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Another settlement, so there won't be definitive case law established. It would be interesting to see if they were counting someone (ie med onc or mid level) as the supervisor while the rad oncs were out of the office or if they just didn't have anyone there designated as the covering provider.
However, this is just another one in the trend of therapists making big time money telling on groups that may play in that "gray area" of direct supervision. It's one of the reasons I would ideally like to cover some rural clinics (not super rural like medicare exempt), but can't send a NP some days as coverage because I"m not willing to play around with all of these cases.
When I go to the floor to see consults we still call that physical presence so we treat, surely that is OK, right? My department is attached to the hospital. Obviously, I'm at the linac for HDR, CT sims, verification, SBRT, etc.
Rumor on street is a certain whistleblower mentioned may have turned in ANOTHER site.
Daily Practice - Reimbursement - Practice Management Resources - Supervision - American Society for Radiation Oncology (ASTRO)
I await Florida jokes from the peanut gallery, but it seems like these shenanigans happen in many places.
You're probably safer in a hospital based situation than freestanding, but either way, the requirements state that the individual providing supervision has to be able to furnish assistance at any time with igrt. How many med oncs/ob gyns/FPs can line up a CBCT?
The IGRT is where the issue is. Completely agree with you.
I go over IGRT goals of alignment at verification with therapists; depending on the case sometimes I physically am at the linac for all pre-treatment CBCT (ie bladder boost or complex case), but for things where they are confident/good at alignment like a prostate or prostate bed CBCT I'm not always there physically at the linac...so they certainly have treated patients when I'm upstairs on the floor while they beam on a CBCT case. This was normal in my residency as well.
so are these 2 cases concerned with IGRT or simply the fact of beam being on without MD "in Department"?
No one in their right mind would ever let a case like that to go court and risk potential triple/treble damages, which is what Medicare allows in these whistleblower cases for a maximum potential payout (I.e. $5 million in fraudulent charges would turn into a $15 million penalty)
so are these 2 cases concerned with IGRT or simply the fact of beam being on without MD "in Department"?
I've always wondered how this could be established, outside of interviewing witnesses like therapists/dosimetrists, etc. We have electronic schedules in our group with ARIA that clearly show patients scheduled in clinic, but for those days where nothing is on the schedule except daily treatment patient's, it's something I've wondered about, especially as witness testimony gets unreliable the further back you go to examine a time period.In the case I quoted it was accusation of no MDs in department. The hospital strongly objected, saying this was untrue and that MDs were physically present. However proving this to the Feds was an onerous, expensive process. In the end, was cheaper to settle.
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Not that I've seen. It almost always revolves around CMS and Tricare patients.This discussion always revolves around medicare/medicaid oversight as that is where all the settlements/penalties arise from. Do commercial insurance companies care and is there any precedent of them coming after groups/hospitals for lack of supervision?
Not that I've seen. It almost always revolves around CMS and Tricare patients.
My department is physically located on the large hospital grounds. However, I do a lot of inpatient rounds during the day and go to OR for seed implants. Do you think therapists may potentially raise the issue of lack of physician supervision?
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I'm in the same boat. I'm not hospital employed though for what that's worth.
Given all of these issues our staff sat down with risk mgmt and the hospital to review our policies. Our policy is that for rounds as inpatient I am readily available to walk downstairs or across campus and help with a CBCT, so we still treat then.
For procedures I notify the department when I am scrubbed in and we turn off the machines then. They treat up until the time I scrub then stop. It's really annoying and probably overkill but you can see in this thread the issues at play. THe therapists actually dislike it and would rather treat, but it is what it is and they understand the issues at play. Again, just keep them happy.
This is exactly what I do and my rationale is the same. I even go as far as to avoid walking 100 yards to the sub shop across the street (and instead walk 2-3 times farther to the hospital cafeteria since although I'm farther I'm technically still on campus).
I have worked in several of those rural 10-15 patients per day centers in exempt locations and there is no way to staff with a full time MD but I was very comfortable with an NP baby sitting/managing side effects while I was available remotely to check IGRT even before treatment. I've also worked at an academic center were an 84 year old radiation oncologist would "cover" vacations but he generally just napped or read the newspaper while the therapists and PA ran the show but it was ok since he was (great)grandfathered and didn't have to recertify (the dude was covering a sim on a prone breast patient and he literally thought the axial slice through the breast was an image of a skull/brain ... the scarier part was that he was apparently in the CT sim room and the woman was on sim table topless right in front of him but he still couldn't put it together!)
I have worked in several of those rural 10-15 patients per day centers in exempt locations and there is no way to staff with a full time MD but I was very comfortable with an NP baby sitting/managing side effects while I was available remotely to check IGRT even before treatment.
we all know its BS. I agree someone should check SBRT bc its high dose but everything else is BS. And if it is SBRT just don't treat that day, doesn't have to be consecutive treatments. We are not gods, any monkey can be trained to look at a film. Make the hospital admins come down to check it, they are the ones that benefit from the $$ flowing in. Oh wait, they have meetings to be at and powerpoints to present
One option is to not bill, not very palatable IMO. Beyond that, you shift the schedule around. If you have more than one person to cover the linac, then I would just rotate, like you suggested.Hate to revive the issue on this topic as it's painful, what do you guys do in your practice at present to make this work in the situation that one physician has daily am childcare responsibilities if your practice is a 2 or 3 person setup? Is it reasonable to have a policy of taking turns as the early physician. Would you consider just starting patients at a later time if you're not a super high volume clinic. Thanks
Along with Medicaid and tricare.you can also not treat medicare pts in the morning- the presence rules only apply to pts medicare/or medicare advantage?
I hate to bother you all with my European views, but:
The problem is that in the US you are able to sustain operation of a LINAC even when it's running with 10-15 patients. This is because radiation oncology actually pays off pretty well in the US, so you earn enough per individual patient to pay off the costs associated with operating a LINAC and even make profit even you treat so few patients.
In Europe, you won't find a place where a LINAC would be running with 10-15 patients.
30-40 patients is a must and I know places with 60 patients on one LINAC.
I don't consider this to be a "problem" in the US. Our country is much more spread out and rural than Germany in many places, so it would be difficult for large segments of our population to travel for care. I like that we can be profitable with 10-15 patients on treatment and continue to serve these communities. I would consider Europe's situation to be the "problem."I hate to bother you all with my European views, but:
The problem is that in the US you are able to sustain operation of a LINAC even when it's running with 10-15 patients. This is because radiation oncology actually pays off pretty well in the US, so you earn enough per individual patient to pay off the costs associated with operating a LINAC and even make profit even you treat so few patients.
In Europe, you won't find a place where a LINAC would be running with 10-15 patients.
30-40 patients is a must and I know places with 60 patients on one LINAC.
if you look at major metropolitan areas -where most of the population resides-, it is likely that within those dense areas you have many single vault linacs treating 10-15 patients. I know of 3 within 5 miles of my hospital. I bet you the vast majority of linacs treating 10-15 pts are not in the rural setting, and that they are treating 10-15 patients because of competition not geography.
So what? Unless we dramatically change reimbursement based on geographic region, that's going to happen. Also, at least in my dense major metropolitan area, that's demonstrably false. We have 75 patients on tx between 2 linacs right now, and all of our centers have between 20-40 patients on tx per linac at any time. You're more accurate when it comes to academic centers, which in my experience have 1/2 to 1/3 the workload per machine compared to non-academic practices.
And I would say we do not have an oversupply, but rather a good geographic distribution which allows treatment of patients in their own community.There has to be a balance and it is my understanding the proliferation of linacs treating 10-15 patients corresponded to increased reimbursement from IMRT. The point is favorable reimbursement encouraged an oversupply of centers, and that there may be a contraction if changes are made to reimbursement/bundled payments.
That's pretty good compared with the departments I've seen. Never made sense to me why some places throw away so much money buying two machines/vaults when one would have sufficed.At my institution our work horse linacs treat 30 - 40 a day.
I think you can make the argument that physicians in academics may have 10 - 15 on treatment, but the linacs are pretty much never that empty.
The entire USA is in dire need of CON laws on LINACs.
I wouldn't disagree with that. Would still allow for rural centers. Would NOT help the current job market, though.The entire USA is in dire need of CON laws on LINACs.
Kinda like Florida and the CK situation a few years ago.... but the free market handled that... I think a few went bankrupt. Protons is seeing that nowexample: Philadelphia area has 4 Gamma knives within several miles of each other: cooper, TJU,pense,temple
if you look at major metropolitan areas -where vast most of the population resides-, it is likely that within/near/outskirts those dense areas you have many single vault linacs treating 10-15 patients. I know of 3 within 5 miles of my hospital. I bet you the vast majority of linacs treating 10-15 pts are not in the rural setting, and that they are treating 10-15 patients because of competition not geography.
So what? Unless we dramatically change reimbursement based on geographic region, that's going to happen. Also, at least in my dense major metropolitan area, that's demonstrably false. We have 75 patients on tx between 2 linacs right now, and all of our centers have between 20-40 patients on tx per linac at any time. You're more accurate when it comes to academic centers, which in my experience have 1/2 to 1/3 the workload per machine compared to non-academic practices.
And that's why when some of these really rural places can't find a rad onc, they can sometimes still treat Medicare patients without direct rad onc supervision, secondary to that CAH (Critical access hospital) designation.Agree with OTN - Look at the geographical size of the US versus any country in Europe (excluding Russia). Either some places have Linacs treating 10-15 patients, or those patients likely don't end up getting radiation like in 3rd world countries.
I wouldn't disagree with that. Would still allow for rural centers. Would NOT help the current job market, though.
I have patients that drive 1 hour to get their radiation therapy one way.I think the question is.... what is a reasonable drive and expectation for patients? At one of the satellites I treat at, we average 15-25 depending on season. Is it reasonable to make those patients drive anywhere from 25-35 mins each way daily to get radiation?
Fair points and I don't pretend to the know the answer.I have patients that drive 1 hour to get their radiation therapy one way.
30 min is pretty normal.
And lots of patients come to radiation using public transportation. I have patients who spend 3 hours on the road between trams, buses and trains to get to us and back home.
Why is that such a big issue?
And in the end why not treat patients as in-patients or in a hotel-like setting?
When Lona Linda was the sole spot treating prostate cancer with protons hundreds of patients traveled from all over the US and anroad and slept in hotels around the treatment center for weeks.
It's all a matter of how you spend public money and what's more prudent to do. Sustain non-profitable Linacs treating tiny amounts of patients by paying big bucks per treatment or covering costs of travelling and sleeping away from home during treatment for patients who are fit enough to do so?
One could also make the argument that fewer large-volume centers probably provide better care than tiny centers and enhance clinical research.