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the monotherapy hdr prostate single fraction data did not pan out, but it is likely a higher dose is needed, will take some time to work out. It can probably be done in one fraction.
RO APM Dies!
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the monotherapy hdr prostate single fraction data did not pan out, but it is likely a higher dose is needed, will take some time to work out. It can probably be done in one fraction.
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We can’t have it both ways. All the prostate data has shown tumor alpha betas are 3 or less, and that normal tissue alpha betas are around 3. This is why 5 fractions (or 20, or 28) is working when 45 fractions worked just as well. Necessity is the mother of invention, and APM... it’s a mother!
To some extent I’m forcing reductio ad absurdum arguments. But at least we should be open minded to one fraction working where 5 does, or at least 3 or 4 working. And when you’re at 5 fractions, 3 or 4 are 40% or 20% less fractions. Which are substantial.
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Wow, is anyone in this ACRO webinar on the APM? It's clear that CMS does not understand the cervical brachy referral issue AT ALL.
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If you're not an ACRO member, you should be. Per the introduction last night, these slides and this presentation will be made available to members.
Personally, I found the following slide most striking (credit to ACRO and Health Management Associates):
The Y axis is "percent change in episode payments", and the X axis is "number of services", which essentially means number of fractions. Graph on the left is conventional EBRT, graph on right is IMRT.
People are going to do what is incentivized, which is ostensibly the point of this model - under FFS, more fractions was incentivized. Looking at this, under APM, the exact opposite is incentivized. A 28.4% increase in pro fees if I keep it under 10 "services" (fractions)?? As people have rightly pointed out earlier in this thread, 5 fraction regimens for Medicare patients using non-IMRT EBRT are going to TAKE OFF in popularity, regardless of the actual strength of the data.
This is the government telling us, with our wallets, how we should practice medicine, in a ridiculously heavy-handed manner.
Personally, I found the following slide most striking (credit to ACRO and Health Management Associates):
The Y axis is "percent change in episode payments", and the X axis is "number of services", which essentially means number of fractions. Graph on the left is conventional EBRT, graph on right is IMRT.
People are going to do what is incentivized, which is ostensibly the point of this model - under FFS, more fractions was incentivized. Looking at this, under APM, the exact opposite is incentivized. A 28.4% increase in pro fees if I keep it under 10 "services" (fractions)?? As people have rightly pointed out earlier in this thread, 5 fraction regimens for Medicare patients using non-IMRT EBRT are going to TAKE OFF in popularity, regardless of the actual strength of the data.
This is the government telling us, with our wallets, how we should practice medicine, in a ridiculously heavy-handed manner.
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For someone in the picked zip code; I'm not going to depend on ASTRO or national politics or the hand of God to delay/change this. I'm trying to think about the consequences for my group; as well as my own personal practice. Even I'm too young to bury my head in the sand about it, or just wring my hands about it. I plan to work another 20 years...
One striking figure is that 2 single fraction bone mets will be more than anything except anal, H&N, prostate or cervical, so paraphrased from Six Mix-a-Lot...
One striking figure is that 2 single fraction bone mets will be more than anything except anal, H&N, prostate or cervical, so paraphrased from Six Mix-a-Lot...
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This paraphrases an old Ronald Reagan speech about Medicare and socialized medicine.
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And at least now we can see, sim, treat all same day without codes bumping. No reason we couldn’t have bone met patient enter dept at 9 am and have them out by 11. Planning, sim, physics. 15 min consult. 5 min tx. And I can IMRT bone mets when I want now without getting accused of fraud or greed. The ideal tx for C spine mets eg is laterals with 20-30 degree couch kicks. Stays out of esophagus and shoulders and really only way to plan this 2 field approach is inverse optimization. Now the greediest shadiest activity that people will get accused of is doing the FEWEST fractions without IMRT. “He just keeps it simple to make more money.”
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I practiced for a bit in a location that had a lot of resources to put towards VMAT palliative plans. The dosimetry was heavenly. My hunch was it probably afforded a bit more retreatments for those that needed it, because of less overlap in non target regions.
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It is nice to be able to do what you think is right for your patients. Some of these palliative cases can be tough and it can be near impossible to do 3D in some cases. Will no longer have modality shaming or fraction shaming. A good VMAT plan in a palliative case is sometimes a great option
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Exactly. There's seldom times, even in palliative cases, where you wouldn't want the higher isodose regions to have as high a conformity index as possible. (And "over sparing" nearby OARs is sometimes WOT in palliation but does easily leave room open for re-tx; easier to over-spare with IMRT/VMAT.)
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absolutely giving AP/PA 30/10 in a patient you know is going to come back likely, it can make your life a lot easier to be conformal. we have all had those multiple irradiated patients with 3d with overlapping fields which can be a total nightmare to treat, keep you up at night
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As long as they come back after the 90 day episode + 28 day washout period...
"Let's try some medical management first" = phrase which will see a significant increase in use for bone met patients trying to come back <90 days.
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The notion the reimbursement is X% less is so completely under estimated due to this "episode and washout" period thing it's laughable.
Add another one on to my list....
Lady I gave 20 GY/5 fraction palliative 3D treatment to a pleural nodule (she has malignant effusion with studding at pleura invading her rib). She got better but at a far distant site has a similar thing going on, now 2 months later. MEd onc calls me to work her in for another short course palliative treatment.
Glad to do it but also I'd like to be paid for it.
In an APM world no one is getting paid for giving this lady a palliative course of treatment. I'll still do it, but you better believe narcotic usage is going to skyrocket to "just get them through a little longer" so you can get paid when you treat after 120 days.
Add another one on to my list....
Lady I gave 20 GY/5 fraction palliative 3D treatment to a pleural nodule (she has malignant effusion with studding at pleura invading her rib). She got better but at a far distant site has a similar thing going on, now 2 months later. MEd onc calls me to work her in for another short course palliative treatment.
Glad to do it but also I'd like to be paid for it.
In an APM world no one is getting paid for giving this lady a palliative course of treatment. I'll still do it, but you better believe narcotic usage is going to skyrocket to "just get them through a little longer" so you can get paid when you treat after 120 days.
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more money for trump crony AZAR and their pharm lobby.
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Doing this without negotiating drug prices is such a slap in the face. It's theater.
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“Average 6% reduction in reimbursement of episodes that don’t have a 100% reduction in reimbursement.”
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I'm not sure what the challenge would be in this situation... C78.2 (secondary pleural malignancy) is not on in the RO APM cancer types. In fact, any metastases that are not bone or brain; such as lung, liver, lymph node are exempt.
Fortunately the prostate is not near the heartAnd some punch-pulling single fx dose on low risk prostate is likely to be heralded as some sort of success.
I don’t know. The hdr 1 vs 2 fx randomized trial results were shocking. Something like3% vs 25% recurrence rate. And that was 19 gy in 1 fx. (how much higher would someone be willing to go?)
But does it really matter if it’s 1 or 2? Is still a lot less than 44
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maybe something to do with cell cycle reassortment
I’m uncomfortable treating most definitive cases single fraction when some substantial percent of cells will be in a relatively resistant cell cycle phase
probably other components to this too
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I stand corrected. Thanks for pointing this out, good to know.
I’m not in APM but I clearly need to read more.
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Correct, on page 162
Comment: A commenter suggested adding a specific category for an isolated lymph node treated with radiation, emphasizing that this is a common clinical situation.
Response: We thank the commenter for their suggestion. However, we believe that the treatment of an isolated lymph node would likely be part of a treatment plan for an included cancer type. If it is not part of a treatment plan for an included cancer type, the treatment would be paid FFS. [/quote]
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So it seems you can just play a coding name game.
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If so, we should all be holding our breath for that webinar.
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And if you're in private practice, make sure your medical coding/billing company is on point.
D
deleted941485
If your only focused on cutting costs then the field won’t innovate. New tech doesn’t develop and meaningful research isn’t done.
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Especially in our field which is so dependant in tech. Incentive will be to cut down on “toys” and have a bare bone clinic with a linac and minimal staffing at many places.
i know some of you are practicing in very sleepy eyed places. Things are about to get sleepier.
Did they have a slide on SBRT?
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They did not - I'm under the impression SBRT is just considered another "radiation service" as part of the "technique/technology agnostic" design of the APM.
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<10 fractions=good in APM for the 16 diagnoses.
I'm so late to this thread, but my group has been doing APM style contracts for many years now, and frankly we love it. We honestly feel like we are getting paid to practice good medicine. Turnaround time from consult to treat is extremely fast, and many of our easy met cases complete 8Gy x 1 day of consult. But our volumes have dropped nearly 50%, so there is no question in my mind this will be the apocalypse for any new grad entering the field. We were considering opening additional sites to expand our geographic reach but the push to hypo-fx has opened up the catchment area for existing sites. To anyone considering this field, just don't...
D
deleted941485
You mean your on treatment has dropped by 50% or the total number of patients treated in a year dropped by 50%? There’s a big difference.
On treat.
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Yeah. Now just call stuff whatever you want... and do it without fear of reprisal. The Moniker Game (SBRT? IMRT? VMAT? 3D? Simple? Complex? Intermediate?) was a bit dumb. All of modern radiotherapy is high tech.
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I had several questions after listening to the ACRO webinar and I was hoping folks here could help.
1. How does APM treat newly minted radiation oncologists joining practices in APM-affected zip codes? Many of the "correction factors" are based on prior data, but for newly minted board-eligible radiation oncologists, they have no historical data to pull from.
2. The press release suggests that freestanding and hospital-based clinics will be paid equally by APM, so that perhaps freestanding clinics will get a pay raise under APM. However, the ACRO webinar suggests that freestanding clinics will get a pay cut, equal or larger than that of hospital-based clinics. What am I missing?
3. In the Q&A, Marcie O'Reilly said that under the APM, historically efficient practices would get a pay raise, because of the blend factor. This seems like a dubious claim. For example, if a URORADS practice is currently paid at $70k per prostate treatment, and the market average is $40k per prostate treatment, then the URORADS practice will continue to get paid well-above the market average, e.g. $70k in year 1, $66k in year 2, $63k in year 3, etc., and certainly above an efficient practice currently using hypofractionation or brachytherapy boost. Am I understanding that correctly?
1. How does APM treat newly minted radiation oncologists joining practices in APM-affected zip codes? Many of the "correction factors" are based on prior data, but for newly minted board-eligible radiation oncologists, they have no historical data to pull from.
2. The press release suggests that freestanding and hospital-based clinics will be paid equally by APM, so that perhaps freestanding clinics will get a pay raise under APM. However, the ACRO webinar suggests that freestanding clinics will get a pay cut, equal or larger than that of hospital-based clinics. What am I missing?
3. In the Q&A, Marcie O'Reilly said that under the APM, historically efficient practices would get a pay raise, because of the blend factor. This seems like a dubious claim. For example, if a URORADS practice is currently paid at $70k per prostate treatment, and the market average is $40k per prostate treatment, then the URORADS practice will continue to get paid well-above the market average, e.g. $70k in year 1, $66k in year 2, $63k in year 3, etc., and certainly above an efficient practice currently using hypofractionation or brachytherapy boost. Am I understanding that correctly?
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Also good to point out that something like C77.0 is NOT in the RO Model, so good for everyone to be familiar with codes that are in or out
1. case mix and historical experience adjuster is participant specific not physician specific. new physician who joins a practice will get the same case mix and HEA of the TIN/CCN
2. Devil is in the payment methodology details. There’s a 3.75% discount on PC and 4.75% discount on TC. 83% of RO model participants will be eligible for 5%incentive bonus payment but only on PC. That discount on TC is gone and drives a lot of loss.
3. CMS claims to try to make a glide path for inefficient practices to lower their costs over time, but the methodology doesn’t really get inefficient and efficient practices to parity by 5 years into the model. The inefficient practice will likely continue to get paid more than the efficient. In effect, this government model is saying that we will reward you if you were inefficient during the historical period.
Very helpful @Irradi8or!
"To develop its proposed RO Model, CMS conducted an analysis of Medicare fee-for-service (FFS) claims for radiation therapy services. This analysis revealed that freestanding radiation therapy centers, which are paid under the Medicare Physician Fee Schedule (PFS), were paid approximately 11 percent more per episode of care than HOPDs, which are paid under the Outpatient Prospective Payment System (OPPS)."
My prior understanding was that freestanding centers are currently paid significantly LESS for a radiotherapy treatment than hospital-based radiotherapy centers? Is it because freestanding centers do more IMRT and less hypofractionation? Under APM, will freestanding centers and HOPDs be paid the same for a radiotherapy treatment (e.g. 8 Gy in 1 fx, 3D-CRT, bone met)?
"To develop its proposed RO Model, CMS conducted an analysis of Medicare fee-for-service (FFS) claims for radiation therapy services. This analysis revealed that freestanding radiation therapy centers, which are paid under the Medicare Physician Fee Schedule (PFS), were paid approximately 11 percent more per episode of care than HOPDs, which are paid under the Outpatient Prospective Payment System (OPPS)."
My prior understanding was that freestanding centers are currently paid significantly LESS for a radiotherapy treatment than hospital-based radiotherapy centers? Is it because freestanding centers do more IMRT and less hypofractionation? Under APM, will freestanding centers and HOPDs be paid the same for a radiotherapy treatment (e.g. 8 Gy in 1 fx, 3D-CRT, bone met)?
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I think we see fake news here, and cherry picking PFS payments and ignoring those lucrative facility fees. Are freestanding centers buying hospital depts or is it the other way 'round?
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Funny right??? Practice the same way and OVER NIGHT, you go from greedy assh— to selfless.
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Only catch is that in 2026 (IF there's a successor model to the RO Model, like the OCF is to the OCM) you can bet that CMS will re-baseline participants
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Hey all, basic billing question... what is the charge you lose out on if you sim an outpatient the same day as a consult? And will this change under the RO APM?
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You can lose the CT sim (77290) and complex treatment planning charge (77263).
If you put a *modifier25 on the consult many times you won’t lose any charges. You need to document it though as medically necessary (ie to avoid delay, start treatment quickly, patient cannot come back another day, or ?COVID? minimizing trips in health care facility ). It doesn’t always work but sometimes does.
Hearsay from my billers is “excessive use of modifier 25 may trigger an audit.” That may be completely wrong.
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Is there a reason why this is a thing? As in, is there some way to defraud the system if we sim a consult the same day? It seems like the right thing to do.
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The expectation at our multiple clinics for over a decade is see and sim. We bill tons of -25 modifier. Have never heard of any issues. Any charges lost however are likely recouped by that one patient that may have gone elsewhere if not for the pure convenience of our operation. No one has ever brought up audit risk. Seems low risk and patient friendly to me.
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I'm with you on this. Patient's appreciate it a lot. I'm not too worried about audit.
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What is a 25 modifier? I always understood you lost the sim charge if you sim same day
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The Current Procedural Terminology (CPT) definition of modifier 25 is as follows: Modifier 25 – this modifier is used to report an Evaluation and Management (E/M) service on a day when another service was provided to the patient by the same physician. .
It's my understanding other specialties use it (like ENT for scopes, or rad onc for scopes in office)...when you want to get paid for your actual E/M (clinic visit) and a procedure you do on the same day. Without that modifier 25 tagged to your clinic visit, it often gets kicked out as "bundled" with your procedure.
I don't know the "success rate" of it actually getting me paid for both a consult and a CT sim/complex treatment plan, but my collections/billing people say it does sometimes help. I believe some insurance companies refuse to recognize a modifier 25.
Modifier 25 Primer Use It Dont Abuse It
Modifier 25 (significant, separately identifiable evaluation and management [E/M] service by the same physician on the same day of the procedure or other service) is the most important modifier for pediatricians in Current Procedural Terminology (CPT©).
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