1. The SDN iPhone App is back and free through November! Get it today and please post a review on the App Store!
    Dismiss Notice
  2. Dismiss Notice

Mandatory oncology payment model is coming

Discussion in 'Radiation Oncology' started by radmonckey, Nov 8, 2018.

  1. radmonckey

    radmonckey boomshakalaka
    5+ Year Member

    Joined:
    Aug 6, 2013
    Messages:
    142
    Likes Received:
    68
    Status:
    Attending Physician
    Azar Announces Mandatory Oncology Payment Model Is Coming

    Mandatory oncology payment model is coming and radiation oncology has been specifically targeted.

    I am not a guru on policy and am not sure what the big picture implications of this announcement are, although if its a step towards bundled and site neutral payments, maybe its not bad? Does seem like a bad thing that radiation oncology has been specifically targeted, although it may be more due to the nature of our work. Bothers me that Azar is an ex pharmaceutical guy, but maybe I'm reading too much into it.
     
  2. Note: SDN Members do not see this ad.

  3. evilbooyaa

    Staff Member Moderator 7+ Year Member

    Joined:
    Oct 10, 2011
    Messages:
    4,654
    Likes Received:
    3,041
    Status:
    Resident [Any Field]
    I don't think it's a good thing about rad onc being targeted either. I wonder how much of it is due to country-wide underutilization of breast hypofrac (and related factors) seen in SEER and NCDB analyses (this is not to get into an academics/PP debate, so please for the love of god let's not turn it into one).

    Given that ASTRO is cautiously optimistic about bundled care in general (just not forced like this guy wants to do) per the ASTRO CEO statement, I can't imagine it's going to lead to site neutral payments, as that's something ASTRO has perenially been against.

    We've been hearing about the bundled care boogeyman for a while now (all metastatic palliation must be 8Gy x 1! all breasts hypofrac'd! minimize radiation costs so that med oncs can continue to give systemic therapies that cost 10x what we do!) but I think this is more smoke. Maybe some people are actively dealing with the bundled care model at their institution... some are voluntary like Kaiser given straight salary with no RVU bonuses, others may be more forced?
    I'm not a fan that this guy was previously the president of Eli Lilly and in the board of directors for a pharma lobbyist company (Alex Azar - Wikipedia), as he's likely going to be more loyal to his own kind (med onc) than to the dirty rad oncs that are further down the referral chain.
     
  4. medgator

    medgator Senior Member
    Physician 10+ Year Member

    Joined:
    Sep 20, 2004
    Messages:
    3,439
    Likes Received:
    424
    Status:
    Attending Physician
    And treatment of low risk prostate ca with protons and the proliferation of proton centers in general with minimal data (or negative data in the case of lung and prostate) to support it, coupled with some insurers and the VA refusing to pay for it.

    There are multiple avenues where RO can be targeted, both on the pp/freestanding and academic side.

    Astro has not done this field any favors by being anti bundle as well, as this will likely lead to bundles being forced upon us, rather than leadership working with payors to incorporate it into clinical care
     
  5. OTN

    OTN Member
    15+ Year Member

    Joined:
    Nov 6, 2003
    Messages:
    511
    Likes Received:
    227
    They wouldn't be doing it if they weren't going to save $$$. The fact he's an old pharma guy is not good. There may be some benefits to some practices, however: I can't imagine our local urorads practice will be able to do that well under a value-based care model. Maybe I can treat prostates again!
     
  6. Gfunk6

    Gfunk6 And to think . . . I hesitated
    Physician PhD Faculty Moderator Emeritus Lifetime Donor Classifieds Approved 10+ Year Member

    Joined:
    Apr 15, 2004
    Messages:
    3,539
    Likes Received:
    472
    Status:
    Attending Physician
    One thing is for certain: there is no stopping them; the feds will soon be here. And I, for one, welcome our new bureaucratic overlords. I'd like to remind them as a trusted ABR certified Radiation Oncologist, I can be helpful in rounding up others to toil in their underground radiation vaults.
     
  7. DebtRising

    2+ Year Member

    Joined:
    Apr 19, 2016
    Messages:
    83
    Likes Received:
    95
    Status:
    Resident [Any Field]
    A drug executive planning to trim oncology spending by focus on radiation oncology is going to turn out to be a huge loser for radiation and access and big winner for immunotherapy spending.

    Targeting radiation, but not “oncology” is a bad omen. Good business move though so downstream they can lump oncology care together and obfuscate how much more goes to drugs. How can define an episode of care for oligomets? Easy - don’t.

    Best field in medicine.
     
  8. radiation

    7+ Year Member

    Joined:
    Oct 28, 2010
    Messages:
    22
    Likes Received:
    6


    Anti-PD-(L)1 class at $17B run rate already only 4 yrs after 1st approval, and they want to single out Radiation Oncology?

    Payment reform will be the single most important facing our specialty in the next decade - not ABR tests, residency expansion, or the job market. Lets see if we can get the same passion we've been seeing on the boards lately into that effort
     
    medgator likes this.
  9. imhopeful432

    Joined:
    Feb 28, 2018
    Messages:
    12
    Likes Received:
    5
    Status:
    Resident [Any Field]
    Just to clarify...ASTRO has been working and advocating for a bundled payment model and Dr. Brian Kavanagh testified to congress to that effect on behalf of ASTRO. The RO-APM proposed by CMMI is pretty much in line with what ASTRO wanted (the episodic model report to congress also suggested it could be site neutral). Leadership has also been working with private payers on this effort.

    The reason this is important is that so RO is not sidelined with med onc centric bundles that would make it even more difficult for independent rad oncs to practice. The fact that they are suggesting is a bit scary (probably unworkable/unrealistic), but I do think ASTRO is doing important work in this area!
     
  10. medgator

    medgator Senior Member
    Physician 10+ Year Member

    Joined:
    Sep 20, 2004
    Messages:
    3,439
    Likes Received:
    424
    Status:
    Attending Physician
    Again these are all recent efforts. Astro opposed bundles for years while freestanding organizations were pushing for them, and in some cases, working with payors to put pilot programs into place.

    Afaik, Astro still remains opposed to site neutral payments which hurts the freestanding/pp community and drives up costs of healthcare delivery on the whole
     
  11. imhopeful432

    Joined:
    Feb 28, 2018
    Messages:
    12
    Likes Received:
    5
    Status:
    Resident [Any Field]
    Agreed - they're not blameless. But its also important to give credit where credit is due - this (or any large scale) episodic payment model proposal would not be possible without concerted effort/coordination by ASTRO with CMMI for the past several years.
     
    evilbooyaa likes this.
  12. Fpg1245

    2+ Year Member

    Joined:
    Mar 8, 2016
    Messages:
    102
    Likes Received:
    37
    I actually had a thought that med Onc would have a tougher time with bundled payments just due to the sheer expense of the drugs they give. To me, episodic payments in RO just means you will take a loss on almost anything that has no good hypofrac data. Safe for breast and prostate. Deescalated head and neck. All fair game. Not so much for lung or upper GI (excluding pancreas) Cervical gyn, advanced endometrial ca, sarcomas, CNS (excluding indicated SRS), and probably some others. The financial sweet spot of the future will be disease sites that just need a short burst of RT. Anything that requires a long drawn out course of RT will be problematic. The BED/EQD2 calcs will definitely be your friend going forward. But then again who knows!
     
  13. Gfunk6

    Gfunk6 And to think . . . I hesitated
    Physician PhD Faculty Moderator Emeritus Lifetime Donor Classifieds Approved 10+ Year Member

    Joined:
    Apr 15, 2004
    Messages:
    3,539
    Likes Received:
    472
    Status:
    Attending Physician
  14. OTN

    OTN Member
    15+ Year Member

    Joined:
    Nov 6, 2003
    Messages:
    511
    Likes Received:
    227
    There's only so much you can do to reduce your costs, though, as the vast majority of ours are fixed. Hard negotiating with vendors, only purchasing technology when there's a clear clinical benefit, and keeping staffing to a minimum will be crucial to financial success. Larger practices or those affiliated with a national organization will be able to use their size to drive prices from vendors down far more than smaller practices, so I worry this could be the nail in the coffin for smaller, independent groups.

    The devil's going to be 100% in the details here, and we obviously don't have any, so all this is just speculation for now.
     
  15. seper

    7+ Year Member

    Joined:
    Dec 22, 2010
    Messages:
    1,082
    Likes Received:
    134
    I'm not sure what exactly you guys are debating here, but my wild guess is that at least 30% of radiation oncology in US is waste. Think daily cone beams, redundant setup verification methods, treating everything curative at 1.8 Gy per fraction, recommending RT for non-painful bone mets, etc...

     
  16. Fpg1245

    2+ Year Member

    Joined:
    Mar 8, 2016
    Messages:
    102
    Likes Received:
    37
    Bundling...weather you want it or not. Azar probably wants it to be mandatory so that you’ll have to accept any level of reimbursement under the guise the we have to try something. But hey ACRO and ASTRO wanted it and now their gonna get sand bagged for it. Get out the limbo stick cause the new paradigm is “how low can you go?”
     
  17. Fpg1245

    2+ Year Member

    Joined:
    Mar 8, 2016
    Messages:
    102
    Likes Received:
    37
    Disagree more like 45% waste. I guess it’s comforting for all newly minted rad oncs coming down the pike that almost half of what they do will be a complete waste. I also wonder what it is compared to other fields
     
  18. radmonckey

    radmonckey boomshakalaka
    5+ Year Member

    Joined:
    Aug 6, 2013
    Messages:
    142
    Likes Received:
    68
    Status:
    Attending Physician
    Hmmm, reimbursement plummets, small practices get squeezed out, large practices don't hire to maintain salary, doesn't paint a rosy picture.
     
  19. Mandelin Rain

    7+ Year Member

    Joined:
    Apr 21, 2011
    Messages:
    302
    Likes Received:
    188
    I'm going to take issue with 30-45% of rad onc is waste.

    I honestly can't think of too many things I'd change about my practice if there were bundled payments tomorrow. I may get paid less for doing them, but I usually have a reason for what I'm doing beyond "C.R.E.A.M."
     
  20. OTN

    OTN Member
    15+ Year Member

    Joined:
    Nov 6, 2003
    Messages:
    511
    Likes Received:
    227
    Any and all practice expansion/cancer center development plans are going to be halted until the details of the plan are released, that's for sure. I'm not personally worried about any "wasteful" radiation from my end, as that's not how I practice.
     
  21. evilbooyaa

    Staff Member Moderator 7+ Year Member

    Joined:
    Oct 10, 2011
    Messages:
    4,654
    Likes Received:
    3,041
    Status:
    Resident [Any Field]
    What? What data/statements do you have to back-up claims that high? You guys really think 1/3rd to 1/2 of what we do is waste? IDK where you guys practice, but that seems excessively excessively high.
     
    OTN and medgator like this.
  22. medgator

    medgator Senior Member
    Physician 10+ Year Member

    Joined:
    Sep 20, 2004
    Messages:
    3,439
    Likes Received:
    424
    Status:
    Attending Physician
    What do you think that percentage is for med onc? esp considering that opdivo got approved without any requirement for pdl1 testing, or that med onc in this country has done things like give carbo and avastin rather than a cis doublet in metastatic nsclc disease which drives up costs big time on an absolute basis as compared to RO.

    I also look forward to how you reached that 45% figure for RO?
     
    #21 medgator, Nov 9, 2018
    Last edited: Nov 9, 2018
  23. RickyScott

    Joined:
    Oct 4, 2017
    Messages:
    196
    Likes Received:
    141
    Status:
    Attending Physician
    RE 30-45%. I can tell you that if I treated most my mets/whole brain 8 x 1 or 4 x5 all prostate 60/20 70/28 (already hypo breast), easily reduce volume 30-45%. If i wasnt hypofractionating breast already, it would be much greater. Rectals could be 5x5, lung 250 x 22 etc.
    On a national scale, I would guess 30-45% may be an undersestimation. None of the 21C or freestanding practices in my area do very much hypofractionation.
    ( and FYI, I am not going to bring the job matket into this)
     
    #22 RickyScott, Nov 9, 2018
    Last edited: Nov 9, 2018
  24. medgator

    medgator Senior Member
    Physician 10+ Year Member

    Joined:
    Sep 20, 2004
    Messages:
    3,439
    Likes Received:
    424
    Status:
    Attending Physician
    Sure, but should you be treating all wbrt 8x1 or 4x5?

    Hospice might be cheaper.... otherwise imo it would be unethical to treat good PS patients like that who are otherwise controlled extracranially.
     
    evilbooyaa and RickyScott like this.
  25. RickyScott

    Joined:
    Oct 4, 2017
    Messages:
    196
    Likes Received:
    141
    Status:
    Attending Physician
    Yes- I would never do that, just trying to make the point that there is still a lot of room for hypofractionation in most practices,
     
  26. Fpg1245

    2+ Year Member

    Joined:
    Mar 8, 2016
    Messages:
    102
    Likes Received:
    37
    Maybe I’m underestimating. Things you might encounter

    Breast. - 16 Fx daily to 6 fx weekly or intraop x1 and just wait till some breast surgeon academic FINALLY finds a subgroup that can do without RT - 63% waste
    Prostate - 79.2in 44fx to 5fx SBRT or 19 x 1 HDR - 89-97% waste
    Palliative - 20in 5fx to 8in 1fx - 80% waste
    CNS - GBMs brain 60 in 30 to 5 x 5. SBRT any and all pituitary, meningioma etc vs conv fx - 83% waste
    Rectal Ca - 50.4 in 28fx to 5x5 - 82% waste
    Pancreas - 50.4gy in 28 to 25 x 1 - maybe even 100% waste as I get pushback even on the inoperable ones
    Lymphoma - 24-36gy in 12-18 to 2x2 (not just palliation either probably won’t even be doing that because they’ll just switch up immuno or targeted agents in future) - 83% waste at least
    Head and Neck - most if not all your p16 positive pts 70 in 35 to 54 in 27-30 possibly can go lower to 36Gy in 18. - 20-50% waste
    Sarcoma - 50-70gy in 25-35fx EBRT to maybe 25-35Gy EBRT plus Brachy boost (lots of unreimbursable work OR coordination and tx planning)



    Lung, esophagus, cervical, endometrial, gastric, skin - haven’t seen a ton of hypofrac out there so sage for now.

    And don’t ever question the pharma med Onc industrial complex EVER...or Alex Azar will mandate ROs shine his shoes and live in huts from now on because “we need to have a willingness to try”. Lol
     
  27. RickyScott

    Joined:
    Oct 4, 2017
    Messages:
    196
    Likes Received:
    141
    Status:
    Attending Physician
    Just download the National Health Service radiation policies for the UK or get a hold of Keiser Permanentes to see the future here.

    In terms of lung, esophagus etc. A lot of seminal trials actually used hypofractionation oversease like Walsh NEJM trial in esophagus and some of the chemorads trials in lung so the data is out there.

    50-55 Gy/20-22 is a common scheme with concurrent chemo in Canada/UK for bladder, lung,
    40-2/15-16 small cell
     
    #26 RickyScott, Nov 9, 2018
    Last edited: Nov 9, 2018
  28. Fpg1245

    2+ Year Member

    Joined:
    Mar 8, 2016
    Messages:
    102
    Likes Received:
    37

    Also If I hear another damn med student tell me about their “passion” for this field I’m just going to ask them if they also have a passion for wasting healthcare dollars and the patients time as well. Honestly even with the oligomets thing it’s so silly to think there’s enough work out there for current attendings. Field needs a serious contraction 45% won’t do try 75%. Even if we are being generous and take 30% as the amount of waste in the system. A Rad Onc spends 30% of the time doing things that is in no way therapeutic for a patients or 3 out of every 10 ROs is basically a non therapeutic entity basically radiating people where it’s at best not helping them. At worst 3 out of every 4 shouldn’t even still be practicing.
     
  29. Fpg1245

    2+ Year Member

    Joined:
    Mar 8, 2016
    Messages:
    102
    Likes Received:
    37

    Darn you are right. I forgot about that bladder regimen. I think it’s BC2001 or something. There I go again being a dumb Rad Onc not knowing another freaking study. They should honestly fire me at this point. I doubt any other field is so hardcore on the literature maybe IM but there just too damn busy.
     
  30. OTN

    OTN Member
    15+ Year Member

    Joined:
    Nov 6, 2003
    Messages:
    511
    Likes Received:
    227
    Breast: Intraop x 1 with 10-fold recurrence rate. Agree 6 weekly fractions might work. Still too early to tell.
    Prostate: SBRT not good for high-risk disease, and I haven't seen enough HDR data to be comfortable with it.
    Palliative: 8 Gy in 1 fraction is associated with a doubling of retreatment rates
    CNS: I haven't seen any convincing data showing 5x5 is equivalent. Lots of pituitaries aren't eligible for SBRT due to chiasm.
    Rectal ca: T4 tumors, low-lying tumors need long-course to improve margin-negative resections. Good data showing we don't have to operate on all patients, so longer course for older patients is coming back into vogue.
    Pancreas: 25 Gy x 1 hurt people very badly (stanford data)
    Lymphoma: 2x2 has not been shown to have the durable control of longer schedules
    Head and Neck: No trials have shown a de-escalation protocol that works as well as conventional fractionation
    Sarcoma: Now you're just making stuff up.
     
    evilbooyaa, Dare2Dream and medgator like this.
  31. RickyScott

    Joined:
    Oct 4, 2017
    Messages:
    196
    Likes Received:
    141
    Status:
    Attending Physician
    How
    You can quibble with some of the specifics, but just breast or prostate going to 15 and 20-28 fractions and mets 1-5 is huge. And BTW Canadian fellows I worked with would treat sarcomas 250 x 20-22, but I am not knowledgeable to quote anything offhand.

    Also wanted to bring up a common misconception about increased retreatment with 8Gy x 1. In many of the retreatment studies, the rate is higher because you can retreat after 8 Gy x1 ( a lot of docs at the time would not retreat the spine or other locations after 300 x10) That was always a point of contention.
     
  32. Fpg1245

    2+ Year Member

    Joined:
    Mar 8, 2016
    Messages:
    102
    Likes Received:
    37
    You’ll be treating breast 6fx weekly in 10years. It’ll make START and Whelan look like Childs play.

    Prostate - most common ones are the low and int risk ones and we are already using it and have treated 70 patientswith little toxicity and good bPFS. I expect the data to bear that out going forward.

    For head and neck p16 positive patients which is what is primarily driving the uptick in head and neck cancers. There are plenty of of De escalation trials out there because we know these patients do quite well and it’s not really that big of a leap to think they do just as well with less fx so I’m calling it. We most definitely will be de escalating for these patients in the near future. Quarterback, ECOG 3311, and Pathos come to mind.

    Pancreas - yes 25 in one shot will hurt them. Just illustrating the point. Go look up a review on Sbrt dose Fx scheme of which there are several and pick the another one. The larger point still stands

    Sarcoma- what exactly is made up? EBRT brachy combos can and have been employed. Not as much now but they certainly are used.

    Rectum - yeah you got me these T4a rectal ca trainwrecks that never go to doctors and won’t come in for treatment that I rarely see and almost never get to treat due to compliance issues. I’m sure they’ll be happy to know they need a months worth of CRT.


    Palliative - 8 x1 is just gonna be more prevalent retreatment be damned. Argument is so old nobody is really listening anymore.

    Lymphoma - 2x2 by itself may not but add in rituxan and perhaps it is. Lymphoma isn’t exactly beating down my door either.
     
  33. medgator

    medgator Senior Member
    Physician 10+ Year Member

    Joined:
    Sep 20, 2004
    Messages:
    3,439
    Likes Received:
    424
    Status:
    Attending Physician
    I still find it funny how obsessed we are about finding waste and decreasing the cost of our specialty, when in the grand scheme of things, radiation spending is a blip compared to onc drug spending.

    I'm curious if they have these type of discussions in the heme/onc subforum.
     
    evilbooyaa likes this.
  34. OTN

    OTN Member
    15+ Year Member

    Joined:
    Nov 6, 2003
    Messages:
    511
    Likes Received:
    227
    Pure conjecture re: 8 Gy x 1, and it’s not logical, either. If you can’t retreat after 30 in 10 but can after 8 x 1, then that suggests 30 in 10 delivers more dose, which should improve local control.
     
  35. Fpg1245

    2+ Year Member

    Joined:
    Mar 8, 2016
    Messages:
    102
    Likes Received:
    37
    This is what passes for innovation in healthcare these days. Especially for Rad Onc. When you don’t have pharma backing you up it’s kind of a hard slog to make things interesting around here.
     
  36. RickyScott

    Joined:
    Oct 4, 2017
    Messages:
    196
    Likes Received:
    141
    Status:
    Attending Physician

    Clearly, one of the fellows in palliative radiation needs to weigh in ? ( over half of the fellowship is devoted to exploring this topic.)

    pain control would be equivalent in many studies, but retreatment rates were higher by a small absolute margin- used to be a standard part of the astro lecture.
     
    #35 RickyScott, Nov 9, 2018
    Last edited: Nov 9, 2018
    evilbooyaa and radmonckey like this.
  37. radmonckey

    radmonckey boomshakalaka
    5+ Year Member

    Joined:
    Aug 6, 2013
    Messages:
    142
    Likes Received:
    68
    Status:
    Attending Physician
    :rofl:
     
  38. Krukenberg

    2+ Year Member

    Joined:
    Jun 18, 2015
    Messages:
    108
    Likes Received:
    42
    Status:
    Resident [Any Field]
    The model he’s referring was designed and proposed by ASTRO. We’d all like the status quo to keep going but if Rad Onc didn’t create its own APM then the Oncology Care Model would have taken hold and screwed us all. This is a positive step.
     
  39. Gfunk6

    Gfunk6 And to think . . . I hesitated
    Physician PhD Faculty Moderator Emeritus Lifetime Donor Classifieds Approved 10+ Year Member

    Joined:
    Apr 15, 2004
    Messages:
    3,539
    Likes Received:
    472
    Status:
    Attending Physician
    Wow, I’m not certain anymore if some of the posts on this thread are serious or sarcastic. If you really want to reduce utilization and waste, 100 Gy x 1 offers 100% palliation and 0% retreatment rate.


    Sent from my iPhone using SDN
     
  40. medgator

    medgator Senior Member
    Physician 10+ Year Member

    Joined:
    Sep 20, 2004
    Messages:
    3,439
    Likes Received:
    424
    Status:
    Attending Physician
    With excellent local control as well
     
  41. RadOncDoc21

    7+ Year Member

    Joined:
    Oct 24, 2010
    Messages:
    1,094
    Likes Received:
    534
    Status:
    Attending Physician
    Saves money on health care cost also.
     
  42. Mandelin Rain

    7+ Year Member

    Joined:
    Apr 21, 2011
    Messages:
    302
    Likes Received:
    188
    Raises malpractice premiums though...
     
  43. Mandelin Rain

    7+ Year Member

    Joined:
    Apr 21, 2011
    Messages:
    302
    Likes Received:
    188
    We just had data presented that treating up to 5 mets with aggressive and expensive SBRT increases patient survival (ultimate outcome) and to celebrate, we have people here fraction shaming and stating that 8Gy x 1, APPA, to the tattoos is the only non wasteful way to treat a patient.

    Cheap care =/= good care
    Expensive care =/= good care
    Good care = good care

    Also, if you believe that nothing you do for your patients actually matters,you honestly should seek some help because you are deep in the throes of burnout.
     
    #42 Mandelin Rain, Nov 10, 2018 at 5:47 AM
    Last edited: Nov 10, 2018 at 5:57 AM
    evilbooyaa and medgator like this.
  44. RadOncDoc21

    7+ Year Member

    Joined:
    Oct 24, 2010
    Messages:
    1,094
    Likes Received:
    534
    Status:
    Attending Physician
    Are you saying the money we save for insurance companies wouldn’t cover that for us? Usually they are so helpful to us and only want what’s best for their patients!
     
    Mandelin Rain likes this.
  45. Mandelin Rain

    7+ Year Member

    Joined:
    Apr 21, 2011
    Messages:
    302
    Likes Received:
    188
    I'm guessing they will pass those savings on to the patients in the form of lower premiums and deductibles.
     
    RadOncDoc21 likes this.
  46. RadOncDoc21

    7+ Year Member

    Joined:
    Oct 24, 2010
    Messages:
    1,094
    Likes Received:
    534
    Status:
    Attending Physician
    Slight increase in acute toxicity, no long-term side effects though.
     
    evilbooyaa likes this.
  47. evilbooyaa

    Staff Member Moderator 7+ Year Member

    Joined:
    Oct 10, 2011
    Messages:
    4,654
    Likes Received:
    3,041
    Status:
    Resident [Any Field]
    Agree with all this. Things that work better should still get reimbursed. Yes, protons for prostate may not get paid for anymore. Standard fx in whole breast may not either. Rest is premature. Maybe the once weekly breast regimen will hold up.
     

Share This Page