Did major supervision change just happen again

[scarbrtj]

To start, ASTRO's summary:

On Friday, November 1, 2019 the Centers for Medicare and Medicaid Services (CMS) issued the 2020 Hospital Outpatient Prospective Payment System final rule lowering the supervision level required for hospital-based therapeutic services, including radiation therapy services, from direct to general supervision. After carefully reviewing the rule and clarifying questions with the Agency, the ASTRO Board of Directors approved this updated guidance to help members understand that the supervision changes are more limited than they appear.
Most notably, direct supervision is still required, and the new general supervision policy does NOT apply when:...
• Diagnostic services, such as image guidance, are performed

CMS's logic seemed to be: all of rad onc's now under general supervision in the hospital. ASTRO's logic: image guidance is not a radiation therapy service (who knew?), it's diagnostic radiology aka a "diagnostic test."

OK.

Now this, for 2021:

Supervision of diagnostic services
Nonphysician practitioners (NPP) will be permitted to supervise the performance of diagnostic tests, within the scope of practice allowed by their state license. NPPs include the following:

• Nurse practitioners (NP)
• Physician assistants (PA)
• Clinical nurse specialists (CNS)
• Certified nurse midwives (CNM)

The definition of "direct supervision" of tests will be expanded to allow the use of real-time interactive audio and video technology. Both of these rules are already in effect temporarily for 2020 due to the COVID-19 public health emergency.

I may be off-base, but it's almost like CMS is attempting to change the supervision rules again. I have not seen ASTRO mention that IGRT can be done by nurse practitioners come 2021. (FWIW, NPs already can supervise chemo.)

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[RadOncDoc21]

Does this mean I can treat patients from home on my couch?

 

[metallica81788]

As a solo hospital-based radiation oncologist, does this (for the moment) mean I can hire a/an NP/PA to cover treatments while I am not physically present? Or was that the case in 2019 but now confirmed further?

This language has been confusing from the beginning and since I'm not ABR fully certified and have only passed 3/4 board exams I'm clearly too dumb to understand.

 

[scarbrtj]

As a solo hospital-based radiation oncologist, does this (for the moment) mean I can hire a/an NP/PA to cover treatments while I am not physically present? Or was that the case in 2019 but now confirmed further?

This language has been confusing from the beginning and since I'm not ABR fully certified and have only passed 3/4 board exams I'm clearly too dumb to understand.

What you're saying CMS is also saying. But zero surprise if ASTRO comes out in the next little bit and says, "Although CMS has decreased supervision for therapy to general and NPPs can now supervise IGRT, the supervision policies as written do not actually change any of the supervision policies themselves and...

Narrator: Here comes ASTRO's favorite phrase...

... are more limited than they appear."

In the meantime one day some poor stupid sap like you or me might just take the regulations at their word as written.

 

[dieABRdie]

As a solo hospital-based radiation oncologist, does this (for the moment) mean I can hire a/an NP/PA to cover treatments while I am not physically present? Or was that the case in 2019 but now confirmed further?

This language has been confusing from the beginning and since I'm not ABR fully certified and have only passed 3/4 board exams I'm clearly too dumb to understand.

I am fairly certain that without "direct" supervision requirement you don't even need an NP/PA to supervise when you aren't there. Or at least that's what my previous hospital is doing after this change. (i.e. doctor there for two days a week to see consults, f/us and otvs... no one there otherwise; except the therapist of course)

 

[Gfunk6]

Does this mean I can treat patients from home on my couch?

That depends, do you have a certified midwife sitting in your center doing your job?

 

[scarbrtj]

That depends, do you have a certified midwife sitting in your center doing your job?

Midwives (strangely) get lots of love from CMS in their supervision regs.

 

[RadOncDoc21]

That depends, do you have a certified midwife sitting in your center doing your job?

I only have one wife, I can’t afford to have any more!

 

[scarbrtj]

As expected.

Proposed Changes in Scope of Practice for Diagnostic Tests
In the 2021 MPFS proposed rule, CMS is proposing changes related to the scope of practice for physician fee schedule services that would allow Nurse Practitioners (NPs), certified Clinical Nurse Specialists (CNSs), Physician Assistants (PAs), and Certified Nurse Midwives (CNMs) to provide the appropriate level of supervision assigned to diagnostic tests, to the extent authorized under State law and scope of practice. In accordance with statute, these non-physician providers (NPPs) would be working either under physician supervision or in collaboration with a physician. According to CMS, this flexibility is designed to increase the capacity and availability of practitioners who can supervise diagnostic tests, which would alleviate some of the demand on physicians as the only source to perform this specific function. In order to pursue this modification, the Agency indicates that it would need to better understand the scope of practice for the different types of auxiliary staff who could potentially provide these tests under the supervision of a non-physician practitioner. According to the proposed rule, CMS is seeking to review state scope of practice laws and licensure requirements, as well as facility specific supervision policies to determine whether additional flexibilities can be granted for the supervision of diagnostic tests. This review potentially applies to existing diagnostic imaging tests associated with image guided radiation therapy (IGRT).

Section 410.32(b)(3) of the Code of Federal Regulations, Title 42 defines three different levels of physician supervision required for the various diagnostic imaging tests used in IGRT. The IGRT codes assigned to a given level are provided in parentheses below.
General Supervision: The procedure is furnished under the physician’s overall direction and control, but the physician’s presence is not required during the performance of the procedure. (76950 or G60012 - Ultrasonic guidance for placement of radiation therapy fields)
Direct Supervision: The physician must be present and immediately available to furnish assistance and direction throughout the performance of the procedure. The physician does not need to be present in the room when the procedure is performed. (77014 - Computed tomography guidance for placement of radiation therapy fields and 77421 or G60023 - Stereoscopic X-ray guidance for localization of target volume for the delivery of radiation therapy4 )
Personal Supervision: The physician must be in attendance in the room during the performance of the procedure. (76965 - Ultrasonic guidance for interstitial radioelement application).

ASTRO believes that NPs, PAs, and other non-physician members of the radiation oncology treatment team can play an important role in the ongoing management of patients receiving radiation therapy. These individuals can assist the radiation oncologist in the recognition and documentation of treatment-related symptoms and advise or prescribe interventions to mitigate acute or chronic treatment-related toxicity. Many practices comply with APEx Accreditation Standards that define specific staff roles and responsibilities, including supervision requirements associated with the delivery of specific modalities of treatment to ensure patient safety:
Standard 6: Safe Staffing Plan The radiation oncology practice (ROP) establishes, measures and maintains staffing requirements for safe operations in clinical radiation therapy.
6.1 - Staffing levels and requirements:
6.1.1 - The ROP has documentation of staffing requirements for each professional discipline that is derived from measurable criteria.
6.1.2 - The documentation specifies the number of each professional discipline required to be on-site, directly involved in patient care or available remotely during operating and non-operating hours.
6.1.3 - Coverage requirements include a qualified Radiation Oncologist to be on-call 24 hours a day and seven days a week to address patient needs and/or emergency treatments.
6.1.4 - There is a documented plan for coverage during planned and unplanned absences of professional staff.

Additionally, practices also adhere to Safety is No Accident for additional guidance regarding certification requirements that ensure radiation oncologists, physicists and other members of the radiation oncology team are adequately trained and educated on the complexities of radiation treatment delivery.5 The supervising physician or non-physician practitioner must have within his or her state scope of practice and hospital-granted privileges the ability to perform the service or procedure that he or she supervises.6 As it specifically pertains to radiation therapy services, many states (as well as hospital privilege guidelines) are likely to limit a non-physician practitioner’s scope of practice such that he or she would not be able to serve as a supervisor.

Additionally, due to the irreversible nature of radiation therapy, to protect patients and to ensure the continued delivery of safe and high-quality radiation therapy services it is ASTRO’s opinion that the existing supervision levels associated with IGRT services (i.e., codes G6001 (previously 76950), 77014, G6002 (previously 77421), and 76965) should remain in place and require the physician’s presence and participation as currently described in the CFR.

 

[Reaganite]

I am fairly certain that without "direct" supervision requirement you don't even need an NP/PA to supervise when you aren't there. Or at least that's what my previous hospital is doing after this change. (i.e. doctor there for two days a week to see consults, f/us and otvs... no one there otherwise; except the therapist of course)

How obtuse can these guys get? CMS has already said a Rad Onc can provide virtual supervision of IGRT. The next step is NPs providing supervision just like they do for much more dangerous chemotherapy. It's clear where CMS is going with all of this. Move on, ASTRO.

 

[scarbrtj]

How obtuse can these guys get? CMS has already said a Rad Onc can provide virtual supervision of IGRT. The next step is NPs providing supervision just like they do for much more dangerous chemotherapy. It's clear where CMS is going with all of this. Move on, ASTRO.

ASTRO's constantly harping on the "radiation is irreversible" angle. Thirsty. XRT never caused a single clearly XRT-related side effect in the clinic, on the visit it was given, in the history of medicine. Especially in comparison to, as you say, a more "dangerous" treatment like chemo (in which in-clinic reactions are, what, a trillion times more likely than RT) where NPs can supervise. In allowing general supv to happen for RT, it was CMS who made the point that not a single adverse outcome had ever been reported in the decade or so that general supervision of RT had been in effect in CAHs. Plus, for the longest, it's been codified that NPs can supervise radiation therapy in the hospital (this was prior to general supv being in effect). So ASTRO is not arguing that an NP can't supervise a patient getting 8 Gy for a bone met; they're arguing an NP can't supervise (too dangerous?) getting ~400-800 times less dose from a cone beam CT. That a radiation therapist actually administers. And a computer auto-matches. All without the NP being aware that a patient was even in-office to get any (tx, or the IGRT) of it done.

 

[RadOncMegatron]

Ok I'm dumb on this stuff, but this means less jobs right? For those with jobs how does this affect compensation, if at all?

 

[scarbrtj]

Ok I'm dumb on this stuff, but this means less jobs right? For those with jobs how does this affect compensation, if at all?

When supervision went from direct to general some higher-ups were (jarringly) saying "that's illegal." It'd be like someone in California saying marijuana is illegal in California. And when marijuana was made legal, it seemed almost overnight everyone availed themselves of marijuana opportunities. People were smoking it, farming it, selling it, taxing it, etc. But in rad onc, we have declared marijuana legal... and everyone's still saying it's taboo. Verboten. IMHO everyone is just kind of standing around looking at one another and thinking who's gonna be the first sucker (or hospital or group or consortium) to openly stick his head up above the parapet. Once that happens, and everyone sees the guy's not decapitated, it'll be Katy bar the door for GenesisCare types etc etc. That is to say, they will say: "why are we paying so many rad oncs to 'work' when it can be done cheaper." I know this for certain: let's say GenesisCare is overseeing a group of 5 rural-ish radiation centers in Australia. You think they have 5 (or more) rad oncs staffing those 5 centers? No. (EDIT: I know I say stuff like this a lot, but you think rad oncs came/come in three times a day on Saturday, and three times a day on Sunday, to treat patients in the UK? And one main reason CHART became CHART-WEL is the UK therapists were ready to stage a Peterloo.)

 

[RadOncDoc21]

When supervision went from direct to general some higher-ups were (jarringly) saying "that's illegal." It'd be like someone in California saying marijuana is illegal in California. And when marijuana was made legal, it seemed almost overnight everyone availed themselves of marijuana opportunities. People were smoking it, farming it, selling it, taxing it, etc. But in rad onc, we have declared marijuana legal... and everyone's still saying it's taboo. Verboten. IMHO everyone is just kind of standing around looking at one another and thinking who's gonna be the first sucker (or hospital or group or consortium) to openly stick his head up above the parapet. Once that happens, and everyone sees the guy's not decapitated, it'll be Katy bar the door for GenesisCare types etc etc. That is to say, they will say: "why are we paying so many rad oncs to 'work' when it can be done cheaper." I know this for certain: let's say GenesisCare is overseeing a group of 5 rural-ish radiation centers in Australia. You think they have 5 (or more) rad oncs staffing those 5 centers? No. (EDIT: I know I say stuff like this a lot, but you think rad oncs came/come in three times a day on Saturday, and three times a day on Sunday, to treat patients in the UK? And one main reason CHART became CHART-WEL is the UK therapists were ready to stage a Peterloo.)

I agree with everything you said but can we at least still use 21c in regards to GenesisCare because I feel like we need to continue to identify their group even though they are trying to shake off their name.

 

[heavyluva]

Do these changes apply to freestanding centers? I believe 21c is mostly comprised of freestanding clinics. I’m sure these changes will eventually impact both hospital and freestanding.. just not sure if that’s the case as of this moment. Does anyone know?

 

[scarbrtj]

Do these changes apply to freestanding centers? I believe 21c is mostly comprised of freestanding clinics. I’m sure these changes will eventually impact both hospital and freestanding.. just not sure if that’s the case as of this moment. Does anyone know?

Mostly freestanding. But some docs staff hospitals, and some of the centers are hospital-attached. "Virtual supervision" is present until Dec 2021 for everyone which in essence supersedes the changes I'm specifically mentioning which are not time-limited and, yes, apply only in the hospital setting. (That said, a CT "diagnostic test" in a freestanding radiology center... which involves technically a bit more dose than an IGRT CT... is general supervision.) I mention GenesisCare because I think it's ironic, or suspicious, that this foreign company which deals with radiation oncology in countries where "direct supervision" is a foreign concept has such a huge, new presence in the US.

 

[scarbrtj]

Looks like it's official?

Read this article by substituting "IGRT" instead of "diagnostic test."

As in...

CMS issued a final rule Dec. 1 that includes updates on policy changes for Medicare payments under the Physician Fee Schedule (PFS) and other Medicare Part B issues, on or after Jan. 1, 2021. CMS initially allowed nurse practitioners (NPs), clinical nurse specialists (CNSs), physician assistants (PAs), and certified nurse-midwives (CNMs) to supervise [IGRT] in May to increase testing capacity during the COVID-19 pandemic. The final rule makes that waiver permanent for [IGRT] within their scope of practice and state law and now includes CRNAs.

 

[Reaganite]

Final rule also extended virtual direct supervision: "After consideration of public comment, we are finalizing that direct supervision may be provided using real-time, interactive audio and video technology through the later of the end of the calendar year in which the PHE ends or December 31, 2021."

 

[fiji128]

Ok I guess this means that there is no point in the hospital ever paying for a locums to cover my one physician clinic for short 1 to 2 day periods that I maybe off (assuming all follow ups and consults are rescheduled) and so long as I continue to sign off on the daily CBCT remotely?

This essentially kills like what 50 to 75% of the locums market?

 

[dieABRdie]

Ok I guess this means that there is no point in the hospital ever paying for a locums to cover my one physician clinic for short 1 to 2 day periods that I maybe off (assuming all follow ups and consults are rescheduled) and so long as I continue to sign off on the daily CBCT remotely?

This essentially kills like what 50 to 75% of the locums market?

Yes. It also kills off some of the full time market. I had posted about this before but its worth repeating here. I personally witnessed one of those high paying, persistently unfillable rural jobs vaporize once the CEO realized he could hire someone for 1-2 days instead.

Doomed.....

 

[fiji128]

Ya this will not be good for our labor market as this plays out. Probably some older docs will postpone retirement as they won't be able to secure the occasional locums gig like in years past. I took a locums call the other day for the hell of it and the person said they definitely had way more docs then open locums positions.

Feel sorry for those 109 US MDs and other qualified non US MDs applicants that choose to ignore this type of stuff for whatever reason.

 

[scarbrtj]

Ya this will not be good for our labor market as this plays out. Probably some older docs will postpone retirement as they won't be able to secure the occasional locums gig like in years past. I took a locums call the other day for the hell of it and the person said they definitely had way more docs then open locums positions.

Feel sorry for those 109 US MDs and other qualified non US MDs applicants that choose to ignore this type of stuff for whatever reason.

It's important to note that RNs can now supervise the IGRT just on the basis of the regulations as written. Since oncology RNs are "advanced nurse specialists," they could supervise the IGRT. (See previous remarks re: parapets.) Many departments, if not hospitals, obviously already have these oncology RNs. And an "oncology RN" should have in their state scope of practice to engage in oncology-ish things (as long as they're just "physically hanging around" directly supervising and not actively personally supervising... I could foresee protocols where they engage w/ MD real time in case there are questions/issues etc etc). So it doesn't have to be a (more expensive?) nurse practitioner or PA per se. But OTOH this is all a Brave New World, and I am merely what-iffing.

 

[Reaganite]

IGRT

Waiting for the upcoming ASTRO paper where they will re-define IGRT, virtual supervision, and "advanced practitioner" to argue that on site supervision by a board certifiedrad onc is still required by CMS. Maybe we will even get an "advanced supervision fellowship" at one of our great rad onc centers of excellence.

 

[fiji128]

I have an oncology nurse and in no universe would I trust her to sign off on igrt stuff. Would much rather just have the therpist themselves make that call if need be.

 

[OTN]

I have an oncology nurse and in no universe would I trust her to sign off on igrt stuff. Would much rather just have the therpist themselves make that call if need be.

There's data from The Red Journal (I believe, though it could have been PRO) which showed that therapists and radoncs don't differ in their interpretation of CBCT/shifts/etc.

 

[scarbrtj]

I have an oncology nurse and in no universe would I trust her to sign off on igrt stuff. Would much rather just have the therpist themselves make that call if need be.

Waiting for the upcoming ASTRO paper where they will re-define IGRT, virtual supervision, and "advanced practitioner" to argue that on site supervision by a board certifiedrad onc is still required by CMS. Maybe we will even get an "advanced supervision fellowship" at one of our great rad onc centers of excellence.

Supervision ≠ "signing off." In all the times it's gone to court (to lazy to link), the courts have held that the "direct supervisor" need not even be aware he or she is directly supervising (since it's just a physical presence requirement). But, to supervise one must be able to "furnish assistance and direction," not actually sign off on and/or perform the procedure. "Assistance and direction" is rather subjective. If an NP were authorized to provide assistance to the therapists to give direction to cancel the day's treatment if the therapists didn't like the match, that'd be assistance/direction. If we're back to the point that no non-MD could ever provide assistance/direction despite CMS' expressly authorizing them to do so... well, I guess ASTRO probably will try to make that point. You're right Reaganite.

 

[radiaterMike]

Supervision ≠ "signing off." In all the times it's gone to court (to lazy to link)

when has this ever happened ??????????

 

[scarbrtj]

(to lazy to link)

when has this ever happened ??????????

True. No link, and a grammar error. Would correct that "to" to "too" but I'm "too" lazy!