Medicare PFS 2026 proposed rule

Started by BobbyHeenan
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Gfunk6 said:
When we were in residency a bunch of us tried to create a business model of a linac on a cruise ship.

Old people who like to cruise. Check
Medical toursim. Check
Don't have to shield the hull. Check
Kills fish who swim around the ship that you can scoop up for food. Check
Register ship in Panama and bypass all US medical regulations. Check
No insurance, cash only. Check

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Had this same discussion in residency!

Seemed ideal for long course prostate and breast at the time.... Even hypo at 3-5 weeks
 
Gfunk6 said:
When we were in residency a bunch of us tried to create a business model of a linac on a cruise ship.

Old people who like to cruise. Check
Medical toursim. Check
Don't have to shield the hull. Check
Kills fish who swim around the ship that you can scoop up for food. Check
Register ship in Panama and bypass all US medical regulations. Check
No insurance, cash only. Check

Animated GIF
Click to expand...
I think every residency room has had the "Prostate SBRT cruise ship" discussion.

Wonder if that'd pencil out.
 
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What kind of generators are you going to need on that boat for a linac? Are we going to use cobalt? How much money are you going to pay therapists to go months long trips? The logistics and overhead would be a nightmare. And I'm in.

homer simpson episode 13 GIF
 
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Sorry, maybe I missed it. Why are we talking about reimbursement and residency size impact on salaries for hospital employed?

The real emphasis here should be on the impact of these changes on RVUs since that is how most employed physicians actually get paid based on their contracts.

I see a real risk of substantial RVU reductions doing the exact same work based on these changes.

They haven't really seen anything assuage my fears here. Lots of talk on the dollar reimbursement and very little about RVUs
 
CaesarRO said:
Sorry, maybe I missed it. Why are we talking about reimbursement and residency size impact on salaries for hospital employed?

The real emphasis here should be on the impact of these changes on RVUs since that is how most employed physicians actually get paid based on their contracts.

I see a real risk of substantial RVU reductions doing the exact same work based on these changes.

They haven't really seen anything assuage my fears here. Lots of talk on the dollar reimbursement and very little about RVUs
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Maybe not in this thread but has been discussed.

Certainly biggest wRVU drop is on image guidance charges.

I haven't taken a deep dive, but are there big $/wRVU drops in 77427 or other codes as well?
 
As best as I can tell the "only" effects on wRVUs will be CBCT going from 0.85 to 0.7 and the proposed 2.5% efficiency cuts to every code except 77427 (including the new CBCT code!). I looked at my RVUs from last year and that amounts to a ~4.5% cut for the same work.
 
TheWallnerus said:
They do always find a way to get their pound of flesh. Eventually they will hit bone, and you wonder “what then.”
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As long as their enrollees or the electorate don’t care, then they don’t care. They’ll amputate and move onto another limb.
 
Fpg1245 said:
As long as their enrollees or the electorate don’t care, then they don’t care. They’ll amputate and move onto another limb.
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Increasing spending isn't in the cards. 10 more years until I should be able to FIRE out hopefully before the whole system falls apart and severe austerity measures are finally forced. My generation of doctors may or may not squeak by. Gen Z? Hah. Sorry. At least remember who did this and will live large at your expense all the way to the grave (the boomers, vastly accelerated by covid policies benefitting them in every imaginable way).

I wouldn't be surprised if "efficiency" revaluations of RVUs for codes become the new norm every year now that that line has been crossed.
If you're in a hard to recruit area, you can try and make the case to admin that they need to bump your wRVU conversion factor. Anywhere else, you will take the cuts and be thankful they aren't worse.
 
alwaysbeIMRTing said:
Increasing spending isn't in the cards. 10 more years until I should be able to FIRE out hopefully before the whole system falls apart and severe austerity measures are finally forced. My generation of doctors may or may not squeak by. Gen Z? Hah. Sorry. At least remember who did this and will live large at your expense all the way to the grave (the boomers, vastly accelerated by covid policies benefitting them in every imaginable way).

I wouldn't be surprised if "efficiency" revaluations of RVUs for codes become the new norm every year now that that line has been crossed.
If you're in a hard to recruit area, you can try and make the case to admin that they need to bump your wRVU conversion factor. Anywhere else, you will take the cuts and be thankful they aren't worse.
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Yeah judging by the offers in these rural areas. I don’t think it would even be a discussion. They’ll happily fill with locums and wait until the next idiot takes the job.

And as usual, boomers win. They always win.
 
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The rural and locums market is completely delusional/dysfunctional. Again, boomers are ruining the entire thing.

There is one particularly grating ad I am constantly spammed with from frontierland Nebraska stating "permanent position only -- we do not have locums positions" Oh really? Then who exactly is providing the services in the building 5 days a week right now? This happened because people like me inquired about staffing it part time with a direct contract. This offends them for some reason, so they will silently staff through comphealth until they can find the "idiot" who will move there that they can control fulltime.
 
Fpg1245 said:
As long as their enrollees or the electorate don’t care, then they don’t care. They’ll amputate and move onto another limb.
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Absolutely. Such a convoluted system, I have been educated a bit but still very confused about 2026. Somehow we apparently received a bump in compensation (upping the conversion factor?) through the spending bill which was more than canceled out by efficiency gains? I'm a diagnostic rad and we are projected to go down 2% for 2026. I am assuming the efficiency gain cuts are the result of budget neutrality?

I have never been a fan/member of the AMA until past few years when CMS reimbursement reform became a major part of their agenda. If I understand correctly, we should expect cuts as long as there is budget neutrality.
 
alwaysbeIMRTing said:
There will be a physician payment for port films now?

Currently:

Cone beam review (77014): 0.85 wRVU
kV review (G6002): 0.39 wRVU
Port films (77417): 0.00 wRVU (the physician port film review component considered part of on treatment management 77427).

Proposed 77387 for all image guidance: 0.70 wRVU

Good day to be a (employed) breast rad onc if that's true.
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HolySmokes said:
Looks like G6002 (kv) and 77417 (ports) codes are still around, so are those just the technical codes and the professional codes for them are now 77387?
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Am I reading ASTRO correctly that 77417 (port films) is no longer going to get paid? Goodbye port films we hardly knew ye?
 
Ray D. Ayshun said:
All these coding changes make me wonder who's narcing.
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So who called medicare to tell them that most rad oncs bill a 77014 for 2 seconds worth of work? Probably some baby boomer on his way out. Salt the earth for the next generation. It's their favorite thing.

If you told me Paul Wallner personally did this, I would believe you. Those stupid 2019 grads who don't understand radiation biology really don't even deserve PCP salaries.
 
alwaysbeIMRTing said:
So who called medicare to tell them that most rad oncs bill a 77014 for 2 seconds worth of work? Probably some baby boomer on his way out. Salt the earth for the next generation. It's their favorite thing.

If you told me Paul Wallner personally did this, I would believe you. Those stupid 2019 grads who don't understand radiation biology really don't even deserve PCP salaries.
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How could a generation who made so much money be so salty? I don’t understand it, it doesn’t make any sense. Usually there should be a motivation but what could possibly motivate them to ruin the field that they made their lives from?
 
DrProtonX said:
How could a generation who made so much money be so salty? I don’t understand it, it doesn’t make any sense. Usually there should be a motivation but what could possibly motivate them to ruin the field that they made their lives from?
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Expanding resident numbers by more than every other field- to be the furthest outlier- reflects the presence of a higher number of “bad and selfish actors” in high positions in radonc vs other specialties. They are going to screw you in every which way.
 
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RickyScott said:
Expanding resident numbers by more than every other field- to be the furthest outlier- reflects the presence of a higher number of “bad and selfish actors” in high positions in radonc vs other specialties. They are going to screw you in every which way.
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What's the plans for residency slots from now on? They've been going down ever year, but are they gonna keep it the same or increase it again, or are there plans to reduce again this year?
 
allseasons said:
What's the plans for residency slots from now on? They've been going down ever year, but are they gonna keep it the same or increase it again, or are there plans to reduce again this year?
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i don’t think they are going down every year and programs are taking fmgs outside the match or allowing radoncs from other countries to work as faculty and then sit for boards. In fact, some programs like Miami brought in 5 residents in the most recent cycle.
 
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allseasons said:
What's the plans for residency slots from now on? They've been going down ever year, but are they gonna keep it the same or increase it again, or are there plans to reduce again this year?
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Residency programs have lowered residency slots as much as Toyota Priuses have lowered global CO2. Even so, it’s a reduction I guess. However I do wonder if the old saying “you can’t unf***k a pig” is now true.
 
Maybe this has been covered previously, but couldn't find, but anyways, here's a little of what I can guess so far, please correct if wrong:

1) 77402 will pay $150, 77407 $300, and and 77412 $600
a) Skin cancer electrons probably always have to be 77402?
b) I bet insurance companies prior auth the heck out of 77412? Look for new guidelines!
2) IGRT technical pays nothing, ever (we knew that), i.e. no 77387-TC or 77387 global
a) Do IGRT images whenever you want, on anyone or any insurance
b) no one will worry about IGRT ever again (technically you don't even have to "order" it, documentation-wise)
3) 77387-26 will definitely be at 0.7 wRVU and pay ~$23

You know, you could make more money waiting on 10 tables in a nice restaurant than checking IGRT images of 10 patients in 2026. Moonlighting at Chez Wallner could pay more than locumsing at Dr. Wallner's. Admittedly it takes a lot longer to wait on 10 tables than check 10 CBCTs. Even so, I hope restaurant waiters are able to achieve the incredible increase in salary that we have achieved in rad onc over the last 15 years!
 
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TheWallnerus said:
Maybe this has been covered previously, but couldn't find, but anyways, here's a little of what I can guess so far, please correct if wrong:

1) 77402 will pay $150, 77407 $300, and and 77412 $600
a) Skin cancer electrons probably always have to be 77402?
b) I bet insurance companies prior auth the heck out of 77412? Look for new guidelines!
2) IGRT technical pays nothing, ever (we knew that), i.e. no 77387-TC or 77387 global
a) Do IGRT images whenever you want, on anyone or any insurance
b) no one will worry about IGRT ever again (technically you don't even have to "order" it, documentation-wise)
3) 77387-26 will definitely be at 0.7 wRVU and pay ~$23

You know, you could make more money waiting on 10 tables in a nice restaurant than checking IGRT images of 10 patients in 2026. Moonlighting at Chez Wallner could pay more than locumsing at Dr. Wallner's. Admittedly it takes a lot longer to wait on 10 tables than check 10 CBCTs. Even so, I hope restaurant waiters are able to achieve the incredible increase in salary that we have achieved in rad onc over the last 15 years!
Click to expand...
No tax on tips!
 
TheWallnerus said:
Maybe this has been covered previously, but couldn't find, but anyways, here's a little of what I can guess so far, please correct if wrong:

1) 77402 will pay $150, 77407 $300, and and 77412 $600
a) Skin cancer electrons probably always have to be 77402?
b) I bet insurance companies prior auth the heck out of 77412? Look for new guidelines!
2) IGRT technical pays nothing, ever (we knew that), i.e. no 77387-TC or 77387 global
a) Do IGRT images whenever you want, on anyone or any insurance
b) no one will worry about IGRT ever again (technically you don't even have to "order" it, documentation-wise)
3) 77387-26 will definitely be at 0.7 wRVU and pay ~$23

You know, you could make more money waiting on 10 tables in a nice restaurant than checking IGRT images of 10 patients in 2026. Moonlighting at Chez Wallner could pay more than locumsing at Dr. Wallner's. Admittedly it takes a lot longer to wait on 10 tables than check 10 CBCTs. Even so, I hope restaurant waiters are able to achieve the incredible increase in salary that we have achieved in rad onc over the last 15 years!
Click to expand...
0.68 wRVUs if the "efficiency cuts" go through
 
TheWallnerus said:
Maybe this has been covered previously, but couldn't find, but anyways, here's a little of what I can guess so far, please correct if wrong:

1) 77402 will pay $150, 77407 $300, and and 77412 $600
a) Skin cancer electrons probably always have to be 77402?
b) I bet insurance companies prior auth the heck out of 77412? Look for new guidelines!
2) IGRT technical pays nothing, ever (we knew that), i.e. no 77387-TC or 77387 global
a) Do IGRT images whenever you want, on anyone or any insurance
b) no one will worry about IGRT ever again (technically you don't even have to "order" it, documentation-wise)
3) 77387-26 will definitely be at 0.7 wRVU and pay ~$23

You know, you could make more money waiting on 10 tables in a nice restaurant than checking IGRT images of 10 patients in 2026. Moonlighting at Chez Wallner could pay more than locumsing at Dr. Wallner's. Admittedly it takes a lot longer to wait on 10 tables than check 10 CBCTs. Even so, I hope restaurant waiters are able to achieve the incredible increase in salary that we have achieved in rad onc over the last 15 years!
Click to expand...

This is my understanding as well.

I think we will definitely see lots of prior auth's on 77412 if there is a big difference in final rule between 77407 and 77412. I also think you will see more purchases of align RT, as from what I am seeing if you use "active motion management" you could theoritically bump up to 77412 - but you're going to see lots of private payors challenge what is approved for 77412.

Curiously enough, I just did a guy 2 Gy X 2 fractions for follicular lymphoma palliation. He had one CT sim, but two iso's (treating two different areas in pelvis/inguinals) Pretty simple 3D plan. Per new rule this gets paid more per fraction than say a single iso complex sarcoma IMRT/VMAT case.

I have been disappointed in commentary (?lack of?) from ASTRO, ACRO, and others on the IGRT 77387 thing. On the physician side that is a HUGE cut. Most recent Bridge email suggested basically "it's not as bad as it could have been" because it is a heavily used code and they (CMS) loves to just bundle it.
 
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Listened to the recording of the town hall. I thought ASTRO did a great job. I’m particularly impressed by the new CEO’s presence and knowledge
 
So based on ASTRO and ACRO "survey data" the RUC came up for the value for the image guidance code it appears ?largely based on this survey data?.

Was anyone surveyed about this?

I'm not an ASTRO member anymore.

ASTRO seems perfectly fine with this cut.
 

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TheWallnerus said:
Let me tell you the key quote from the ASTRO PFS 2026 town hall “We [ASTRO] did very well.”
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BobbyHeenan said:
So based on ASTRO and ACRO "survey data" the RUC came up for the value for the image guidance code it appears ?largely based on this survey data?.

Was anyone surveyed about this?

I'm not an ASTRO member anymore.

ASTRO seems perfectly fine with this cut.
Click to expand...
People more intelligent and attuned to this than me have commented that academic medical centers disproportionately use multi-isocenter plans and motion management so will be minimally impacted by these changes.
 
Gfunk6 said:
People more intelligent and attuned to this than me have commented that academic medical centers disproportionately use multi-isocenter plans and motion management so will be minimally impacted by these changes.
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I think people are fooling themselves if they think motion management is going to get you to tier 3 for commercial payers.

Sure, for Medicare it may.

But we will be entering a new era for prior auth if that HUGE jump exists between level 2 and 3.

Be prepared for new evicore guidelines about which sites need multiple isos or motion management. Or if say tangent breast DIBH is “really” motion management the way they don’t consider tangent breast Imrt to be actual Imrt .
 
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drowsy12 said:
Since when are motion management and multiple iso centers not for the community? Don’t most of us here do this all
The time?
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50 bucks those intelligent people work at a big name academic center. We even do non-coplanar treatment sometimes!

BobbyHeenan said:
So based on ASTRO and ACRO "survey data" the RUC came up for the value for the image guidance code it appears ?largely based on this survey data?.

Was anyone surveyed about this?

I'm not an ASTRO member anymore.

ASTRO seems perfectly fine with this cut.
Click to expand...

I believe this is standard process. My gripe is we should have heard about this much earlier. The first I heard about these changes was just 6 months ago from Amar Rewari's LinkedIn post. Even in that town hall sometimes I wondered if they really want to fix some policy issues or if they just want to sell webinars and conference registrations.

ASTRO and ACRO need to get a lot more transparent in their lobbying efforts if they want my support in the future. I have very low expectations that will ever happen.

You are free to comment on the proposed rule and/or write your representative, and it will land the same. Potentially even better because you are a real physician putting your name on a personalized letter. No society needed.
 
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