Beggars Can't Be Choosing Wisely

[TheWallnerus]

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This is an open-book, single question test.

Here is the book:

Centers for Medicare & Medicaid Services Data

data.cms.gov

Here are the study guides:

Single-Fraction RT for Bone Mets Should Be 'Standard'

In the first-ever 'real world' study of palliative radiotherapy for bone metastases, single and multiple fractions were equivalent.

www.medscape.com

 

[medgator]

Choosing wisely is easy when you're not in network with Medicaid and are typically getting paid either 1) PPS exempt rates or 2) ridiculous negotiated private rates or 3) getting paid by the briefcases when treating foreign VIPs.

Even then many still may not choose wisely while virtue signaling to others to consider doing so

 

[RickyScott]

Choosing wisely is easy when you're not in network with Medicaid and are typically getting paid either 1) PPS exempt rates or 2) ridiculous negotiated private rates or 3) getting paid by the briefcases when treating foreign VIPs.

Even then many still may not choose wisely while virtue signaling to others to consider doing so

And most importantly… you are a destination center with jam packed machines so “Choosing wisely” improves business model by increasing throughout and capturing distant ( usually wealthy) patients. (Recently had pt /who lived within walking distance- travel to guess where in nyc for mri guided sbrt g8 disease.

 

[jondunn]

Some of this is a little out of hand

If you actually look at what the Choosing Wisely recommendations are about - what is in there that anyone of us would disagree with? Or do differently? I do think some rad oncs left to their own devices and unwatched will do some crazy ****, we have all seen it

These ASTRO committees have tons of community rad oncs


We are mixing up completely different points here

 

[medgator]

Some of this is a little out of hand

If you actually look at what the Choosing Wisely recommendations are about - what is in there that anyone of us would disagree with? Or do differently? I do think some rad oncs left to their own devices and unwatched will do some crazy ****, we have all seen it

These ASTRO committees have tons of community rad oncs


We are mixing up completely different points here

You really think a proton registry is going to do something to advance the field? Has it already?

 

[BobbyHeenan]

Some of this is a little out of hand

If you actually look at what the Choosing Wisely recommendations are about - what is in there that anyone of us would disagree with? Or do differently? I do think some rad oncs left to their own devices and unwatched will do some crazy ****, we have all seen it

These ASTRO committees have tons of community rad oncs


We are mixing up completely different points here

I'm perfectly fine with most of them.

But as medgator mentions. That "registry trial" proton BS was such a cop out. No registry trial will solve anything in prostate cancer or move the needle forward AT ALL. All these proton centers had years upon years upon years to run a randomized trial and we're still waiting. They enriched themselves under the guise of "on trial" prostate cases that haven't solved any clinical questions.

 

[jondunn]

This is the list I see

Choosing Wisely- American Society for Radiation Oncology (ASTRO) - American Society for Radiation Oncology (ASTRO)

Choosing Wisely aims to promote conversations between providers and patients by helping patients choose care that is supported by evidence, not duplicative of other tests or procedures already received, free from harm and truly necessary.

www.astro.org

what's the proton one? i may be missing it. I think maybe I have heard about it before - is it something like 'patient should only be treated with proton if on registry'?

sure it would be better if it said that 'patients should only be treated on trial with proton' but then im again im glad that they havent or would never say 'patients should only be treated for oligomets' on trial or on registry, and though im glad they dont say that, they would be justified by the current existing data to say it....

 

[BobbyHeenan]

This is the list I see

Choosing Wisely- American Society for Radiation Oncology (ASTRO) - American Society for Radiation Oncology (ASTRO)

Choosing Wisely aims to promote conversations between providers and patients by helping patients choose care that is supported by evidence, not duplicative of other tests or procedures already received, free from harm and truly necessary.

www.astro.org

what's the proton one? i may be missing it. I think maybe I have heard about it before - is it something like 'patient should only be treated with proton if on registry'?

sure it would be better if it said that 'patients should only be treated on trial with proton' but then im again im glad that they havent or would never say 'patients should only be treated for oligomets' on trial or on registry, and though im glad they dont say that, they would be justified by the current existing data to say it....

2013 Choosing Wisely List- American Society for Radiation Oncology (ASTRO) - American Society for Radiation Oncology (ASTRO)

List display of the 2013 Choosing Wisely statements.

www.astro.org

Don’t routinely recommend proton beam therapy for prostate cancer outside of a prospective clinical trial or registry.

• There is no clear evidence that proton beam therapy for prostate cancer offers any clinical advantage over other forms of definitive radiation therapy. Clinical trials are necessary to establish a possible advantage of this expensive therapy.

===

Aside: I've sat in on enough of these meetings to hypothesize that the initial draft said "prospective clinical trial" and someone then added "or registry" and no one wanted to put up a fight about it so it ended up being "clinical trial or registry."

 

[metallica81788]

Single institution phase I trial/registry = justification for larger centers to do whatever they well please in terms of modality, fractionation, dose, etc, backed by their name and reputation

 

[BobbyHeenan]

Single institution phase I trial/registry = justification for larger centers to do whatever they well please in terms of modality, fractionation, dose, etc, backed by their name and reputation

There are further reaching effects as well.

I'm guilty of it (so it's not like this is a "proton thing", but I've used these trials as rationale for some techniques/cases at times. As it pertains to proton, as others have noted, breast is a common proton case. I've seen a fair amount of proton APBI, and many using the MD Anderson series as justification.

 

[jondunn]

Aside: I've sat in on enough of these meetings to hypothesize that the initial draft said "prospective clinical trial" and someone then added "or registry" and no one wanted to put up a fight about it so it ended up being "clinical trial or registry."

oh absolutely. i'm glad they made a comment on proton at all.

 

[BobbyHeenan]

oh absolutely. i'm glad they made a comment on proton at all.

Yes. As part of many prostate consults I do I print off this choosing wisely, NCCN guidelines, and AUA/SUO/ASTRO guidelines.

Which basically all say what I at this time think to be true. Protons and photons seem equivalent so far.

 

[Gfunk6]

Here's a suggestion for an additional choose wisely:

We strongly recommend employment with a large academic center or health-care system.

• Physician-owned private practices lead to increased costs, futile treatments, worse toxicity, and lower survival. Clinical trials like APM are necessary to establish the viability of private practice.

 

[RickyScott]

There are further reaching effects as well.

I'm guilty of it (so it's not like this is a "proton thing", but I've used these trials as rationale for some techniques/cases at times. As it pertains to proton, as others have noted, breast is a common proton case. I've seen a fair amount of proton APBI, and many using the MD Anderson series as justification.

What is the possible justification for proton pbi? 99% The heart and lungs are not an issue in pbi?

 

[TheWallnerus]

No one got the right answer.

According to Medicare's own 2019 data, the treatment management code indicating only 1-2 fractions of radiotherapy was given (ie what you would/should bill when doing single fraction 8 Gy palliative) to 811 patients nationally in 2019.

Yeah, 811 patients, in the whole goddang country. Out of ~350,000 patients.

So the answer is ~0% for single fraction.

About 25,000-30,000 got SBRT, and about 5000 got an SRS.

The answer is 88/12/0.

 

[medgator]

This is the list I see

Choosing Wisely- American Society for Radiation Oncology (ASTRO) - American Society for Radiation Oncology (ASTRO)

Choosing Wisely aims to promote conversations between providers and patients by helping patients choose care that is supported by evidence, not duplicative of other tests or procedures already received, free from harm and truly necessary.

www.astro.org

sure it would be better if it said that 'patients should only be treated on trial with proton' but then im again im glad that they havent or would never say 'patients should only be treated for oligomets' on trial or on registry, and though im glad they dont say that, they would be justified by the current existing data to say it....

Already happens. Good luck getting evilcore to authorize SBRT for oligometastatic disease even with good data from brain for years

 

[jondunn]

No one got the right answer.

According to Medicare's own 2019 data, the treatment management code indicating only 1-2 fractions of radiotherapy was given (ie what you would/should bill when doing single fraction 8 Gy palliative) to 811 patients nationally in 2019.

Yeah, 811 patients, in the whole goddang country. Out of ~350,000 patients.

So the answer is ~0% for single fraction.

About 25,000-30,000 got SBRT, and about 5000 got an SRS.

The answer is 88/12/0.

I don't really get what the point is? few people do single fraction SBRT? duh? the highest level data exists for lung, and people do use it. also single fraction spine done on prospective study on 0631. people have different comfort levels and experience.

not getting the point. what am i missing?

 

[TheWallnerus]

I don't really get what the point is? few people do single fraction SBRT? duh? the highest level data exists for lung, and people do use it. also single fraction spine done on prospective study on 0631. people have different comfort levels and experience.

not getting the point. what am i missing?

Single fraction SBRT is different than single fraction RT.

Single fraction palliative bone met RT (ie to 8 Gy) should be done a lot; it's a "Choosing Wisely." It's done almost not at all.

~75% of all Medicare RT claims are for four diagnoses: breast, lung, prostate, and bone mets.

We would expect a significantly greater percent than ~0% for single fraction 8 Gy treatments in the Medicare data.

The hypothesis that American rad oncs are Choosing Wisely (for bone mets) is strongly, strongly rejected.

 

[jondunn]

Got it, seemed like you were talking about single fraction SBRT.

 

[TheWallnerus]

Now I'm going to be very literal and super explanatory about what I searched for in the Medicare data.

In rad onc there are only a few "management" codes and these are they:

They can not, except for 77470, exist simultaneously per episode in a patient's treatment course. CPT 77427 is the weekly tx mgmt code and should be billed if a patient gets 3 or more RT fractions. CPT 77431 gets billed for only 1-2 fx treatment. For single fx SRS, you bill 77432. For 2-5 fraction stereotactic, you bill 77435. (You can't bill 77427 or 77431 with 77435.)

And the Medicare data shows that 811 patients, across the whole country, were billed using CPT 77431 in 2019. (About 315,000 pts were billed 77427.)

So one of two things. Medicare data is bad, and they erroneously think we are SEVERELY over-fractionating in rad onc nationally. Or, we are SEVERELY over-fractionating in rad onc nationally.

 

[jondunn]

is there an update saying use 8/1?

this is what the choosing wisely says:

'Don’t routinely use extended fractionation schemes (>10 fractions) for palliation of bone metastases. '

 

[TheWallnerus]

is there an update saying use 8/1?

this is what the choosing wisely says:

'Don’t routinely use extended fractionation schemes (>10 fractions) for palliation of bone metastases. '

Lol, yes, an "update"... I guess (see my first post).

In America, roughly 16 Medicare patients, per state... per year... are getting single or two fraction non-SBRT radiotherapy.

The Choosing Wisely Native American is looking out over the land and shedding a tear.

 

[Mandelin Rain]

Lol, yes, an "update"... I guess (see my first post).

In America, roughly 16 Medicare patients, per state... per year... are getting single or two fraction non-SBRT radiotherapy.

The Choosing Wisely Native American is looking out over the land and shedding a tear.

I did at least 25 one-fraction bone mets in 2020. Not sure about 2019. Probably many less.

 

[TheWallnerus]

I did at least 25 one-fraction bone mets in 2020. Not sure about 2019. Probably many less.

Yeah the 2020 data will be interesting. At least in theory, all bone met palliation could be single fraction. But if we did that, and went all 5 fraction for early breast, we'd decimate many American rad oncs' livelihoods.

 

[GI_RadOnc]

I use 8 Gy in 1 fraction all the time; in fact; in our area there is a statewide quality measure to use 8 Gy / 1 fraction for uncomplicated bone metastases. I have said it before here, I think this is an untapped population that we don't see as much; mostly because we make it a pain in the a$$ on our referring physicians with the consultation, simulation, multiple fractions; etc. Some in this group have commented on how they make this easier for their referrings; and I have been trying to do the same at my place.

@TheWallnerus - I looked back on several patients, and sure enough, we are billing 77427, not 77431 for these. So my practice n of 1 says we are miscoding it.

 

[TheWallnerus]

I use 8 Gy in 1 fraction all the time; in fact; in our area there is a statewide quality measure to use 8 Gy / 1 fraction for uncomplicated bone metastases. I have said it before here, I think this is an untapped population that we don't see as much; mostly because we make it a pain in the a$$ on our referring physicians with the consultation, simulation, multiple fractions; etc. Some in this group have commented on how they make this easier for their referrings; and I have been trying to do the same at my place.

@TheWallnerus - I looked back on several patients, and sure enough, we are billing 77427, not 77431 for these. So my practice n of 1 says we are miscoding it.

Oh neat. Good info to know TBH. But it's harmful to miscode this way just again from the standpoint Medicare may see the relative overutilization of 77427 as evidence of overfractionating.

Re: the "miscoding"... What is SUPPOSED to happen is that the payor (insurance or Medicare) sees 1 fraction, and then sees a 77427, and goes "That does not compute" and then doesn't even reimburse the 77427 because there needs to be 3 fractions minimum for the code to be valid. If you're billing it out but not getting paid, yet another example of the tiny billing nuances in rad onc that makes it worthwhile to have someone constantly scrutinizing every single charged code.

 

[medgator]

Oh neat. Good info to know TBH. But it's harmful to miscode this way just again from the standpoint Medicare may see the relative overutilization of 77427 as evidence of overfractionating.

Re: the "miscoding"... What is SUPPOSED to happen is that the payor (insurance or Medicare) sees 1 fraction, and then sees a 77427, and goes "That does not compute" and then doesn't even reimburse the 77427 because there needs to be 3 fractions minimum for the code to be valid. If you're billing it out but not getting paid, yet another example of the tiny billing nuances in rad onc that makes it worthwhile to have someone constantly scrutinizing every single charged code.

Or you know, payment bundles for non stereo bone mets.....