ve seen many people who’ve taken three bus transfers to get care in those suburbs or even main hub in city center. It’s an all day affair for them. It's gross, but it's reality.

 

[elementaryschooleconomics]

Do you live in a big city with a large inner city?

Let me tell you, they are not saturated with rad oncs, let alone primary care clinics, pharmacies, grocery stores, parks, whatever.

The hospitals all moved to the burbs where the private insurance is long ago.

And yes, I’ve seen many people who’ve taken three bus transfers to get care in those suburbs or even main hub in city center. It’s an all day afraid for them.

I interviewed with a large practice back in "the old days".

Their practice included a site in the "bad" part of a large city.

It was considered "critical access". I don't remember the exact number (if I even asked), but it was staffed by a RadOnc physician perhaps 2 days a week.

It had been staffed this way for many years.

So this point always leads us back to "well we can just do non-enforcement again!"

But like...what are we even saying about supervision, then? We either need it or we don't. And if we need it, I would argue the environment lacking infrastructure needs it more, not the other way around.

Of course, I'm talking about the ostensible/stated reasons given for supervision, not our interpretation of it re: workforce.

 

[thecarbonionangle]

The taking all day (hours!)to get to treatment and back home thing is real. I have had/heard of multiple patients tell one that they have to take multiple bus connections and once you mistime something you might wait for hours. This is most common in cities that are large urban sprawls without good rail/train public transit.

 

[communitydoc13]

Do you live in a big city with a large inner city?

Let me tell you, they are not saturated with rad oncs, let alone primary care clinics, pharmacies, grocery stores, parks, whatever.

The hospitals all moved and/or transitioned services to the burbs where the private insurance is long ago.

And yes, I’ve seen many people who’ve taken three bus transfers to get care in those suburbs or even main hub in city center. It’s an all day affair for them. It's gross, but it's reality.

Fair.

I cannot speak to all cities.

To not doxx myself, I can tell you that I am very familiar with DC, Baltimore and Philly, all of which have major problems, but I would not put radonc geographic availability in the top one million of those. I used to take the public transport in the worst of those metro systems...if you know, you know.

So I guess there should be no stance on in-person supervision by our professional society. In fact, maybe they should encourage virtual?

BTW, I am all for the present practice at the overwhelming majority of places (although I suspect that some cooperate radonc is already acting in ways regarding supervision that are making our leaders (and probably would make me) squeamish). None of these relate to remote rural or urban care-desert settings.

Edit: as another aside. Where I work presently, we transport patients who are unable to get themselves to clinic. This should always be the policy for all centers serving the community (I believe regulations limiting this are not applicable to the circumstances we are discussing). The cost of transportation, relative to the billable services provided, is almost uniformly trivial. Of course, in truly remote locations, this becomes a very difficult service to provide.

 

[Mandelin Rain]

BTW, I am all for the present practice at the overwhelming majority of places (although I suspect that some cooperate radonc is already acting in ways regarding supervision that are making our leaders (and probably would make me) squeamish). None of these relate to remote rural or urban care-desert settings.

Yes. This is the piece that I have no concept of.

 

[elementaryschooleconomics]

BTW, I am all for the present practice at the overwhelming majority of places (although I suspect that some cooperate radonc is already acting in ways regarding supervision that are making our leaders (and probably would make me) squeamish). None of these relate to remote rural or urban care-desert settings.

Well...

So this is, for me, probably the hardest part of this conversation.

We're a very small field. Many of us know many of us.

ASTRO, or, specifically: the ASTRO leadership cabal is engaged in a wild "throwing stones from glass houses" campaign with this.

Speaking for myself: a lot of my opinions are formed, in part, by specific things I know people have done or said. While some is hearsay, or something I witnessed/experienced personally, some of these things have paper trails. There's a lot of paper trails.

But to bring these things up to support or refute specific arguments would look like a personal attack and be received poorly.

But it's also not a classic ad hominem attack, in that if Person XYZ is saying "we need to enact Rule ABC to prevent this safety/exploit/fraud thing", it is sometimes possible to say "well you did Unsafe Thing XYZ which this rule you're proposing would not have prevented at all, and you know this".

SDN has shown a lot of restraint in airing dirty laundry. Everyone with any length of experience in this field knows what I'm talking about.

In short: I'm sure there are RadOncs doing unethical things.

I'm sure some of those RadOncs sit on ASTRO committees, too.

But in terms of public-facing data...the CMS supervision rules are not an evidenced-based intervention.

 

[BobbyHeenan]

I initially thought the ASTRO supervision stance may have something to do with job market (and I still think it does to a lesser degree)...but after watching the town hall I started to think it may be a play to CMS to emphasize the importance/expertise/value of our services and avoid worsening cuts.

Look, CMS can't understand what we do....90% of physicians don't know what we do. They don't know about nuances of contouring, elective nodal coverage, where to aim, symptom management, etc. It's easier to explain our worth by saying we must be there to oversee these dangerous high energy X rays.

It sounds like the last thing you want is CMS looking at your codes and doing a re-eval. ASTRO talked about not wanting to do direct or general on a code by code basis (ie for SBRT codes that is in person direct, but for regular fraction codes that can be general) because then CMS then sniffs around your codes and will likely modify down. Stemming from that, my perception is that they want to give them no reason to think our worth is less because we can do what we do remotely. Yes...I understand this is not the way the rest of medicine is moving...but I think that's their reasoning/play here be it right or wrong.

 

[TheWallnerus]

I initially thought the ASTRO supervision stance may have something to do with job market (and I still think it does to a lesser degree)...but after watching the town hall I started to think it may be a play to CMS to emphasize the importance/expertise/value of our services and avoid worsening cuts.

Look, CMS can't understand what we do....90% of physicians don't know what we do. They don't know about nuances of contouring, elective nodal coverage, where to aim, symptom management, etc. It's easier to explain our worth by saying we must be there to oversee these dangerous high energy X rays.

It sounds like the last thing you want is CMS looking at your codes and doing a re-eval. ASTRO talked about not wanting to do direct or general on a code by code basis (ie for SBRT codes that is in person direct, but for regular fraction codes that can be general) because then CMS then sniffs around your codes and will likely modify down. Stemming from that, my perception is that they want to give them no reason to think our worth is less because we can do what we do remotely. Yes...I understand this is not the way the rest of medicine is moving...but I think that's their reasoning/play here be it right or wrong.

Are we sort of deluding ourselves in thinking that CMS didn't already know that rad oncs don't press the "beam on" button, don't set patients up for daily radiation, don't even see patients (4/5ths of the time) for daily radiation eyeball to eyeball, etc? I am ~100% certain CMS doesn't value any rad onc code on the basis of the rad onc hanging around the building ready to be brought into clinical action, family discussion, etc., at a moment's notice. I mean there's oversight and there's performance art... please don't let this offend anyone's delicate sensibilities. Did radiology cry "the sky will fall" as teleradiology became a thing, and did the sky actually fall (genuinely asking)? I remember in the town hall ASTRO had a slide up being concerned about teleradonc. And thought "Why are they concerned".... safety? Money? Other doctors will make fun of us? Our self-worth in life will plummet?

So I guess there should be no stance on in-person supervision by our professional society. In fact, maybe they should encourage virtual?

Everything in life, science, and statistics is two-sided. There are potential benefits to virtual. No one at ASTRO wants to admit that, obviously.

 

[Ray D. Ayshun]

Are we sort of deluding ourselves in thinking that CMS didn't already know that rad oncs don't press the "beam on" button, don't set patients up for daily radiation, don't even see patients (4/5ths of the time) for daily radiation eyeball to eyeball, etc? I am ~100% certain CMS doesn't value any rad onc code on the basis of the rad onc hanging around the billing ready to be brought into clinical action, family discussion, etc., at a moment's notice. I mean there's oversight and there's performance art... please don't let this offend anyone's delicate sensibilities. Did radiology cry "the sky will fall" as teleradiology became a thing, and did the sky actually fall (genuinely asking)? I remember in the town hall ASTRO had a slide up being concerned about teleradonc. And thought "Why are they concerned".... safety? Money? Other doctors will make fun of us? Our self-worth in life will plummet?

This is more or less why I'd discourage med students from this field. There's a lot of this. It's why breast is the worst, even.

 

[elementaryschooleconomics]

Are we sort of deluding ourselves in thinking that CMS didn't already know that rad oncs don't press the "beam on" button, don't set patients up for daily radiation, don't even see patients (4/5ths of the time) for daily radiation eyeball to eyeball, etc? I am ~100% certain CMS doesn't value any rad onc code on the basis of the rad onc hanging around the billing ready to be brought into clinical action, family discussion, etc., at a moment's notice. I mean there's oversight and there's performance art... please don't let this offend anyone's delicate sensibilities. Did radiology cry "the sky will fall" as teleradiology became a thing, and did the sky actually fall (genuinely asking)? I remember in the town hall ASTRO had a slide up being concerned about teleradonc. And thought "Why are they concerned".... safety? Money? Other doctors will make fun of us? Our self-worth in life will plummet?

Everything in life, science, and statistics is two-sided. There are potential benefits to virtual. No one at ASTRO wants to admit that, obviously.

After I first caught wind of ASTRO's concern over the effect of virtual on codes I spent an insane amount of time trying to see if there was any evidence supporting this concern.

Obviously, I'm not privy to any "behind the scenes" conversations that may have happened. This is ALWAYS their go-to move, some vague "people say" sort of crap.

But, in terms of any documentation I can find around the actual factors that were considered when developing the RVUs for radiotherapy codes, there appears to be absolutely no consideration of "physician physical location" in our code values.

Which makes sense, of course. My "work", as valued by the radiotherapy codes, is completed regardless of the location of my body...as long as my body has access to a computer and internet.

Now, it's definitely true that some of the radiotherapy CPT values are based on the physical presence of the therapists.

I would hope, desperately, that the fine folks at ASTRO did not mentally misinterpret those descriptions.

I would also hope, if there ever were clear rumblings over our physical location affecting code value, it would be repeatedly articulated that our work is not less, or less complicated, because of where the body of the physician existed in time and space when that work was completed.

 

[NotMattSpraker]

I initially thought the ASTRO supervision stance may have something to do with job market (and I still think it does to a lesser degree)...but after watching the town hall I started to think it may be a play to CMS to emphasize the importance/expertise/value of our services and avoid worsening cuts.

Look, CMS can't understand what we do....90% of physicians don't know what we do. They don't know about nuances of contouring, elective nodal coverage, where to aim, symptom management, etc. It's easier to explain our worth by saying we must be there to oversee these dangerous high energy X rays.

If that is the case they are doing an absolutely terrible job.

Also, in my opinion, its lazy to say "people cant understand what we do". Its also offensive to our colleagues. Teach them and don't dumb down the nuance or hide the uncertainty. I understand its easier to just say the simple thing but its a way worse strategy. Same one that destroyed the public's trust in medicine through COVID.

Screwing up "The Value of Radiation" argument to CMS is like snatching defeat from the jaws of victory. The world wide narrative around radiation right now is that it is an incredible value that is under utilized in cancer care. Just parrot our international colleagues that are much better at this than ROs in the US. You don't even need an original thought, Dave, you're good.

 

[communitydoc13]

But in terms of public-facing data...the CMS supervision rules are not an evidenced-based intervention.

This is true, but IMO basically inconsequential, and I agree with you that ASTRO's stance is unlikely to drive CMS rules. Hopefully ASTRO knows this and this is mostly a cultural move (itself powerful).

The best evidence can ever get us to is reductio ad unlikely (to paraphrase Ellenberg). Unlikely is always what you are concerned about with regard to safety and most quality. As discussed many years ago, we all know good docs and bad docs. The difference is vanishingly unlikely to be statistically significant, despite our hopes and dreams.

I think all points here have been great, and I particularly value the input from @MidwestRadOnc, @Mandelin Rain and you, who all clearly have experience in clinics that are not what most of us would call typical. It is also clear to me that in each of your circumstances, it is in fact your in- person presence that provides the greatest relative value over any alternative for staffing (be that 100% remote or locums or whatever).

But, I would ask one question of any advocate of virtual care.

1. Is there anything that you can do better, in terms of clinical care, virtually as opposed to in person?

So virtual should be an option when it needs to be an option IMO. This is why the rest of medicine is moving that way. Not because they believe stroke care or psych care or primary care is better performed virtually, but because it is necessary to offer these things virtually when there are not in-person docs available (and on occasion when trying to improve compliance for marginal patients).

As we all know, with the exception of certain niche jobs/locales, there are plenty of radoncs available.

 

[elementaryschooleconomics]

1. Is there anything that you can do better, in terms of clinical care, virtually as opposed to in person?

So virtual should be an option when it needs to be an option IMO. This is why the rest of medicine is moving that way. Not because they believe stroke care or psych care or primary care is better performed virtually, but because it is necessary to offer these things virtually when there are not in-person docs available (and on occasion when trying to improve compliance for marginal patients).

As we all know, with the exception of certain niche jobs/locales, there are plenty of radoncs available.

Yes!!!!

That's why I choose to be here, in person, almost all of the time (even staying in clinic after the linac is done for the day).

Which is why ASTRO should have stayed silent.

First, this was the wrong time to try any stunt like this. Everyone else in medicine - including CMS - is going through the motions of making Virtual Direct permanent. Doing it this way is just a silly speck of noise in the setting of overwhelming signal.

After Virtual Direct is permanent, there were several avenues they could have taken.

But the easiest would have been to continue to make supervision part of their APEX accreditation, as well as publish "guidelines" recommending Direct Supervision "most of the time".

This is an infinite rabbit hole to speculate on, of course.

The only thing I can say for certain, in my opinion, at least, was "unilaterally authoring a surprise letter to CMS advocating for not only no permanent Virtual Direct, but also revoking General Supervision, just for Radiation Oncology" in unique opposition to the messaging from all other societies...

That was the wrong choice.

 

[Mandelin Rain]

I 'm not advocating for virtual care. I'm advocating for general supervision.

 

[elementaryschooleconomics]

I 'm not advocating for virtual care. I'm advocating for general supervision.

Good point, me too.

I'm a staunch advocate of the status quo!

(disclaimer: basically only for this, I never get to say that sentence and took the opportunity)

 

[TheWallnerus]

1. Is there anything that you can do better, in terms of clinical care, virtually as opposed to in person?

Reach more people.

Why has virtual care "exploded" in other specialties (radiology included)? HUGE DEMAND.

The premise of the question is a little loaded too, as being there in person is not an option 100% of the time (truly solo rad oncs), so in those cases being available by phone, video, etc., must be better than nothing.

We can't forget that Ron D was promulgating the myth that image checking from home was fraud as recently as ~2016, so "virtual supervision" putting a knife in that and other nonsense ("I had friends reported to hospital admin for leaving the clinic to grab lunch at the hospital cafeteria") makes us better doctors, too, I would argue because it gives us autonomy and improves quality of life.

 

[TheWallnerus]

At MUSC, according to Brian Lally, they have zero work from home policies and do not authorize any physician image checking remotely off-site. Weird stuff. Anti-doctor stuff imho. Should you only have the privilege of remote/virtual work if you're not a solo or rural rad onc??? That's what would happen with a return to direct. There would be a carve out for solo/rural, but it would be penurious: they couldn't be virtual.

 

[medgator]

At MUSC, according to Brian Lally, they have zero work from home policies and do not authorize any physician image checking remotely off-site. Weird stuff. Anti-doctor stuff imho. Should you only have the privilege of remote/virtual work if you're not a solo or rural rad onc??? That's what would happen with a return to direct. There would be a carve out for solo/rural, but it would be penurious: they couldn't be virtual.

Big ACRO guy. I guess we know where they stand too then. Disappointing

 

[communitydoc13]

HUGE DEMAND.

Yes, of course. If there were a "huge demand" for radonc services relative to docs available, I would be advocating for expansion of virtual services.

Also...The MUSC stuff is weird IMO. In a big academic center, docs should be working from home a fair bit IMO. While I doubt an exam or a sim or even the RTTs day is necessarily better without a doc on-site, there are probably a fair number of folks who can read, write and think better at home.

 

[RO28]

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.

you should see my inbox...not sure whats worse, my gmail inbox, my actual physical inbox or my aria task pad

to be clear, i do all the tasks, I just don't use the task pad.

 

[RO28]

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

Right?? I have SO.MANY.QUESTIONS

 

[TheWallnerus]

Yes, of course. If there were a "huge demand" for radonc services relative to docs available, I would be advocating for expansion of virtual services.

And thus, very Mufasa and Simba like, we circle back to ASTRO.

In the equation of supply and demand, ASTRO's letter... and numerous other of their past behaviors... shows their repeated ability to be lazy instead of energetic. Brittle minded instead of creative. Mean instead of loving. Self-serving instead of magnanimous. Deaf instead of listening.

And it shows why one of the stupidest things I think you can do as a practicing rad onc right now is not support virtual or not, but to be an ASTRO member.

 

[BobbyHeenan]

If that is the case they are doing an absolutely terrible job.

Also, in my opinion, its lazy to say "people cant understand what we do". Its also offensive to our colleagues. Teach them and don't dumb down the nuance or hide the uncertainty. I understand its easier to just say the simple thing but its a way worse strategy. Same one that destroyed the public's trust in medicine through COVID.

Screwing up "The Value of Radiation" argument to CMS is like snatching defeat from the jaws of victory. The world wide narrative around radiation right now is that it is an incredible value that is under utilized in cancer care. Just parrot our international colleagues that are much better at this than ROs in the US. You don't even need an original thought, Dave, you're good.

People absolutely can learn, but I've seen literal CEO's of large cancer systems have minimal knowledge about what the rad oncs do. People can understand it, but at the same time they can obtain positions of power/decision making clout, and still not know what we do.

 

[BobbyHeenan]

At MUSC, according to Brian Lally, they have zero work from home policies and do not authorize any physician image checking remotely off-site. Weird stuff. Anti-doctor stuff imho. Should you only have the privilege of remote/virtual work if you're not a solo or rural rad onc??? That's what would happen with a return to direct. There would be a carve out for solo/rural, but it would be penurious: they couldn't be virtual.

That's a messed up policy.

In the town hall ASTRO leadership said explicitly checking IGRT images from home was perfectly fine with them.

 

[medgator]

ACRO just sent out a supervision survey to its membership and included a link to it's CMS letter from 9/27/2019 regarding supervision (which I imagine is the comment period before CMS made the general supervision rule change in Jan 2020 pre-covid):

Under the current direct supervision regulations, it is impermissible for
providers to bill Medicare for those services requiring direct supervision but performed in the absence of a radiation oncologist.

As a result, a single radiation oncologist operator often cannot attend tumor boards, see patients in the hospital ER to help determine whether an admission is appropriate, assist in initial evaluations, provide brachytherapy procedures in the operating room while treating Medicare patients, or perform consultations on critical inpatients in a timely manner.

We believe regulations could be revised to permit general supervision for limited temporal periods and circumstances that might require the radiation oncologist to be “directly” absent from the site for a specific and time-limited purpose (e.g. participation in a hospital tumor board/conference, performance of a consultation on a hospital inpatient or emergency room patient, performance of a brachytherapy procedure, etc.). We would propose such limited general supervision rules be applied equally in the hospital and non-hospital setting.

ACRO continues to believe that all patients are best served if they have the opportunity to receive state-of-the-art cancer treatments close to home. This is best accomplished if their care providers have the opportunity to participate in ongoing tumor boards and prospective case review as
advocated by virtually all of the nationally certified programs and to provide those occasional
services outside of the actual radiation therapy site, as might be periodically necessary.

This looks 100000x better than the garbage ASTRO has been saying imo, actually looks like it was written by someone who practices IRL away from an overstaffed single-site academic dept

 

[TheWallnerus]

That's a messed up policy.

In the town hall ASTRO leadership said explicitly checking IGRT images from home was perfectly fine with them.

Yes. They are dumb, and by dumb I mean they’re trying to (re)pass a law they don’t understand. In freestanding, the IGRT is billed globally. However the technical part of the code carries the direct supervision requirement under the MPFS. But billing the code globally puts the implication the professional was done under direct, and would make for possible lucrative qui tams (were someone to try and make a case). This was always Ron D’s line of logic; I am sure I’m explaining something here many already understand or know.

 

[elementaryschooleconomics]

I am sure I’m explaining something here many already understand or know.

Based on observing the conversations around this point for many years, I suspect the number of people who understand this point is actually very, very low.

(but yeah, they're probably all on SDN, lol)

Regardless, I don't think this has EVER been tested in any case or challenged anywhere in any official capacity.

But, I've always found this super weird:

For the IGRT code you're talking about (77014 off the top of my head), the "02 - Direct Supervision" is only for TC

Both the global AND the professional carry "09 - Does Not Apply".

Scrolling through the CPT codes, this breakdown seems really uncommon (obviously I haven't meticulously examined ALL codes, though).

1) What was the point of that?
2) Is anyone out there ever ONLY dropping 77014-TC? Seems unlikely, post-2015 bundle.
3) If both the global and professional have the 09 - Does Not Apply, why would anyone make the inductive leap the Direct Supervision is required?

Now, to be clear: I know exactly why Ron and ASTRO think that.

Taking that crew and their conflicts of interest aside, I'm asking in a vacuum, as in, can anyone construct an unbiased argument?

 

[BobbyHeenan]

Yes. They are dumb, and by dumb I mean they’re trying to (re)pass a law they don’t understand. In freestanding, the IGRT is billed globally. However the technical part of the code carries the direct supervision requirement under the MPFS. But billing the code globally puts the implication the professional was done under direct, and would make for possible lucrative qui tams (were someone to try and make a case). This was always Ron D’s line of logic; I am sure I’m explaining something here many already understand or know.

It's also another reason why we need clarity from CMS. THere are very clear-cut scenarios that need clear cut rules on..unfortunately gray areas are either abused or milked/weaponized by multiple players (be it qui tams or billing /scare companies)....

1. Can daily IGRT be checked remotely after it is performed, even in a "direct supervision" environment? We need a clear answer here. I would interpret it as the physican is directly avialable to review/supervise the IGRT if needed, but the actual process of signing off on the image/reviewing the image may be done remotely before the next fraction. Like you are saying though, there is some wiggle room in interpretation and that wiggle room can be weaponized. The ASTRO interpretation is that yes, you can check films remotely. But ASTRO doesn't matter, CMS does.

2. If direct supervision is required, does it absolutely have to be a rad onc? yes, we understand it is best to have a rad onc, but in some situations can a formally designated other non rad onc physician and/or physician extender serve as the supervising physician when a rad onc is not immediately available?

 

[TheWallnerus]

It's also another reason why we need clarity from CMS. THere are very clear-cut scenarios that need clear cut rules on..unfortunately gray areas are either abused or milked/weaponized by multiple players (be it qui tams or billing /scare companies)....

1. Can daily IGRT be checked remotely after it is performed, even in a "direct supervision" environment? We need a clear answer here. I would interpret it as the physican is directly avialable to review/supervise the IGRT if needed, but the actual process of signing off on the image/reviewing the image may be done remotely before the next fraction. Like you are saying though, there is some wiggle room in interpretation and that wiggle room can be weaponized. The ASTRO interpretation is that yes, you can check films remotely. But ASTRO doesn't matter, CMS does.

2. If direct supervision is required, does it absolutely have to be a rad onc? yes, we understand it is best to have a rad onc, but in some situations can a formally designated other non rad onc physician and/or physician extender serve as the supervising physician when a rad onc is not immediately available?

Easy questions under virtual

Problematic questions under blanket return to direct (and they were always problematic pre 2020)

 

[elementaryschooleconomics]

1. Can daily IGRT be checked remotely after it is performed, even in a "direct supervision" environment? We need a clear answer here. I would interpret it as the physican is directly avialable to review/supervise the IGRT if needed, but the actual process of signing off on the image/reviewing the image may be done remotely before the next fraction. Like you are saying though, there is some wiggle room in interpretation and that wiggle room can be weaponized. The ASTRO interpretation is that yes, you can check films remotely. But ASTRO doesn't matter, CMS does.

2. If direct supervision is required, does it absolutely have to be a rad onc? yes, we understand it is best to have a rad onc, but in some situations can a formally designated other non rad onc physician and/or physician extender serve as the supervising physician when a rad onc is not immediately available?

1) We have to remember that these rules are ONLY about Medicare billing. They are NOT about the practice of medicine.

If you were a cash-only practice, none of this would exist. As long as you have a license to practice medicine, and follow any applicable state regulations about who can operate X-ray emitting devices for human patients (vs veterinary patients), you can do whatever you want.

By the same logic: if ASTRO wants to claim IGRT has to be Direct Supervision, technically that is only for dates when 77014 is charged. Speaking generally, IGRT is mostly used in definitive cases. For definitive cases, IMRT/VMAT is most often used. IGRT (77014) has been bundled with IMRT since 2015 and cannot/is not charged daily.

Further, this is only in regards to Medicare patients. Private payors will often mimic CMS rules but not always.

So, let's say we live in a world where ASTRO gets IGRT back to Direct Supervision for everyone, and a clinic is unable to have a RadOnc on-site 100% of the time. You would be precisely following the letter of the law if you did daily IGRT for IMRT cases, but the RadOnc was only present for the day 77014 was charged.

2) No. This has legal precedence from a Kentucky qui tam case. This specific point was brought up (in Direct Supervision of radiotherapy, does it have to be a Radiation Oncologist). The court ruled initially, and on multiple appeals - no, no, no. Any doctor will do.

 

[BobbyHeenan]

Easy questions under virtual

Problematic questions under blanket return to direct (and they were always problematic pre 2020)

True.

They don't have to be problematic though.

I'm not for 100% direct supervision but if they go that route I'd like it to be clear that image acquisition/treatment requires in person direct, image review may be remote. It would literally take one sentence.

Same for NP/PA. Just one sentence.

 

[TheWallnerus]

True.

They don't have to be problematic though.

I'm not for 100% direct supervision but if they go that route I'd like it to be clear that image acquisition/treatment requires in person direct, image review may be remote. It would literally take one sentence.

Same for NP/PA. Just one sentence.

God would have to perform just one miracle to prove he’s real. But what fun would that be for human existence.