How RadOnc Changes post COVID

[xrthopeful]

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[OTN]

- Small practices gone by winter
- Job market even worse as docs close to retirement freak out about their savings
- Cuts to everything in medicine as the federal government tries to figure out how to pay for a $200 billion hospitalization bill.
- Telemedicine appointments more prevalent

 

[Gfunk6]

Has anyone witnessed any concrete examples (e.g. not hearsay) of job offers being pulled due to COVID-19?

 

[BobbyHeenan]

I didn't quite understand the "small practices go out" comments.

I guess maybe due to APM just not enough $ to keep the doors open for these places treating only 12 patients, day?

Is that the thinking there?

 

[xrthopeful]

I didn't quite understand the "small practices go out" comments.

I guess maybe due to APM just not enough $ to keep the doors open for these places treating only 12 patients, day?

Is that the thinking there?

I mean outside of APM (no one has any idea if or when this will hit so should be ignored for the short term) if there are small practices that have very tight margins to stay open, the reduction in consults will cause some to have to consider closing I would think.

 

[RickyScott]

i dont think posters on this board fully appreciate how much conventional fractionation is out there in small practices etc. those practices are not posting on sdn or twitter. CMS noted that these types of facilities/outpt centers were overutilizing and running up the bill as part of rational for apm! Between APM and covid inspired adoption of hypofrctionation, I expect a lot of small practices to fold. I already see posters entertaining the notion that conventional prostate fract is not standard of care. I disagree, but expect that sentiment to become more common.

 

[Mandelin Rain]

I guess if you're a small practice operating on a razor thin margin, you're not hypofractionating even during COVID

 

[RadOncDoc21]

I guess if you're a small practice operating on a razor thin margin, you're not hypofractionating even during COVID

Not even small practices, I still see some of the urorads and whatnots giving that nice long course of slow easy going radiation. Water fountains in the lobby, expresso machines and all.

 

[Mandelin Rain]

A therapist from one of the local academic satellites rolled through our department, and he asked why breast cancer only got 3 weeks and prostate only 4 weeks. Had never heard of that.

This was like a month ago.

So.... yeah....

 

[BobbyHeenan]

Makes sense then.

Makes me feel like APM will hurt me, but not as much as others...though that initial formula for how you're paid it actually was better to have been long coursing everyone and you're penalized for having been treating with short courses over past few years.

 

[Mandelin Rain]

Makes sense then.

Makes me feel like APM will hurt me, but not as much as others...though that initial formula for how you're paid it actually was better to have been long coursing everyone and you're penalized for having been treating with short courses over past few years.

Like most things related to reimbursement, that particular stipulation makes no sense.

 

[Palex80]

Ignorant docs discover the wonder of hypofractionation!

 

[xrthopeful]

Makes sense then.

Makes me feel like APM will hurt me, but not as much as others...though that initial formula for how you're paid it actually was better to have been long coursing everyone and you're penalized for having been treating with short courses over past few years.

Can you clarify? My understanding is that since the APM is based on how much the average charge has been for a typical prostate course, if you already hypofrac, it won’t be a pay cut and will be a bit more actually since many do standard frac so the average is actually higher

However if you do standard frac now, the gravy train over in APM.

So for the BobbyHeenans and Medgators of the world, they may make out okay.

 

[BobbyHeenan]

Can you clarify? My understanding is that since the APM is based on how much the average charge has been for a typical prostate course, if you already hypofrac, it won’t be a pay cut and will be a bit more actually since many do standard frac so the average is actually higher

However if you do standard frac now, the gravy train over in APM.

So for the BobbyHeenans and Medgators of the world, they may make out okay.

I might be wrong, but somewhere in the formula (a multiplier) for what you receive there is a little factor in there for what you would be paid based upon your individual billing on a prostate case over the past few years.

So yes, while the APM formula starts with a base rate of what was typical for the across the country for a prostate case, there's a little "bump" in pay if your particular rate has been high the past few years.

Again, I may be wrong on this but that's the way I understood it.

 

[Mandelin Rain]

I might be wrong, but somewhere in the formula (a multiplier) for what you receive there is a little factor in there for what you would be paid based upon your individual billing on a prostate case over the past few years.

So yes, while the APM formula starts with a base rate of what was typical for the across the country for a prostate case, there's a little "bump" in pay if your particular rate has been high the past few years.

Again, I may be wrong on this but that's the way I understood it.

Yes. That’s my understanding. They don’t want any individual clinic to see their reimbursement completely tank. So you get a Multiple the standard APM rate if you’ve been over utilizing, to smooth the drop a bit.

completely nonsensical

 

[OTN]

I didn't quite understand the "small practices go out" comments.

I guess maybe due to APM just not enough $ to keep the doors open for these places treating only 12 patients, day?

Is that the thinking there?

I can only comment in my neck of the woods. The small practice where I'm located still gives chemotherapy, but they have to have large quantities of cash on hand to pay for said chemo before their reimbursement for it comes back. They're already hanging on by a thread, so a drop in patients for several months- which we're all surely going to see- will interrupt their cash flow significantly.

It's the drop in patients from the lack of elective procedures that's going to kill these practices.

 

[medgator]

Can you clarify? My understanding is that since the APM is based on how much the average charge has been for a typical prostate course, if you already hypofrac, it won’t be a pay cut and will be a bit more actually since many do standard frac so the average is actually higher

However if you do standard frac now, the gravy train over in APM.

So for the BobbyHeenans and Medgators of the world, they may make out okay.

Man you and @radoncgrad2019 need to make a club, assuming you aren't the same poster.

 

[xrthopeful]

Man you and @radoncgrad2019 need to make a club, assuming you aren't the same poster.

I’m confused - was giving you guys credit as users of hypofrac

 

[medgator]

I’m confused - was giving you guys credit as users of hypofrac

Oh ok, thought i was being fraction shamed for not adopting it in prostate as readily as everyone else . My bad.

In terms of breast, some of the payors won't even allow more than 21 fx unless you get p2p approval. Hate that it came to that, but i understand why it happened

 

[Gfunk6]

The central purpose of APM is to decrease utilization and decrease costs of Medicare beneficiaries . . . THAT'S IT.

Of course, CMS cannot come right and out say it so they cloak it under the rubric of "quality." The idea is for them to get everyone right above the point of fiscal collapse.

Nowhere is this more apparent than (as stated above) the fact that they use your own utilization rate as a baseline for cutting rates further. Logically, if my practice (like many others) has been faithfully hypofractionating over the years we would not be penalized for it.

 

[Chartreuse Wombat]

Yes but normofractionaters are protected in the sense that the year on year decrease is capped.

 

[medgator]

Yes but normofractionaters are protected in the sense that the year on year decrease is capped.

I'm sure evicore will let me know when i can start hypofx all prostate ca

 

[Reaganite]

Between APM and covid inspired adoption of hypofrctionation, I expect a lot of small practices to fold.

I think it remains to be seen. Don't underestimate the private guys who have survived this long. They generally have a good handle on the economics of their centers. You'd be surprised how low you can get the overhead once the equipment is paid off. At that point, staffing becomes the big expense, especially therapy and physics. Grind those costs down (and don't hire any new grads or locums) and you can get your overhead so low you're "almost" too lean to fail. You can almost cut your overhead proportionate to your decreased reimbursement. I think they'll be OK, but doubt they'll be hiring anyone any time soon.

 

[scarbrtj]

I think it remains to be seen. Don't underestimate the private guys who have survived this long. They generally have a good handle on the economics of their centers. You'd be surprised how low you can get the overhead once the equipment is paid off. At that point, staffing becomes the big expense, especially therapy and physics. Grind those costs down (and don't hire any new grads or locums) and you can get your overhead so low you're "almost" too lean to fail. You can almost cut your overhead proportionate to your decreased reimbursement. I think they'll be OK, but doubt they'll be hiring anyone any time soon.

Kid you not I knew of a few freestanding centers where the doc and his wife were the doc, therapist, receptionist, billing dept, dosimetrists, physicists, social workers and baristas.

 

[RickyScott]

Kid you not I knew of a few freestanding centers where the doc and his wife were the doc, therapist, receptionist, billing dept, dosimetrists, physicists, social workers and baristas.

there is no way that they had a barista license

 

[xrthopeful]

 

[Reaganite]

I have actually seen an increase in referrals if you can believe it. I work in an area with a good mix of private and academic satellite surgeons competing for business out of the same hospitals, and I feel like the academic guys have taken a step back, while the private guys are acggressively looking for the cancer cases and expediting their work up and surgeries. I know several of our local hospitals have cancelled elective surgeries, but cancer surgeries are excluded. (I should also mention these are advanced cases...not gleason 3+3s or T1 breasts in 80 year olds!).

 

[RadOncDoc21]

I have actually seen an increase in referrals if you can believe it. I work in an area with a good mix of private and academic satellite surgeons competing for business out of the same hospitals, and I feel like the academic guys have taken a step back, while the private guys are acggressively looking for the cancer cases and expediting their work up and surgeries. I know several of our local hospitals have cancelled elective surgeries, but cancer surgeries are excluded. (I should also mention these are advanced cases...not gleason 3+3s or T1 breasts in 80 year olds!).

This is true, as the hospitals ramp up to focus on the acute patients, outside docs can strictly focus on all the low hanging fruit. I guess the issue is getting those people out their homes.

 

[Mandelin Rain]

I'm seeing a lot of referrals because I think the med oncs don't want to deal with anyone right now and they are trying to buy some time.

 

[medgator]

I have actually seen an increase in referrals if you can believe it. I work in an area with a good mix of private and academic satellite surgeons competing for business out of the same hospitals, and I feel like the academic guys have taken a step back, while the private guys are acggressively looking for the cancer cases and expediting their work up and surgeries. I know several of our local hospitals have cancelled elective surgeries, but cancer surgeries are excluded. (I should also mention these are advanced cases...not gleason 3+3s or T1 breasts in 80 year olds!).

Mets don't stop for anyone, just got an add on for tomorrow from Pulmonary for a pt with a lung mass eroding through the scapula....

 

[chemsmith]

- Small practices gone by winter
- Job market even worse as docs close to retirement freak out about their savings
- Cuts to everything in medicine as the federal government tries to figure out how to pay for a $200 billion hospitalization bill.
- Telemedicine appointments more prevalent

Maybe I'm naive but how is it that these old rad oncs don't have enough to retire comfortably? They practiced during the glory years of rad onc reimbursement.

 

[medgator]

Maybe I'm naive but how is it that these old rad oncs don't have enough to retire comfortably? They practiced during the glory years of rad onc reimbursement.

Do you not know any baby boomers?

 

[Irradi8or]

Has anyone witnessed any concrete examples (e.g. not hearsay) of job offers being pulled due to COVID-19?

Yes, witnessed one over the last week (different practice). Colleague had verbally accepted a few weeks ago but that spot has been rescinded.

 

[Irradi8or]

Makes me feel like APM will hurt me, but not as much as others...though that initial formula for how you're paid it actually was better to have been long coursing everyone and you're penalized for having been treating with short courses over past few years.

Can you clarify? My understanding is that since the APM is based on how much the average charge has been for a typical prostate course, if you already hypofrac, it won’t be a pay cut and will be a bit more actually since many do standard frac so the average is actually higher

However if you do standard frac now, the gravy train over in APM.

So for the BobbyHeenans and Medgators of the world, they may make out okay.

I might be wrong, but somewhere in the formula (a multiplier) for what you receive there is a little factor in there for what you would be paid based upon your individual billing on a prostate case over the past few years.

So yes, while the APM formula starts with a base rate of what was typical for the across the country for a prostate case, there's a little "bump" in pay if your particular rate has been high the past few years.

Again, I may be wrong on this but that's the way I understood it.

Yes. That’s my understanding. They don’t want any individual clinic to see their reimbursement completely tank. So you get a Multiple the standard APM rate if you’ve been over utilizing, to smooth the drop a bit.

completely nonsensical

Here's a detailed analysis this group published pretty recently on the proposed RO Model's payment methodology, and how it does hurt even practices with low baseline historical episode costs. Bottom line is that the proposed RO Model is a cost cutting measure across the board as GFunk stated. I'm hearing in the background that CMS has not only heard these critiques loud and clear but also made substantive changes to the payment methodology for the final rule. We'll have to see it to believe it once that final rule is released...

De-Constructing the Proposed Radiation Oncology Model Payment Methodology: Implications for Practices and Opportunities for Improvement — JCO OP DAiS

By Nikhil G. Thaker, MD Arizona Oncology, Tucson, AZ Stuart Staggs The US Oncology Network and McKesson Corporation, The Woodlands, TX Rehman Meghani The US Oncology Network and McKesson Corporation, The Woodlands, TX The Centers for Medicare

jcoopblog.org

 

[medgator]

Here's a detailed analysis this group published pretty recently on the proposed RO Model's payment methodology, and how it does hurt even practices with low baseline historical episode costs. Bottom line is that the proposed RO Model is a cost cutting measure across the board as GFunk stated. I'm hearing in the background that CMS has not only heard these critiques loud and clear but also made substantive changes to the payment methodology for the final rule. We'll have to see it to believe it once that final rule is released...

De-Constructing the Proposed Radiation Oncology Model Payment Methodology: Implications for Practices and Opportunities for Improvement — JCO OP DAiS

By Nikhil G. Thaker, MD Arizona Oncology, Tucson, AZ Stuart Staggs The US Oncology Network and McKesson Corporation, The Woodlands, TX Rehman Meghani The US Oncology Network and McKesson Corporation, The Woodlands, TX The Centers for Medicare

jcoopblog.org

Guessing that final rule got knocked back for awhile.

Right now, CMS is trying to accelerate payments to help out practices.

 

[Irradi8or]

Guessing that final rule got knocked back for awhile.

Right now, CMS is trying to accelerate payments to help out practices.

Agreed - Have heard that the final rule is basically completing and budgeted, and before COVID, plan was to have released it this month (March) for a July 2020 start. Lots of folks asked to push back the start date to January 2021 but release the final rule asap so that selected practices could at least prepare. With COVID issues, everything will get pushed back but who knows for how long... In yesterday's release of info from CMS, they didn't specifically discuss the RO-APM, but they may make some changes to APM participants given COVID issues. They're pushing back deadlines for MIPS reporting among other things as well.

 

[BobbyHeenan]

If MIPS wasn't already a huge joke, how ridiculous does it look now to be scoring me on evaluating a pain score as a quality measure in the middle of a pandemic. Ugh.

 

[Mandelin Rain]

If MIPS wasn't already a huge joke, how ridiculous does it look now to be scoring me on evaluating a pain score as a quality measure in the middle of a pandemic. Ugh.

AND an opioid crisis....

 

[BobbyHeenan]

AND an opioid crisis....

You mean discussing pain at every visit and detailing how I discussed the pain plan might increase opiate prescribing? What are you, some kind of crazy genius? Who could have ever foreseen such a correlation? What foresight.

Why couldn't the government have hired you (or had two brain cells) when they devised this craziness?

 

[Mandelin Rain]

I discuss pain at exactly zero of my visits that I I don’t think should be having pain either from their cancer or their treatment, for that exact reason. When patients offer up how bad their fibromyalgia is my typical response is, “Oh my. You’re dealing that AND breast cancer? Well, let’s get one of them handled today...” or some such throw away to get back on topic.

Once you open that door, even a little, you’re more or less forced to walk though.

 

[scarbrtj]

"In China they are working on 'washing machine' radiation. Four buttons will do the treatment with a remote doctor: one doctor, 70 clinics, 70 million people."
- Dr. Vincenzo Valentini, July 21, 2017

"For services requiring direct supervision by the physician or other practitioner, that physician supervision can be provided virtually using real-time audio/video technology."
- Centers for Medicare & Medicaid Services, March 30, 2020

"Once a man has tasted freedom, he will never be content to be a slave."
- Walt Disney, March 1, 1941

 

[radoncgrad2019]

The key will be, and there is zero reason technically why this can’t happen, is when we can make on line shifts ourselves from our home computer for sbrt on line cone beams.

That
Will be awesome

 

[scarbrtj]

The key will be, and there is zero reason technically why this can’t happen, is when we can make on line shifts ourselves from our home computer for sbrt on line cone beams.

That
Will be awesome

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[medgator]

The key will be, and there is zero reason technically why this can’t happen, is when we can make on line shifts ourselves from our home computer for sbrt on line cone beams.

That
Will be awesome

Unless you need a job soon