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RO APM lives

elementaryschooleconomics

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I guess some of these guys have such low self-esteem, getting that “academic position” has to mean something important even though most docs who are in private practice or work for other systems decided to do it.
Bingo. One of my partners was trying to decide between two job offers several decades ago. Both were at big-name academic institutions, one was Man's Best Hospital. The salary at Harvard was appreciably lower than the other place. When my partner brought this up in an attempt to negotiate, he was hit with "that's the salary, it's not changing, we pay you in prestige".

I guess that there are a significant number of folks happy to be "paid in prestige". After spending 17 years in the miasma of academic egos, there is no amount of prestige I could be "paid" to make me want to go back.
 
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RickyScott

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God he's obtuse.
....
By implementing a policy of equivalent reimbursement regardless of chosen radiation technique, the financial incentive to recommend IMRT will be removed.
Attributing nefarious financial incentives to others re: IMRT while charging MDACC prices (worlds highest) and pushing protons. And, he is on the ASTRO board.
 
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Just politics. Started nearly 40 years ago in a Social Security Bill. Our elites really are horrible creatures.

Posted many times but here they are again

Thank you. Wow.


Previous research by the U.S. Government Accountability Officeestimated that CMS paid these exempt centers approximately $0.5 billion per year more than it would have reimbursed under the PPS system.”

I know I shouldn’t be surprised by now, but this is really unbelievable.
 
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Neuronix

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Ben Smith's arguments about IMRT not being cost effective for breast cancer are null and void for two reasons.

1. Cost of protons blows 3D and IMRT out of the water. Any use of protons in breast should be immediately criticized as much more costly and not cost-effective until efficacy data is published. The financial incentives to use protons off protocol or in a flimsy registry protocol are high for centers with protons. A similar statement should be made about financial incentives for protons, and if not made, any argument about IMRT ignored.

2. Private payer rates for a course of 3D breast are almost certainly higher at MDACC than a course of IMRT breast at a private, standalone facility. Until Ben Smith begins advocating for site neutral payments, any discussion of financial incentives from him should be struck down as conflict of interest.

Still waiting for a retraction of the 2010 paper that destroyed our job market...
 
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OTN

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Ben Smith's arguments about IMRT not being cost effective for breast cancer are null and void for two reasons.

1. Cost of protons blows 3D and IMRT out of the water. Any use of protons in breast should be immediately criticized as much more costly and not cost-effective until efficacy data is published. The financial incentives to use protons off protocol or in a flimsy registry protocol are high for centers with protons. A similar statement should be made about financial incentives for protons, and if not made, any argument about IMRT ignored.

2. Private payer rates for a course of 3D breast are almost certainly higher at MDACC than a course of IMRT breast at a private, standalone facility. Until Ben Smith begins advocating for site neutral payments, any discussion of financial incentives from him should be struck down as conflict of interest.

Still waiting for a retraction of the 2010 paper that destroyed our job market...

Any missive from Dr. Benjamin Smith on anything remotely policy-related should be struck down on sight because of that 2010 paper. How anyone can be so tremendously wrong about the direction of an entire field yet still be allowed to comment on the policies of said field as if they know what they're talking about is waaaaaaay beyond me.
 
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fiji128

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Any missive from Dr. Benjamin Smith on anything remotely policy-related should be struck down on sight because of that 2010 paper. How anyone can be so tremendously wrong about the direction of an entire field yet still be allowed to comment on the policies of said field as if they know what they're talking about is waaaaaaay beyond me.

In a lot of ways Ben Smith is the poster boy of what is so wrong with this field. Its absolutely bonkers that he is on the Astro board or has any say in anything beyond his clinic. Double residency spots? Proton partial breast? Ways in on cost of treatment issues while working at MDACC? What a joke.
 
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RickyScott

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In a lot of ways Ben Smith is the poster boy of what is so wrong with this field. Its absolutely bonkers that he is on the Astro board or has any say in anything beyond his clinic. Double residency spots? Proton partial breast? Ways in on coast of treatment issues while working at MDACC? What a joke.
cant agree more. Astro works against us.
 
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medgator

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cant agree more. Astro works against us.
They were happy to screw over the PP folks in urorads setups with their campaign via ASTRO PAC screaming IMRT overuse, but not a peep over zealous and unscrupulous proton marketing to prostate CA patients in many of our backyards which was going on for years at the same time.

Fairly certain IMRT is a better treatment than cryo or hifu for prostate CA. And from a financial standpoint, better than protons too

The hypocrisy is disgusting
 
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medgator

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But... but... he tweeted about it which is probably worth more for promotion than a new article about how he was wrong:

Still isn't even close to enough contraction realistically. Maybe he should follow folks like Chirag Shah who actually know what they are talking about
 
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TheWallnerus

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Ben Smith's arguments about IMRT not being cost effective for breast cancer are null and void for two reasons.

1. Cost of protons blows 3D and IMRT out of the water. Any use of protons in breast should be immediately criticized as much more costly and not cost-effective until efficacy data is published.

They were happy to screw over the PP folks in urorads setups with their campaign via ASTRO PAC screaming IMRT overuse, but not a peep over zealous and unscrupulous proton marketing to prostate CA patients in many of our backyards which was going on for years at the same time.
Keep in mind there is now data that breast cancer makes up the largest cohort of patients treated at proton centers. (Probably attributable to the drop-off in prostate cancer cases nationwide.)
 
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Mandelin Rain

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Keep in mind there is now data that breast cancer makes up the largest cohort of patients treated at proton centers. (Probably attributable to the drop-off in prostate cancer cases nationwide.)
oh my god what GIF by So You Think You Can Dance
 
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SubserviantToABR

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Keep in mind there is now data that breast cancer makes up the largest cohort of patients treated at proton centers. (Probably attributable to the drop-off in prostate cancer cases nationwide.)
Seriously? Choosing wisely, huh? IMRT is not okay for breast but certainly protons. Got it.
 
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OTN

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Protons is more than okay for breast, it's better! Now, that's not coming from me, but I'm not an "expert" so what do I know? We need the experts from MDACC to weigh in. Fortunately, they have a webpage that does just that for protons in breast cancer:


DID YOU KNOW?​

By reducing both high and low doses of radiation to non-target tissues, as compared to intensity modulated radiation therapy (IMRT) or 3-D (three-dimensional) radiation planning, protons offer the potential of reduced long-term functional and cosmetic side effects from radiation treatments for breast cancer.


 
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fiji128

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Protons is more than okay for breast, it's better! Now, that's not coming from me, but I'm not an "expert" so what do I know? We need the experts from MDACC to weigh in. Fortunately, they have a webpage that does just that for protons in breast cancer:


DID YOU KNOW?​

By reducing both high and low doses of radiation to non-target tissues, as compared to intensity modulated radiation therapy (IMRT) or 3-D (three-dimensional) radiation planning, protons offer the potential of reduced long-term functional and cosmetic side effects from radiation treatments for breast cancer.


It’s ca
Protons is more than okay for breast, it's better! Now, that's not coming from me, but I'm not an "expert" so what do I know? We need the experts from MDACC to weigh in. Fortunately, they have a webpage that does just that for protons in breast cancer:


DID YOU KNOW?​

By reducing both high and low doses of radiation to non-target tissues, as compared to intensity modulated radiation therapy (IMRT) or 3-D (three-dimensional) radiation planning, protons offer the potential of reduced long-term functional and cosmetic side effects from radiation treatments for breast cancer.


It’s called the MDACC way, respect✊. 065DB5A6-61E4-4108-B738-25B9185A6745.jpeg
 
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TheWallnerus

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By reducing both high and low doses of radiation to non-target tissues, as compared to intensity modulated radiation therapy (IMRT) or 3-D (three-dimensional) radiation planning
Strongly reminds me of when Katie Couric asked VP candidate Sarah Palin “You say you read a lot; which of the daily newspapers and magazines do you read regularly?”

And Sarah replied “All of them.”

Which doses do protons reduce? ALL OF THEM.
 
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Krukenberg

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Protons is more than okay for breast, it's better! Now, that's not coming from me, but I'm not an "expert" so what do I know? We need the experts from MDACC to weigh in. Fortunately, they have a webpage that does just that for protons in breast cancer:


DID YOU KNOW?​

By reducing both high and low doses of radiation to non-target tissues, as compared to intensity modulated radiation therapy (IMRT) or 3-D (three-dimensional) radiation planning, protons offer the potential of reduced long-term functional and cosmetic side effects from radiation treatments for breast cancer.


What? I have no idea how they can claim protons reduce high dose. The PTV literally gets expanded because of range uncertainty. Also, protons are skin searing
 
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Neuronix

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What? I have no idea how they can claim protons reduce high dose. The PTV literally gets expanded because of range uncertainty. Also, protons are skin searing

I agree with you in part.

We prescribe to CTV and then with IMPT robustness uncertainties it ends up looking a lot like an IMRT PTV. Like 3%/3mm looks like 3 mm PTV expansion, basically.

Still, yeah high dose there's no sparing because coverage is coverage. I don't see any benefit to proton plans until you're at less than about 50% prescription isodose.
 
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TheWallnerus

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"Dr. Aileen Chen, a Radiation Oncologist (ed note: Dr. Chen not subject to the model) practicing at MD Anderson Cancer Center, Houston (ed note: MDACC won't be subject to the RO-APM either), will join the RO Model Team (ed note: the team decided not to put MDACC in the model) to discuss RO participant requirements (which won't be required of Dr. Chen) and summarize details of peer review (with which Dr. Chen won't have to be bothered)."

Question from back of room:
If you're a solo rad onc, and there are no other rad oncs (or maybe even docs) in your group, how do you get this peer review? Is any MD a peer? Does it have to be a BC rad onc? Can I use a rad onc from another country? Can I use a retired rad onc? Can a neurosurgeon (ed note: they have to do radiosurgery cases in residency) be a peer on SRS cases? Can I get an MD board certified by the American Board of Radiology (ed note: radiologist)? Can I use a rad onc "fellow"? Does it have to be an MD; can it be an ACGME accredited board certified PhD physicist? Or can I only have them peer review "special physics consult" cases? Can I charge for peer reviewing other docs' work? If I don't get a peer review, do I get paid by CMS for the "episode"? If I get paid and forget to do peer review, is it fraud? Should I refund paid money if the peer review gets overlooked? If so, how much... all the $$$ for the episode?

 
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elementaryschooleconomics

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"Dr. Aileen Chen, a Radiation Oncologist (ed note: Dr. Chen not subject to the model) practicing at MD Anderson Cancer Center, Houston (ed note: MDACC won't be subject to the RO-APM either), will join the RO Model Team (ed note: the team decided not to put MDACC in the model) to discuss RO participant requirements (which won't be required of Dr. Chen) and summarize details of peer review (with which Dr. Chen won't have to be bothered)."

Question from back of room:
If you're a solo rad onc, and there are no other rad oncs (or maybe even docs) in your group, how do you get this peer review? Is any MD a peer? Does it have to be a BC rad onc? Can I use a rad onc from another country? Can I use a retired rad onc? Can a neurosurgeon (ed note: they have to do radiosurgery cases in residency) be a peer on SRS cases? Can I get an MD board certified by the American Board of Radiology (ed note: radiologist)? Can I use a rad onc "fellow"? Does it have to be an MD; can it be an ACGME accredited board certified PhD physicist? Or can I only have them peer review "special physics consult" cases? Can I charge for peer reviewing other docs' work? If I don't get a peer review, do I get paid by CMS for the "episode"? If I get paid and forget to do peer review, is it fraud? Should I refund paid money if the peer review gets overlooked? If so, how much... all the $$$ for the episode?

Ah, our benevolent overlords from Texas will take a break from treating breasts with protons to dispense knowledge to the unwashed masses?

Excellent.
 
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Lamount

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"Dr. Aileen Chen, a Radiation Oncologist (ed note: Dr. Chen not subject to the model) practicing at MD Anderson Cancer Center, Houston (ed note: MDACC won't be subject to the RO-APM either), will join the RO Model Team (ed note: the team decided not to put MDACC in the model) to discuss RO participant requirements (which won't be required of Dr. Chen) and summarize details of peer review (with which Dr. Chen won't have to be bothered)."

Question from back of room:
If you're a solo rad onc, and there are no other rad oncs (or maybe even docs) in your group, how do you get this peer review? Is any MD a peer? Does it have to be a BC rad onc? Can I use a rad onc from another country? Can I use a retired rad onc? Can a neurosurgeon (ed note: they have to do radiosurgery cases in residency) be a peer on SRS cases? Can I get an MD board certified by the American Board of Radiology (ed note: radiologist)? Can I use a rad onc "fellow"? Does it have to be an MD; can it be an ACGME accredited board certified PhD physicist? Or can I only have them peer review "special physics consult" cases? Can I charge for peer reviewing other docs' work? If I don't get a peer review, do I get paid by CMS for the "episode"? If I get paid and forget to do peer review, is it fraud? Should I refund paid money if the peer review gets overlooked? If so, how much... all the $$$ for the episode?



...to be (undeservedly) fair, the entire undercurrent of the APM is that we get paid too much for what we do, and that the government is 'wasting' taxpayer money on us. Why would they ask for the input of someone who stands to be hurt by this thing in the immediate future?
 
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elementaryschooleconomics

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...to be (undeservedly) fair, the entire undercurrent of the APM is that we get paid too much for what we do, and that the government is 'wasting' taxpayer money on us. Why would they ask for the input of someone who stands to be hurt by this thing in the immediate future?
It's a good point, though I would argue places like Anderson would potentially benefit from the APM via reimbursement cuts forcing smaller shops to either close or consolidate into their network (by "their" I mean Anderson and other academic conglomerates of similar ilk).

It's basically the government stifling competition, which is very un-American. Come on Texas, do better! You're supposed to be a state which votes for "little government", yet you appear to be very in favor of the government mandating what folks can do with their bodies.
 
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RickyScott

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Only in America!

- Don King
...to be (undeservedly) fair, the entire undercurrent of the APM is that we get paid too much for what we do, and that the government is 'wasting' taxpayer money on us. Why would they ask for the input of someone who stands to be hurt by this thing in the immediate future?
Agree that this is a good point, but in addition to competition, mdacc is an exploitative price gouger who refuses to comply with cms own price transparency law.
 
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medgator

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Gfunk6

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I've heard through the grapevine that the state pension fund in Texas actually invested in MDACC's proton center. That being the case, the state legislature will do everything it can to prevent proton profitability from ever being jeopardized.

Similar to how the Oklahoma legislature protected proton coverage - https://www.okhouse.gov/Media/ShowStory.aspx?MediaNewsID=5045
 
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Chartreuse Wombat

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I've heard through the grapevine that the state pension fund in Texas actually invested in MDACC's proton center. That being the case, the state legislature will do everything it can to prevent proton profitability from ever being jeopardized.

Similar to how the Oklahoma legislature protected proton coverage - https://www.okhouse.gov/Media/ShowStory.aspx?MediaNewsID=5045
Florida politicians did the same more than a decade ago. What is good for protons is good for Florida
 
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BobbyHeenan

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Just had this scenario. I presume under APM I would never be paid for this upcoming course, correct?

Guy with C spine bone mets treated 30 days ago. Complete palliative pain response. Had bone mets in L spine and hip but was asymptomatic there a month ago...now very symptomatic. So we're going to treat him now.

THis doesn't get paid for at all in APM since the ICD code is still the same as the prior course, correct?

What about if he now had a brain met, if that was a different ICD code would I then get paid for that?
 
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elementaryschooleconomics

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Just had this scenario. I presume under APM I would never be paid for this upcoming course, correct?

Guy with C spine bone mets treated 30 days ago. Complete palliative pain response. Had bone mets in L spine and hip but was asymptomatic there a month ago...now very symptomatic. So we're going to treat him now.

THis doesn't get paid for at all in APM since the ICD code is still the same as the prior course, correct?

What about if he now had a brain met, if that was a different ICD code would I then get paid for that?
Yup, my understanding is you're treating the L spine for free under APM. I believe that, even though the brain is a different ICD code, that you're ALSO doing that for free. Anything radiation related in the episode + washout is "covered". I'm foggy on the details, but I remember the interpretation of the APM being, for cases like small cell with PCI, you're only getting reimbursed for either the lung or the brain course of XRT - not both. I remember people trying to get answers, but as was pointed out by Join Luh in JCO, the Q&A sessions from the government were UTTERLY USELESS, and I never heard or read what I consider to be a satisfactory answer on this topic...probably because CMS doesn't know, because they haven't considered it, because this is the most hatchet-job payment model anyone could have devised.

You greedy RadOnc you, wanting to get paid for your services. I bet you have a toilet bowl full of emeralds!
 
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BobbyHeenan

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Yup, my understanding is you're treating the L spine for free under APM. I believe that, even though the brain is a different ICD code, that you're ALSO doing that for free. Anything radiation related in the episode + washout is "covered". I'm foggy on the details, but I remember the interpretation of the APM being, for cases like small cell with PCI, you're only getting reimbursed for either the lung or the brain course of XRT - not both. I remember people trying to get answers, but as was pointed out by Join Luh in JCO, the Q&A sessions from the government were UTTERLY USELESS, and I never heard or read what I consider to be a satisfactory answer on this topic...probably because CMS doesn't know, because they haven't considered it, because this is the most hatchet-job payment model anyone could have devised.

You greedy RadOnc you, wanting to get paid for your services. I bet you have a toilet bowl full of emeralds!

Ugh. Insane.

Is there a correlation to this in any other field?

If you’re an orthopedic and fix an arm but the patient breaks a leg - you get paid for both.

If you’re a radiologist and read a chest CT but a few days later the patient needs a head MRI - you get paid for both. Or if they need a repeat chest CT due to new symptoms. Still paid.

If you’re a PCP and a patient with lower extremity edema presents a few days later now with shortness of breath (due to underlying heart issues) you get paid for both office visits.

Who designed this APM ****?
 
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Chartreuse Wombat

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Justin Bekelman from Penn was involved in a lot of the development of this model. Now, Aileen Chen from MDACC. Obviously both are PPS exempt and not in the model
I don’t think UPenn is exempt and they are in. Bekelman has been arguing for protons being in.
 
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RealSimulD

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I don’t think UPenn is exempt and they are in. Bekelman has been arguing for protons being in.
If they go by their historical rates, it’s still going to be very good for them to have stabilized rates. The expensive just get a little less expensive, while the cost effective ones feel more pain.
 
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Chartreuse Wombat

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If they go by their historical rates, it’s still going to be very good for them to have stabilized rates. The expensive just get a little less expensive, while the cost effective ones feel more pain.
Unless I am misunderstanding APM (which is possible), UPenn gets the case rate for Medicare patients (as do all providers in APM zip codes). Their negotiated rates with private insurers are irrelevant.
 
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RickyScott

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Unless I am misunderstanding APM (which is possible), UPenn gets the case rate for Medicare patients (as do all providers in APM zip codes). Their negotiated rates with private insurers are irrelevant.
That is not what I understand. For pts with Medicare and supplement, the supplement would make up the difference between apm and negotiated rate? For Medicare advantage, the negotiated rates would apply. For the rare pt with straight up Medicare, penn would get the apm rate. Insurance companies are still going to be at the mercy of penns huge leverage.
 
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Lamount

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That is not what I understand. For pts with Medicare and supplement, the supplement would make up the difference between apm and negotiated rate? For Medicare advantage, the negotiated rates would apply. For the rare pt with straight up Medicare, penn would get the apm rate. Insurance companies are still going to be at the mercy of penns huge leverage.
That's interesting.

So if the patient has a medicare + supplement and they come back 30 days after palliative bone tx for another painful lesion, UPenn bills as normal and APM doesn't pay anything... does the supplement pay for the entire second palliative course?
 
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RickyScott

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That's interesting.

So if the patient has a medicare + supplement and they come back 30 days after palliative bone tx for another painful lesion, UPenn bills as normal and APM doesn't pay anything... does the supplement pay for the entire second palliative course?
That’s a good question,
 
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That is not what I understand. For pts with Medicare and supplement, the supplement would make up the difference between apm and negotiated rate? For Medicare advantage, the negotiated rates would apply. For the rare pt with straight up Medicare, penn would get the apm rate. Insurance companies are still going to be at the mercy of penns huge leverage.

This is not correct. Supplements cover the 20% out of pocket for medicare, and will continue to do so. The APM would set a rate, Medicare pays 80% of that rate, and the supplement picks up the remainder.
 
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RickyScott

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This is not correct. Supplements cover the 20% out of pocket for medicare, and will continue to do so. The APM would set a rate, Medicare pays 80% of that rate, and the supplement picks up the remainder.
I was told supplements pick up diff between negotiated rate and medicare. Reagenite (?) also had a post on this. Large centers like upenn are getting much more than 100% medicare on their medicare + supplement patients.
 
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Tigerstang

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I was told supplements pick up diff between negotiated rate and medicare. Reagenite (?) also had a post on this. Large centers like upenn are getting much more than 100% medicare on their medicare + supplement patients.

This is not correct. Supplements pick up the 20% gap between what Medicare pays and benficiaries are supposed to pay. When Medicare is primary there is no negotiated rate.

Now some centers don't take assignment of Medicare, like Mayo Clinic. In that setting, Medicare will pay the beneficiary directly. I am not certain if the supplement will cover the difference.
 
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TheWallnerus

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From this article...

op.21.00298t1.jpeg


If you do the math here, docs will be paid on average 16% of the global under RO-APM (across all RO-APM disease sites, low to high). This is quite the dip from historical norms. Someone approached me recently about being offered 18% of global collections and whether that was a good percentage... I'd say in our new RO-APM future, take that and run.
 
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w00tz

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I'm trying to stay positive, but reading this thread and learning more about APM has got me down....

Say my radiation center is in an APM zip code and also next to a PPS-exempt center.
If a patient gets treated for a bone met by me and within 90 days has another bone met, if I
A) don't treat, patient suffers
B) treat them, I will not get paid for additional services
C) send patient to the PPS-exempt center for treatment that will still get paid (and likely steal my patient), and it ultimately doesn't save CMS any money. After CMS does not save any money, I would hope that it scraps this silly experiment, but the more likely scenario is that it finds more ****ty ways to squeeze little rad onc.

Am I understanding this correctly? If so, this is a no-win situation...feels sickening.

Rad oncs have talked a lot about anti-trust with residency numbers. What about this blatantly anti-competitive PPS-exempt non-sense? Such incredibly unfair advantages to being exempt. Going to be a lot harder to spend money for new technology if our reimbursements are getting slashed. Meanwhile, PPS-exempt center is building proton center #2. This can't be legal?
 
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