RO APM Dies!

[medgator]

One of them does not take assignment of Medicare (Mayo, the one not yet built)

Link?

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[Gfunk6]

More proton facts from the document:

1. The RO APM is more interested at looking at national trends in RO utilization, not explicitly protons.
2. Proton use can still be fee for service on randomized clinical trials
3. Protons cannot use registry trials to get fee for service because ". . . these registry trials are unlikely to generate the type of evidence needed to change the standard of care."

 

[evilbooyaa]

This is a fascinating document... and frankly above my paygrade to understand completely. Being an employed doc; I quickly typed in the approximate professional fees per diagnosis from the national base rates. {This is not the overall payment, that has a way more complicated formula!}. It's going to be an interesting new economy. Three bone mets > cervical cancer ! Pivoting our clinical resources to increase throughput and efficiency for palliative cases may be quite worthwhile!

Dz	Prof(hundreds)
Bone	14​
Brain	16​
Lymph	17​
Breast	21​
Liver	21​
Lung	22​
Colorectal	24​
Pancreatic	24​
Uterine	24​
CNS	25​
UpperGI	26​
Bladder	27​
Anal	30​
HN	30​
Prostate	33​
Cervical	38​

Seems like it's excluding brachytherapy, so perhaps the external beam component of cervical cancer only? Still get paid more for doing the BT?

 

[Gfunk6]

"An RO episode includes all included RT services furnished to an RO beneficiary with an included cancer type during the 90-day episode. If an RO episode includes RT services for different included cancer types (for example, there may be claims for RT services included in the pricing for that episode that indicates more than one cancer type according to the ICD-10 diagnosis code listed on the various claims), those RT services and their costs are all included in the calculation of the payment rate for that episode."

In other words - you treat a primary lung cancer with chemoXRT after staging MRI Brain is negative. 60 days later the patient has headaches and you get a new MRI Brain - shows solitary 1.5 cm brain met. Patient is Medicare beneficiary. Here are your choices:

1. Wait 31 days to do SRS
2. Do SRS straight away and eat the cost
3. Refer patient out, perhaps to your "exempt" academic medical center

 

[elementaryschooleconomics]

"An RO episode includes all included RT services furnished to an RO beneficiary with an included cancer type during the 90-day episode. If an RO episode includes RT services for different included cancer types (for example, there may be claims for RT services included in the pricing for that episode that indicates more than one cancer type according to the ICD-10 diagnosis code listed on the various claims), those RT services and their costs are all included in the calculation of the payment rate for that episode."

In other words - you treat a primary lung cancer with chemoXRT after staging MRI Brain is negative. 60 days later the patient has headaches and you get a new MRI Brain - shows solitary 1.5 cm brain met. Patient is Medicare beneficiary. Here are your choices:

1. Wait 31 days to do SRS
2. Do SRS straight away and eat the cost
3. Refer patient out, perhaps to your "exempt" academic medical center

This is what I'm confused about - in order to start a new CNS Episode of Care, I think you would need to wait 59 days, right? To account for the "clean period"?

 

[CaesarRO]

"An RO episode includes all included RT services furnished to an RO beneficiary with an included cancer type during the 90-day episode. If an RO episode includes RT services for different included cancer types (for example, there may be claims for RT services included in the pricing for that episode that indicates more than one cancer type according to the ICD-10 diagnosis code listed on the various claims), those RT services and their costs are all included in the calculation of the payment rate for that episode."

In other words - you treat a primary lung cancer with chemoXRT after staging MRI Brain is negative. 60 days later the patient has headaches and you get a new MRI Brain - shows solitary 1.5 cm brain met. Patient is Medicare beneficiary. Here are your choices:

1. Wait 31 days to do SRS
2. Do SRS straight away and eat the cost
3. Refer patient out, perhaps to your "exempt" academic medical center

Based on 28 day wash out you'd have to wait 59 days to treat to initiate a new episode

 

[scarbrtj]

I honestly don’t understand why you bother lol. Trying to hack CMS is like trying to get into Fort Knox except instead of gold you get a plastic buzz lightyear.

Actually it's more like walking up to Fort Knox and finding no security. You walk up to the front gate and say to the guy "Hi, can I take $1 billion in gold" and guy goes "According to my rules here, it looks OK. Go ahead." So you walk in and get the gold. On the way out, all the guards help you load your gold in your truck. About 10 days later you see your face on the news for massive theft, and the Fort Knox security team busts into your house and shoots you in the leg and kills your dog. In jail, you find out the security gate guard got promoted to head of Fort Knox and everyone on the security team works in private security now making $1 million a year. In your jail cell, they confiscate your Buzz Lightyear doll.

 

[BobbyHeenan]

"An RO episode includes all included RT services furnished to an RO beneficiary with an included cancer type during the 90-day episode. If an RO episode includes RT services for different included cancer types (for example, there may be claims for RT services included in the pricing for that episode that indicates more than one cancer type according to the ICD-10 diagnosis code listed on the various claims), those RT services and their costs are all included in the calculation of the payment rate for that episode."

In other words - you treat a primary lung cancer with chemoXRT after staging MRI Brain is negative. 60 days later the patient has headaches and you get a new MRI Brain - shows solitary 1.5 cm brain met. Patient is Medicare beneficiary. Here are your choices:

1. Wait 31 days to do SRS
2. Do SRS straight away and eat the cost
3. Refer patient out, perhaps to your "exempt" academic medical center

There is no way this doesn't actually harm overall patient care. No way.

Should be different ICD 10's and different episodes. This is my major beef with this right now.

Is there any corollary to this type of model anywhere else in medicine?

If you break your arm and ortho fixes it if you come back with a leg fracture they get paid for fixing that too, right? What if a patient progresses on one line of chemo and 80 days later they start another one. They get paid for that too, right?

 

[Gfunk6]

Based on 28 day wash out you'd have to wait 59 days to treat to initiate a new episode

Even better!

 

[OTN]

"Another commenter stated that NCI-designated centers deliver innovative cancer treatments to patients in communities across the United States, and dedicate significant resources toward developing multidisciplinary programs and facilities that lead to better and innovative approaches to cancer prevention, diagnosis, and treatment. This commenter stated that introducing an APM based on complex calculations and historical rates would represent a significant burden that would negatively impact the innovation and discovery missions of NCI designated centers."

HAHAHAHAHAHAHAHAHAHAHAHAHASOB

"Innovation and discovery missions" my ass.

 

[scarbrtj]

This is what I'm confused about - in order to start a new CNS Episode of Care, I think you would need to wait 59 days, right? To account for the "clean period"?

All you guys saying RO-APM is difficult to understand. It's just not so. It's a cinch... it's no more difficult than, say, playing mah-jongg inside a tumble dryer while the principles of quantum mechanics are shouted at you in fluent Esperanto.*

*I stole this from The New Yorker's review of "Tenant"

 

[OTN]

"An RO episode includes all included RT services furnished to an RO beneficiary with an included cancer type during the 90-day episode. If an RO episode includes RT services for different included cancer types (for example, there may be claims for RT services included in the pricing for that episode that indicates more than one cancer type according to the ICD-10 diagnosis code listed on the various claims), those RT services and their costs are all included in the calculation of the payment rate for that episode."

In other words - you treat a primary lung cancer with chemoXRT after staging MRI Brain is negative. 60 days later the patient has headaches and you get a new MRI Brain - shows solitary 1.5 cm brain met. Patient is Medicare beneficiary. Here are your choices:

1. Wait 31 days to do SRS
2. Do SRS straight away and eat the cost
3. Refer patient out, perhaps to your "exempt" academic medical center

If CMS is not going to pay for the treatment, no one is under any moral obligation whatsoever to provide it.

This whole thing is abhorrent.

 

[BobbyHeenan]

All you guys saying RO-APM is difficult to understand. It's just not so. It's a cinch... it's no more difficult than, say, playing mah-jongg inside a tumble dryer while the principles of quantum mechanics are shouted at you in fluent Esperanto.*

*I stole this from The New Yorker's review of "Tenant"

It's easy to understand the end game, just not the logic that this in any way won't hurt patient care.

LIke Gfunk says - they're just saying this is what we're paying you, regardless of the work. You get X dollars, go to town. Just don't expect to get paid again in four months.

 

[elementaryschooleconomics]

If CMS is not going to pay for the treatment, no one is under any moral obligation whatsoever to provide it.

This whole thing is abhorrent.

"Sure I'll treat your new brain met. Sad news though - you're still in the initial episode of care. In this case I accept cash, credit, or cashier's check."

 

[Gfunk6]

As @BobbyHeenan wrote, the end game is to reduce payments. That's it. They are going to bend RO until they reach the breaking point. Let's say a hypothetical RO group does a fantastic job with this model - they provide "value" as defined by CMS while simultaneously delivering low-cost care.

What do you think CMS will do? They are not going to pat them on the back and give them a big incentive payment. Rather they will say "great job, now let's see if we can go 5% lower next year."

 

[deleted941485]

It's easy to understand the end game, just not the logic that this in any way won't hurt patient care.

LIke Gfunk says - they're just saying this is what we're paying you, regardless of the work. You get X dollars, go to town. Just don't expect to get paid again in four months.

But that’s the issue, patients return for treatment. I had one with stage I lung ca and then found out she had rectal cancer. Wtf I have to eat the entire course of reveal therapy because she’s within a 90day window? Suddenly all the costs go out the window?

Solution would be to just break now, make a mess of the thing as it stands because if it meets even CMSs low expectations after 5 years. They’ll Be imposing this on the rest of the nation.

 

[deleted941485]

As @BobbyHeenan wrote, the end game is to reduce payments. That's it. They are going to bend RO until they reach the breaking point. Let's say a hypothetical RO group does a fantastic job with this model - they provide "value" as defined by CMS while simultaneously delivering low-cost care.

What do you think CMS will do? They are not going to pat them on the back and give them a big incentive payment. Rather they will say "great job, now let's see if we can go 5% lower next year."

Like I said, no field ever bean counted and cost cut it’s way to greatness. CMS isn’t your friend so stop trying to work with them. The best thing would be to not get roped into this game to begin with.

 

[BobbyHeenan]

But that’s the issue, patients return for treatment. I had one with stage I lung ca and then found out she had rectal cancer. Wtf I have to eat the entire course of reveal therapy because she’s within a 90day window? Suddenly all the costs go out the window?

Happens all the time.

Or we palliate bone mets/tumors that go from asymptomatic to symptomatic all the time.

Should be different ICD codes/different "episodes."

Again - would love to see if this goes on in other parts of medicine. I'm ignorant on it, but it seems novel to us right now.

 

[scarbrtj]

Next stop: Medicare For All.

 

[elementaryschooleconomics]

At least someone's happy:

 

[OTN]

As @BobbyHeenan wrote, the end game is to reduce payments. That's it. They are going to bend RO until they reach the breaking point. Let's say a hypothetical RO group does a fantastic job with this model - they provide "value" as defined by CMS while simultaneously delivering low-cost care.

What do you think CMS will do? They are not going to pat them on the back and give them a big incentive payment. Rather they will say "great job, now let's see if we can go 5% lower next year."

Monopsonies gonna monopsonize

 

[deleted941485]

At least someone's happy:

View attachment 318567

I guess no one told them you can do CK treatments with a linac and still treat 25- 30 a day. What’s the max on CK 8?

 

[Tigerstang]

Link?

To what are you asking for a link? That Mayo Clinic doesn't take assignment of Medicare? Or to their new Jacksonville proton center under development? Both are imminently and easily searchable facts

 

[Tigerstang]

At least someone's happy:

View attachment 318567

Sounds like Cowen needs to do a few more GLG consults with underemployed radoncs to understand what this actually means

 

[scarbrtj]

At least someone's happy:

View attachment 318567

I guess no one told them you can do CK treatments with a linac and still treat 25- 30 a day. What’s the max on CK 8?

Tailwind? Ha. A tailwind in their general direction. These "analysts" never get it. They don't try to; they just try to ride a share price higher. If I'm investing in any rad onc company now, it's the one that can provide an IG-IMRT machine at the lowest conceivable price with the highest possible ROI. And Cyberknife wouldn't be it, nor would protons, nor would MRgRT. And I hate to say it, such a company needs to make/market/lobby the cheap IG-IMRT machine where such a machine needn't be confined to sale to rad oncs only. We're a teeny market, and as our lucrativeness dives, people (rad oncs and those in the rad onc market) are gonna have to "innovate" as the NCI centers say.

 

[deleted941485]

Sounds like Cowen needs to do a few more GLG consults with underemployed radoncs to understand what this actually means

Wow the stock went from 2.41 to 2.6. Way to hype that! I hope you have a few million shares

 

[cancer_doc]

Not sure if anyone has clarified this- if I am reading it correctly, This RO model will start on 1/1/2021 and run to 12/21/2025. So if you are not in one of the affected zip codes, you won't be "APM-ed" till at least 1/1/2026?

 

[elementaryschooleconomics]

Tailwind? Ha. A tailwind in their general direction. These "analysts" never get it. They don't try to; they just try to ride a share price higher. If I'm investing in any rad onc company now, it's the one that can provide an IG-IMRT machine at the lowest conceivable price with the highest possible ROI. And Cyberknife wouldn't be it, nor would protons, nor would MRgRT. And I hate to say it, such a company needs to make/market/lobby the cheap IG-IMRT machine where such a machine needn't be confined to sale to rad oncs only. We're a teeny market, and as our lucrativeness dives, people (rad oncs and those in the rad onc market) are gonna have to "innovate" as the NCI centers say.

I'm about to innovate my way to Palliative Care:

 

[BobbyHeenan]

Not sure if anyone has clarified this- if I am reading it correctly, This RO model will start on 1/1/2021 and run to 12/21/2025. So if you are not in one of the affected zip codes, you won't be "APM-ed" till at least 1/1/2026?

That is my understanding as well.

 

[deleted941485]

I'm about to innovate my way to Palliative Care:

View attachment 318570

Gonna innovate my way out of medicine.

I hope those RT therapists have a bumping catering business on the side. Cause it’s about to be a full time gig.

 

[DoctwoB]

If CMS is not going to pay for the treatment, no one is under any moral obligation whatsoever to provide it.

This whole thing is abhorrent.

Not a radonc, but I disagree with this statement. The risk of having to eat an unreimbursed service is baked into the payment of the initial service.

I'm a surgeon, and many of the things I bill have a 90 day global, meaning I'm responsible for any care within the 90 days. Infection? Complication? Reoperation? Just a whiny patient that wants to be seen every day? I eat the cost. That is factored into the rate of payment for the CPT code.

There was recently a medicare proposal to get rid of globals, and surgeons quashed it. Why? Because they reduced the amount paid for the CPT to compensate for it, and most surgeons would have come out behind. Push back on this, and I'm sure medicare would be happy to get rid of the 90 day rule . . . in exchange for lowering the payment by 20%.

Incidentally, there are a lot of surgeons who (after initial post op check if necessary) recommend a follow up in "3 months or so"

 

[Gfunk6]

Not a radonc, but I disagree with this statement. The risk of having to eat an unreimbursed service is baked into the payment of the initial service.

I'm a surgeon, and many of the things I bill have a 90 day global, meaning I'm responsible for any care within the 90 days. Infection? Complication? Reoperation? Just a whiny patient that wants to be seen every day? I eat the cost. That is factored into the rate of payment for the CPT code.

There was recently a medicare proposal to get rid of globals, and surgeons quashed it. Why? Because they reduced the amount paid for the CPT to compensate for it, and most surgeons would have come out behind. Push back on this, and I'm sure medicare would be happy to get rid of the 90 day rule . . . in exchange for lowering the payment by 20%.

Agree but that is already built in the RO fee for service model. You need to deal with all treatment complications for 90 days as that it is part of your payment.

However, if patient has new ICD10 code, you can bill again.

Let’s say a trauma/general surgeon performed a lap appy on a patient. 40 days later patient has accident, ruptures his spleen and needs it removed. You can still bill for that - it’s completely separate. Not so In the RO APM

 

[evilbooyaa]

Not a radonc, but I disagree with this statement. The risk of having to eat an unreimbursed service is baked into the payment of the initial service.

I'm a surgeon, and many of the things I bill have a 90 day global, meaning I'm responsible for any care within the 90 days. Infection? Complication? Reoperation? Just a whiny patient that wants to be seen every day? I eat the cost. That is factored into the rate of payment for the CPT code.

There was recently a medicare proposal to get rid of globals, and surgeons quashed it. Why? Because they reduced the amount paid for the CPT to compensate for it, and most surgeons would have come out behind. Push back on this, and I'm sure medicare would be happy to get rid of the 90 day rule . . . in exchange for lowering the payment by 20%.

Incidentally, there are a lot of surgeons who (after initial post op check if necessary) recommend a follow up in "3 months or so"

More than happy to see a patient in follow-up for ongoing management of the same issue. Say they're a lung cancer or H&N patient and I need to see them at 1, 2, and/or 4 weeks post-op to manage symptoms. HAPPY to do that.

The issue is as Gfunk described, where if you see them for a completely new issue, unrelated to their previous problem, then you have to deliver that service for free.

Imagine you saw somebody for hematuria and you did a diagnostic cysto + fulguration. Now imagine they come back with severe hematuria and you have to cysto + stent + TURB-T + other stuff. CMS is telling Rad Oncs that NOTHING from the second thing will get paid for.

Separate example - say you cysto + fulgurate on Day 1. Patient comes back with prostate cancer at day 45 and wants surgery in the next month. As it currently reads (which folks may be wrong about), it would be like CMS telling you to RALP that patient for free since you billed anything on them within the past 90 days.

Hell in this situation I may have an 'agreement' with my competitors where we see each others patients that require treatment within a 90 day global. Of course trusting your direct competitor is always a tough ask but tough times may call for tough measures.

 

[Irradi8or]

Page 868 of the Final Rule: " Based on the final design of the RO Model, we believe that on average, Medicare FFS payments to PGPs will be reduced by 6.0 percent and Medicare FFS payments to HOPDs will be reduced by 4.7 percent." Thats stated in black and white in the Final Rule.

 

[medgator]

At least someone's happy:

View attachment 318567

Viewray ain't

 

[medgator]

To what are you asking for a link? That Mayo Clinic doesn't take assignment of Medicare? Or to their new Jacksonville proton center under development? Both are imminently and easily searchable facts

I had heard about Arizona, didn't know that that applies to all Mayo sites. Not sure how they survive in Rochester without Medicare?

 

[thecarbonionangle]

The four horsemen are a-coming.

 

[Lamount]

Agree but that is already built in the RO fee for service model. You need to deal with all treatment complications for 90 days as that it is part of your payment.

However, if patient has new ICD10 code, you can bill again.

Let’s say a trauma/general surgeon performed a lap appy on a patient. 40 days later patient has accident, ruptures his spleen and needs it removed. You can still bill for that - it’s completely separate. Not so In the RO APM

On preliminary review, if a patient does need a second course of treatment within 90 days, I didn't see anything that would compel the clinic to offer it... which is a little concerning, to say the least.

Clinics who lack the good will and/or resources to eat the costs for this second course of treatment will either 1) simply not offer a second to course to patients, or 2) form alliances with neighboring clinics to shuffle patients around

...either way, I don't see this resulting in great outcomes

 

[elementaryschooleconomics]

On preliminary review, if a patient does need a second course of treatment within 90 days, I didn't see anything that would compel the clinic to offer it... which is a little concerning, to say the least.

Clinics who lack the good will and/or resources to eat the costs for this second course of treatment will either 1) simply not offer a second to course to patients, or 2) form alliances with neighboring clinics to shuffle patients around

...either way, I don't see this resulting in great outcomes

Is there anything that would stop people from directly billing the patient? It's America - that would be a viable Option 3 unless some sort of law prevents it.

 

[DebtRising]

It’s a significant forced reimbursement cut after the Medicare home or whatever model they were using to disincentive Med oncs to refer out didn’t have the expected results.

of course patient care will suffer - practices are financially stretched from covid as it is, and technology is not getting any cheaper. Can’t keep doing less with less. No evidence that providers are abusing the system now either - already strict limits on fractions for bone mets baked into Medicare guidelines.

kudos to Scott Azar for doing all his pharma bro’s a solid and hammering rad onc to allow as much immuno profit in onc bucket as possible. Because from a cost savings perspective, attacking rad onc in the new era of years of immunotherapy is truly indefensible from a budget perspective.

 

[OTN]

Is there anything that would stop people from directly billing the patient? It's America - that would be a viable Option 3 unless some sort of law prevents it.

Not sure if anyone has clarified this- if I am reading it correctly, This RO model will start on 1/1/2021 and run to 12/21/2025. So if you are not in one of the affected zip codes, you won't be "APM-ed" till at least 1/1/2026?

Doctors gave up their right to ‘balance bill’ decades ago. Tragically.

 

[deleted941485]

Doctors gave up their right to ‘balance bill’ decades ago. Tragically.

You’ll literally have to drop your Medicare patients in order to get out.

Seriously Medicare is the bane of medicines existence.

 

[Tigerstang]

I had heard about Arizona, didn't know that that applies to all Mayo sites. Not sure how they survive in Rochester without Medicare?

they do not take assignment. Meaning patients can get Medicare to reimburse them, but Medicare does not pay mayo directly.

 

[DoctwoB]

More than happy to see a patient in follow-up for ongoing management of the same issue. Say they're a lung cancer or H&N patient and I need to see them at 1, 2, and/or 4 weeks post-op to manage symptoms. HAPPY to do that.

The issue is as Gfunk described, where if you see them for a completely new issue, unrelated to their previous problem, then you have to deliver that service for free.

Imagine you saw somebody for hematuria and you did a diagnostic cysto + fulguration. Now imagine they come back with severe hematuria and you have to cysto + stent + TURB-T + other stuff. CMS is telling Rad Oncs that NOTHING from the second thing will get paid for.

Separate example - say you cysto + fulgurate on Day 1. Patient comes back with prostate cancer at day 45 and wants surgery in the next month. As it currently reads (which folks may be wrong about), it would be like CMS telling you to RALP that patient for free since you billed anything on them within the past 90 days.

Hell in this situation I may have an 'agreement' with my competitors where we see each others patients that require treatment within a 90 day global. Of course trusting your direct competitor is always a tough ask but tough times may call for tough measures.

Oh I completely agree from a practical standpoint, that being on the hook for an issue entirely unrelated to your initial treatment (new symptomatic bone met, etc) through no fault of your own is unfair and provides extremely perverse incentives to the provider. All I'm saying is that Medicare probably included that in the calculation in deciding how much to reimburse for the initial episode of care. To make things revenue neutral in removing the 90 day rule they would almost certainly decrease the payment provided for the initial service.

 

[Tigerstang]

Anyone stop to think of the massive gains made by varian executives who likely were fully aware of the coming implementation of the APM? If you thought the docs were the ones making money in radiation oncology, you thought wrong.

 

[Chartreuse Wombat]

Anyone stop to think of the massive gains made by varian executives who likely were fully aware of the coming implementation of the APM? If you thought the docs were the ones making money in radiation oncology, you thought wrong.

This is always the case.

 

[thecarbonionangle]

The old timers in this field have raked it in for too long, having the young for brunch with three martinis. Old timers need to step aside to allow fresh new blood to reap some benefit before it is too late. Breadlines are a sure thing. How much more money do you need to make? Just a lil’ bit mo’?

 

[Chartreuse Wombat]

I regret to inform you that APM and decreased supervision requirements are working against oldsters retiring. I intend to depart at the age of 59 1/2 but i know of many in their late 60's who say why should I retire? I can hear you...OK Boomer...

 

[thecarbonionangle]

I regret to inform you that APM and decreased supervision requirements are working against oldsters retiring. I intend to depart at the age of 59 1/2 but i know of many in their late 60's who say why should I retire? I can hear you...OK Boomer...

of course, many of these people will die in their office. It is never enough for them

 

[scarbrtj]

The tradition, and probably rationale, for seeing a patient no matter what exactly every 5th fraction dies Jan 1. Brachy may essentially die with this too if what I'm reading on twitter comes to fruition. ASTRO's kabuki-ish arguments re: IGRT supervision (since that code tumbleth into the dustbin of history) shuffles off this mortal coil Jan 1. Boy did ASTRO waste a lot of breath on all that. And breath is a commodity in short supply these days. I am reading the tea leaves. It looks bleak-ish. Tigerstang's point re: Varian execs is super spot-on; I shoulda seen that one coming. Rad onc, we hardly knew ye!