Medicare PFS 2026 proposed rule
Started by BobbyHeenan
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I would never hire from a program with a chair or PD that has either SOAP'd or published in favor of residency program expansion. That hiring criterion is as important as the 3 A's. If a certain group of academic programs want to overtrain residents and hire amongst themselves assistant clinical professors to staff their satellites, so be it.
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We haven't hired anyone for our group in years and have no plans to do so in the future. That's the main issue here. My opinion about who to hire/not hire is irrelevant, as there isn't a job for any of them anyway.
Didn’t anybody see that video on twitter where the University of Miami cardiologist was bragging about the hospital’s new lobby. Dude got draggggged. Had to delete video. Pianist on the piano, video wall, marble floors… looked like a Ritz Carlton. Those places have rad onc jobs. The more rad oncs they hire, the more pianists they can hire.
I received and heeded this same advice during the comment period. The next time we’re on the chopping block, I don’t plan to stay silent and let the “influential” groups comment on my behalf so as not to muddy their messsage.
Not saying anything would have changed if more of us spoke out, but at least I’d have the satisfaction of screaming into the void before getting kneecapped.
Correction: the more rad oncs treat patients, the more pianists they can hire. They are trimming the fat on the academic side and opening plenty of satellites.
Exactly what I said and did. Sadly this was a major hammer and I wasn’t able to rally enough people.
How many fractions or patients do you think a PPSE RadOnc has to treat for their salary to be covered all other things considered?
I've seen charges from non PPSE places, and I'd be surprised if it's more than 5 patients.
I mean it could be super variable. It could be one patient per year (protons). Probably fifteen per year. Three new patients a month should definitely cover it.
Agreed, maybe a month of work from a typical doctor supports their full year. Luckily they are just producing such extreme advances in cancer care.... especially new and improved radiation care... oh wait.
One or 2 G6 prostate cancers per year? UPenn which is not pps exempt was taking in over 300k- in the most extreme cases 4 years ago - for a course of prostate imrt. That is only higher now.
Large academic centers purposefully overhire to induce docs to overtreat. back of the envelope calcs looking at website facility listings and knowing daily census make this obvious. A chairman at one of the pps exempt centers explicitly told me this.
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This is a thing.
Community practices in general are pretty happy to enroll in collaborative group trials. This seems to be really variable among academic programs.
Is it just that "it's a hassle and it's not investigator initiated by us, so it's not worth it...career wise" or is there another reason for this?
Do we have aggregate numbers regarding collaborative group trial accrual by type of institution or by name of institution itself? This would actually be a valuable thing to be publicized. All community places participating in NCORP keep accrual numbers.
I would think (given the expansion of academic radonc over the past 20 years) that just getting academics to buy in on collaborative group accrual would be a really meaningful thing.
I have often questioned the value of so many small, investigator-initiated trials in academia (outside of truly out of the box stuff). We just end up with bad data and change SOC base on little more than speculation.
Part of it is incentives. The reason that there's so much support for trials in medical oncology is because pharma will pay institutions for trial enrollment. That money pays for trial coordinators, research nurses, and people to say "hey I looked at this chart and we should enroll this patient on trial xxx." The investigators are also incentivized because this means that they'll get their names on the paper, get more trials from the company, and further their academic careers.
Cooperative group trials (ie, the radiation ones) are generally paid at a much lower rate than industry sponsored trials, and you can think of industry sponsored trials "subsidizing" the infrastructure for cooperative group trials in larger institutions. Institutions have less of an incentive to push those, and they may compete with smaller IITs, which are more likely to advance a radonc's research career.
They are already getting paid orders of magnitude for the same services freestanding centers provide. God Forbid they use some of that money to actually do academic medicine.
Just for giggle, which large academic department historically really has done nothing in terms contributing to practice of care in last 40 years. I am thinking Harvard.
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This is quite variable among community practices as well. The practice I was referring to is specifically very involved in research.
As previously noted, cooperative group trials don't pay. Academic centers in general seem to be addicted to pharma money. The difference in reimbursement per patient in a pharma study is multiples higher than a cooperative group study.
The NCI tries to mandate accrual to some extent by reviewing their designated cancer centers on cooperative group trial accruals since these studies are supported by NCI. Still, I've noticed that there are several NCI designated cancer centers with little to no rad onc trial participation who continue to be designated every cycle. I'm a bit unclear how they get away with this--either they are accruing on trials outside of radiation oncology or the NCI doesn't really enforce this.
From a career standpoint (it is publish or perish after all), the pharma trials will generally include every investigator who participated on their study in the publication. In cooperative group studies, the criteria for authorship heavily skews towards the PIs of the study and committee chairs who participated within the cooperative group. Opening a study is heavily political, and becoming a committee chair is also heavily political and insular. This leads to a lot of people just not participating or dropping out since accrual is extra work that really does nothing for them.
Yes they have this.
Getting a multi-institutional trial done is hard. There are a lot of people here on SDN who sit around and bash academics. It's easy to be a critic and look down your noses at academics, just like it's easy for academics to look down their noses at you.
But, as someone who actually does write and try to get these trials off the ground, it's a complex and expensive process that involves too much regulatory burden and politics.
Ultimately, single institution trials are much easier to perform, both politically (many fewer people who need to agree) and financially (significantly cheaper).
It depends what you mean by academic medicine. There are some centers that do not view rad onc research as valuable, but are happy to support medical and surgical oncology. Rad onc then serves a more technical and revenue producing role for supporting the research of other departments.
Didn't mean to bash academics personally.
But as a consumer of medical literature, it's hard not to appreciate disparate work contingent on exactly the scale of collaboration (I should have used cooperative group trials above).
For example.
ORIOLE trial...US...4 institutions...50+ patient accrual over 2+years. An example of a successful but small US trial.
PEACE V_STORM trial...EU/Australia...eff load places....almost 200 patient accrual over similar time frame.
It would be interesting to know accrual time normalized per patient for trials run in the EU vs the US for instance.
IMO, this is such a foundational and important thing to address. It would make radonc academics...what is the word...better!
How do you think a functional, national level professional society would be able to help address this?
Can't emphasize this enough. Most academic rad onc departments have their profits skimmed off to support med onc or whatever else. It's a rare academic department that retains enough to support research in any meaningful way. The local private practice that Neuronix refers to is unusually well supported by the hospital -- credit to the chair there.
Anyone follow the update from ASTRO today? They are maintaining the old PE valuations. Sounds like a big deal for the freestanding centers
77387 drops to 0.68 form 0.7
And I didn't totally follow their explanation of how this nets positive for the field instead of negative.
Can someone ELI5?
77387 drops to 0.68 form 0.7
And I didn't totally follow their explanation of how this nets positive for the field instead of negative.
Can someone ELI5?
Comparing US with EU/Canada/Australia without mentioning that most EU/Canada/Aus are nationalized systems misses the boat. STAMPEDE enrolls thousands of patients and most cooperative groups in the US struggle to enroll hundreds.
PROTECT would never succeed in the US. Different delivery models.
I'm sure this matters quite a bit, but it cannot strictly be payor status. Some of these trials accrue across countries with disparate payment models.
In addition, I trained at an NCI designated place that, to my knowledge, accrued basically no one to cooperative group trials (at least during my time there). In comparison, I've thrown a few patients onto the Janus trial, some head and neck and lung trials over my years at a small community place. (Not to mention significant accrual to low hanging survivorship trials and toxicity tool trials).
Are you saying that we are functioning remotely at capacity regarding academic accrual to cooperative group trials in the US?
All I am saying is that the US system is very different. I worked at three NCI designated CCCs. I also was the PI of two cooperative group studies; one PhII and one PhIII. (I am retired and don't care if I doxx myself). At the majority of NCI designated CCCs investigator-initiated trials (IITs) were clearly prioritized. As many have made clear IITs are difficult in RadOnc unless supported by Pharma.
EORTC OR STAMPEDE is very different than RTOG/NRG. One individual is the PI of at least three PhIII trials in EORTC from the mid 1990s to 2010 and two people dominate STAMPEDE. The GU portfolio in NRG/RTOG has multiple PIs over the last few decades.
Finally, the culture of US patients is very different. Autonomy trumps (sorry) the "public good" that Zeke Emanuel encourages.
US patient in multi-D. Sees three different specialists and they say you have option A or B; you decide.
European patient in multi-D. Sees three different specialist and they say we recommend randomized PhIII. National health system recommends as well. Patient enrolls on rPhIII.
I read it. Also don’t understand it. Any insight (also at 5 year old level) appreciated.
Best I can tell, the 1BBB Act had a one time statutory increase to conversion factor of 2.5% while also having a q3years 2.5% decrease in RVUs for physicians due to increased efficiency from technology.
Somehow this nets out as a +3.26% increase in conversion factor over 2025 (I’m guessing related to inflation). I don’t get it, but if true, would be better than nothing. Of course, you may be losing 5-10% of your RVUs, so who knows?
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This was my experience with those trials. Two or three enrollments for the med onc repeatedly led to middle author on JAMA/NEJM for drug trials. The cancer center would love them for it. Meanwhile I’m accruing 5-10 for many cooperative group trials that come through and never anything to show for it.
I'm not like a huge patrolling threads for off-topic posts and have contributed to the current off-topicalness. But can we try to keep this thread on the MPFS rule? Maybe a new thread for the clinical trial back and forth?
Lets do it. This is an incredible table from ASTRO, who has spent the last few years guaranteeing that we will all be out of a job due to cuts.
The last president guaranteed me I would see a pay cut specifically in part because 77427 would be "decimated".
CMS not only cemented tele-77427, but gave us a raise.
Of course, cuts could happen in future years, but this is... well, it's something.
Discuss 🙂
I couldn't understand where these numbers are coming from?
If it's the conversion factor adjustment wouldn't it be even across all codes?
2026 MPFS. The table is from an ASTRO letter someone forwarded to me.
My understanding is the MPFS was released a week ago and revised a bit this week with a new release. This adjusted some rates. I was most interested in that they adjusted the payment rates of intermediate and complex delivery seemingly to try to influence the rate at which practices bill them. But I am no expert, and frankly it is becoming frustrating to get clear, unbiased information on this stuff.
The HOPPS final rule is still not out which may, sort of, maybe, possibly have a bigger impact on the average rad onc (employed in a large system). If at all. Certainly reasonable people disagree on that.
Source?
Thank you
For those of us who get paid by wRVU, does this seem like a reasonable way to assess wRVU impact:
- E/M wRVUs: unaffected
- CBCT wRVUs: down 20% (0.85 -> 0.68)
- All other wRVUs: down 2.5% for "efficiency"
If so, our practice is looking at ~5.5% decrease based on our 2025 wRVU distribution
If I adjust my 2025 billing to the new values I get a 5.1% decrease in total wRVUs. I think 5-5.5% is a pretty reasonable estimate for most folks.
I did some rough math and it was right around 5% as well.
That’s 80% of us.
My back of envelope math was RVUs will be down 5% as well. If the Conversion factor is up 3.26%, it still nets out as a 2% decrease in pay for those who collect directly from Medicare.
0.95 x 103.26 = 98.09
0.95 x 103.26 = 98.09
As I understand it, SGRT was lumped in with all other IGRT like CBCTs. Departments who heavily invested in SGRT with the false assurance that it will be spared in this rule are not happy. SGRT vendors are now advertising using it for motion management to bill level 3 complex treatment reimbursement (CPT 77412).
Never let a bad rule stop a good grift.
Never let a bad rule stop a good grift.
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SGRT made it out like a bandit in this rule imho. I think investment in SGRT might have been bitcoiny.
I am thinking about standing at the treatment console and saying “please be still” over the in-room PA while the beam is on to “manage motion.” Very low tech but effective!
I suspect CMS (or ASTRO) will issue clarification/statement regarding SGRT and how it does or does not "upgrade" to the 77412. Our therapists really like it for routine use (though we aren't billing it unless it is DIBH), but I bet some less discriminating departments will get wild with the use of it and try to bill the 77412 on a HUGE chunk of cases.
Will be curious to see how this plays out. I may have missed it, but there really didn't seem to be a lot of granular detial on exactly what cases "need" motion management or what entails motion management....as you're alluding to here in your post.
Old hotness: how many cases “need” IMRT or IGRT
New hotness: how many cases “need” motion management
A funny observation about the billing/coding changes is there are arguably now just five external beam RT codes (SRS, SBRT, and level 1,2, 3)… one for each year of rad onc residency.
(You’ll have to learn about level 1 radiation on your own in your prelim year.)
Our practice has instructed that motion management cannot only be used for initial setup to qualify, it has to monitor throughout the entire treatment. Likely will be limited to thorax/abdomen/breast.
Bridge was saying they are assuming CMS is estimating that 77412 will be around 30% of cases. I wonder if mechanisms will be in place to "flag" outliers?
