RO APM Dies!

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Hey a computer can do most of the contouring now? Why not. "Clinical grade" contouring?!
If you're getting paid the same or less with APM (especially for those irksome, zero-reimbursing retreats) the easiest way to boost your hourly pay is work less hours. Credit Palex on this one.

September 18, 2020
Limbus AI receives FDA clearance for Limbus Contour


Limbus AI announces 510(k) clearance from the U.S. Food and Drug Administration for Limbus Contour, the company’s artificial intelligence (AI) powered automatic contouring software. Limbus AI is focused on the development of products designed to improve efficiency in cancer diagnosis, treatment, and follow up. Their flagship product, Limbus Contour, is backed by comprehensive research and produces clinical grade contours that are revolutionizing the speed of planning radiation therapy treatments.

“With Limbus Contour, clinicians have significantly reduced contouring time, allowing them to dedicate more time to direct patient care. We believe our product will set the standard for AI based automatic contouring and dramatically improve the productivity in any radiotherapy department. The product shows expert level performance, is simple to use and integrates with any treatment planning platform.” - Dr. Joshua Giambattista, Medical Lead, Limbus AI.

510(k) clearance for Contour is a significant milestone for Limbus AI. The company will now be seeking to expand into the US market while continuing the development of additional AI contouring products. With an established network of international clinical partners and a growing list of peer reviewed research publications, Limbus AI is well positioned to develop, validate and market test new AI based products for cancer care.

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Hey a computer can do most of the contouring now? Why not. "Clinical grade" contouring?!
If you're getting paid the same or less with APM (especially for those irksome, zero-reimbursing retreats) the easiest way to boost your hourly pay is work less hours. Credit Palex on this one.

September 18, 2020
Limbus AI receives FDA clearance for Limbus Contour


Limbus AI announces 510(k) clearance from the U.S. Food and Drug Administration for Limbus Contour, the company’s artificial intelligence (AI) powered automatic contouring software. Limbus AI is focused on the development of products designed to improve efficiency in cancer diagnosis, treatment, and follow up. Their flagship product, Limbus Contour, is backed by comprehensive research and produces clinical grade contours that are revolutionizing the speed of planning radiation therapy treatments.

“With Limbus Contour, clinicians have significantly reduced contouring time, allowing them to dedicate more time to direct patient care. We believe our product will set the standard for AI based automatic contouring and dramatically improve the productivity in any radiotherapy department. The product shows expert level performance, is simple to use and integrates with any treatment planning platform.” - Dr. Joshua Giambattista, Medical Lead, Limbus AI.

510(k) clearance for Contour is a significant milestone for Limbus AI. The company will now be seeking to expand into the US market while continuing the development of additional AI contouring products. With an established network of international clinical partners and a growing list of peer reviewed research publications, Limbus AI is well positioned to develop, validate and market test new AI based products for cancer care.

Maybe I can set up shop in the Bahamas ?

5-5-5 + AI + living in the Bahamas

Sounds like heaven on earth to me

Now if only I had the capital
 
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I agree with Storey here - if you haven't already, it's worth checking out the zip codes included vs excluded.
 
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The Houston and Columbus zip codes with MDACC and Ohio State exemptions seems cruel and unusual.
 
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If you look at the map it absolutely reeks of corruption, if you know the markets. Got to love the sausage being made.
 
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Future Rad Onc pondering their choices in life after having to supplement their rural income with a fast food job
 
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View attachment 318630

Future Rad Onc pondering their choices in life after having to supplement their rural income with a fast food job

Think about the radiation therapist job market after this. On-treat patients will likely halve... effectively wiping out half the radiation therapy jobs in a given market overnight. To quote the alligator - breadlines.
 
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Think about the radiation therapist job market after this. On-treat patients will likely halve... effectively wiping out half the radiation therapy jobs in a given market overnight. To quote the alligator - breadlines.
So many physics jobs though.... just look at this practice in NC:

 
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I am still confused about the goal of APM. Is HHS...
1) testing out APM in random markets to evaluate if it is a good idea?
2) starting APM in a fraction of clinics as a means of ultimately phrasing it in?
3) just saying they are doing 1) so they can do 2)?
 
I am still confused about the goal of APM. Is HHS...
1) testing out APM in random markets to evaluate if it is a good idea?
2) starting APM in a fraction of clinics as a means of ultimately phrasing it in?
3) just saying they are doing 1) so they can do 2)?

I've been under the impression #3 is correct - the only way this doesn't become the permanent future for all of us is if Medicare spending for RadOnc increases or if the quality metrics are somehow abysmal...but even if they are abysmal, CMS will probably be fine with it if it saves them money.
 
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I am still confused about the goal of APM. Is HHS...
1) testing out APM in random markets to evaluate if it is a good idea?
2) starting APM in a fraction of clinics as a means of ultimately phrasing it in?
3) just saying they are doing 1) so they can do 2)?
The goal is to reduce costs. Plain and simple. 30% of practices take a 5% hit on Medicare patients. Other secular events (decreased supervision) lower demand. IN 2025 it becomes the CMS standard and the other insurers follow.
 
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The goal is to reduce costs. Plain and simple. 30% of practices take a 5% hit on Medicare patients. Other secular events (decreased supervision) lower demand. IN 2025 it becomes the CMS standard and the other insurers follow.

But what actually happens in 5 years? Is this a forgone conclusion for everyone?
 
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Does anyone know how RVus would work in the apm?
Discussions are going to be kafkaesque I bet. And completely arbitrary as new "rules" are designed. Those designing the rules will be doing so to make it where MDs don't make more; probably just equal, or less.
So many physics jobs though.... just look at this practice in NC:

People are going to find new and innovative ways to streamline their medical physics usage. Eg, I know many centers that actually never do per plan IMRT QA on the machine. I think this is safe actually with the high quality beam data and planning nowadays. But technically you have to QA each plan to bill IMRT. But not under APM...
 
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It is much harder to become medical physicist now than 15 years ago. Have to go to designated program and then residency. Complete opposite of residency expansion?
I think about 10 to 15y ago there was a glut and all the physicists’ hair was on fire. Then they got their house in order.
 
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I think about 10 to 15y ago there was a glut and all the physicists’ hair was on fire. Then they got their house in order.
Those physicists sure are smart

But the relentless march of AI will come for all
 
Medicare expects to save $230 million over next 5 years in rad onc. To put this in a "number needed to treat" context, I have calculated that the avg American rad onc is responsible for $1.5 million in business per year. And $230 million per 5 years equals $46 million/year, and $46 million/$1.5 million per rad onc equals 31 rad oncs. So to put in context, APM is a nationwide program imposing huge changes in how rad oncs deliver care to the entire country, and it is designed to essentially eliminate the "cost" of 31 (rad onc) U.S. citizens per year. That's 31 out of ~5200 American rad oncs. And even more starkly, it's a program designed to target (in some ways) 31 U.S. citizens out of ~330 million.

 
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Medicare expects to save $230 million over next 5 years in rad onc. To put this in a "number needed to treat" context, I have calculated that the avg American rad onc is responsible for $1.5 million in business per year. And $230 million per 5 years equals $46 million/year, and $46 million/$1.5 million per rad onc equals 31 rad oncs. So to put in context, APM is a nationwide program imposing huge changes in how rad oncs deliver care to the entire country, and it is designed to essentially eliminate the "cost" of 31 (rad onc) U.S. citizens per year. That's 31 out of ~5200 American rad oncs. And even more starkly, it's a program designed to target (in some ways) 31 U.S. citizens out of ~330 million.


As others have noted...this is literally the definition of "penny wise, pound foolish".

If only Big RadOnc would turn some of their deep pockets loose on key government officials...oh, wait. :(
 
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Medicare expects to save $230 million over next 5 years in rad onc. To put this in a "number needed to treat" context, I have calculated that the avg American rad onc is responsible for $1.5 million in business per year. And $230 million per 5 years equals $46 million/year, and $46 million/$1.5 million per rad onc equals 31 rad oncs. So to put in context, APM is a nationwide program imposing huge changes in how rad oncs deliver care to the entire country, and it is designed to essentially eliminate the "cost" of 31 (rad onc) U.S. citizens per year. That's 31 out of ~5200 American rad oncs. And even more starkly, it's a program designed to target (in some ways) 31 U.S. citizens out of ~330 million.

And with how much IO costs compared to RT, if CMS made this rule to apply to med onc/IO, imagine how much they would really save despite perseverating over the pennies they save with RT...
 
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It's been posted before but this is the beginning of the end.
1600700228105.png

NEJM, Jan 26 2012

The sources of the SGR Hole (or who is to blame). Of course this is a relative percentage and the absolute $$ number may be small potatoes but as Steve Hahn made clear many politicians don't understand relative versus absolute differences. Being an outlier in a small specialty with limited political power is not a favorable indicator.
 
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Three cases on my schedule this week and I'm pretty sure in an APM world there's no way either our cancer center or this patient isn't getting hosed with APM rules. Incentives to either delay or avoid care or give appropriate care and you never get reimbursed for it.

- case 1: Breast cancer, bony mets. Palliated a rib met (kind of a big soft tissue component) 2.5 months ago (5 fractions). New acetabular met I"m about to treat.

- case 2: cholangiocarcinoma, bony mets at diagnosis. T spine met, symptomatic... palliated that in between chemo cycles. Now her hip met 8 weeks later is more symptomatic.

- case 3: Cervical cancer. Outside hospital closer to her home doing her EBRT. Referred for brachy.

The brachy thing is most scary. I see some chatter on twitter about it but I don't see anything definite about what we're going to do about this in an APM world. These cases are TONS of time and resources. We can argue about brachy boost for prostate, but if we can't figure out a way to have a viable brachy payment solution for cervix we're literally costing lives.
 
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Three cases on my schedule this week and I'm pretty sure in an APM world there's no way either our cancer center or this patient isn't getting hosed with APM rules. Incentives to either delay or avoid care or give appropriate care and you never get reimbursed for it.

- case 1: Breast cancer, bony mets. Palliated a rib met (kind of a big soft tissue component) 2.5 months ago (5 fractions). New acetabular met I"m about to treat.

- case 2: cholangiocarcinoma, bony mets at diagnosis. T spine met, symptomatic... palliated that in between chemo cycles. Now her hip met 8 weeks later is more symptomatic.

- case 3: Cervical cancer. Outside hospital closer to her home doing her EBRT. Referred for brachy.

The brachy thing is most scary. I see some chatter on twitter about it but I don't see anything definite about what we're going to do about this in an APM world. These cases are TONS of time and resources. We can argue about brachy boost for prostate, but if we can't figure out a way to have a viable brachy payment solution for cervix we're literally costing lives.

These are perfect examples of where the APM makes absolutely no sense in its current form. I've also seen the Twitter conversations about brachy...if those interpretations are correct, it's extremely concerning.
 
- case 3: Cervical cancer. Outside hospital closer to her home doing her EBRT. Referred for brachy.

The brachy thing is most scary. I see some chatter on twitter about it but I don't see anything definite about what we're going to do about this in an APM world. These cases are TONS of time and resources. We can argue about brachy boost for prostate, but if we can't figure out a way to have a viable brachy payment solution for cervix we're literally costing lives.

From my read of the final APM ruling, you should be fine with the combo EBRT + Brachy. CMS will pay APM rate to whomever gives the first course and FFS for the second. So in this setting, you (brachy) should be able to collect standard FFS.
 
From my read of the final APM ruling, you should be fine with the combo EBRT + Brachy. CMS will pay APM rate to whomever gives the first course and FFS for the second. So in this setting, you (brachy) should be able to collect standard FFS.

Will that FFS then be "deducted" from the amount paid for the person giving the EBRT?
 
No, language did not specify that. It's separate.

What about if the person/place doing the EBRT is affiliated with the same practice/cancer center but at a different facility? Would that make a difference?
 
APM was known when the sold

yes, implementation date was not known. unless you knew it was for sure being finalized Friday and implemented 1/1/2021. I can admit I did not know these things as facts until Friday.
 
What about if the person/place doing the EBRT is affiliated with the same practice/cancer center but at a different facility? Would that make a difference?

Same practice participating in APM can perform both and charge APM for the first course and FFS for the second course. What is unclear to me is whether both the EBRT and brachy can or cannot be done by the same provider in the practice....
 
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I am still confused about the goal of APM. Is HHS...
1) testing out APM in random markets to evaluate if it is a good idea?
2) starting APM in a fraction of clinics as a means of ultimately phrasing it in?
3) just saying they are doing 1) so they can do 2)?

They need “evidence” that APM will be successful but honestly it doesn’t matter what the data says because HHS wins either way. If it works: they save money by cutting reimbursements. If it doesn’t work: they’ll just cut FFS reimbursements anyway.

This is largely for show
 
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Three cases on my schedule this week and I'm pretty sure in an APM world there's no way either our cancer center or this patient isn't getting hosed with APM rules. Incentives to either delay or avoid care or give appropriate care and you never get reimbursed for it.

- case 1: Breast cancer, bony mets. Palliated a rib met (kind of a big soft tissue component) 2.5 months ago (5 fractions). New acetabular met I"m about to treat.

- case 2: cholangiocarcinoma, bony mets at diagnosis. T spine met, symptomatic... palliated that in between chemo cycles. Now her hip met 8 weeks later is more symptomatic.

- case 3: Cervical cancer. Outside hospital closer to her home doing her EBRT. Referred for brachy.

The brachy thing is most scary. I see some chatter on twitter about it but I don't see anything definite about what we're going to do about this in an APM world. These cases are TONS of time and resources. We can argue about brachy boost for prostate, but if we can't figure out a way to have a viable brachy payment solution for cervix we're literally costing lives.

Sometimes it’s those palliative cases that take up more mental bandwidth
 
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Medicare expects to save $230 million over next 5 years in rad onc. To put this in a "number needed to treat" context, I have calculated that the avg American rad onc is responsible for $1.5 million in business per year. And $230 million per 5 years equals $46 million/year, and $46 million/$1.5 million per rad onc equals 31 rad oncs. So to put in context, APM is a nationwide program imposing huge changes in how rad oncs deliver care to the entire country, and it is designed to essentially eliminate the "cost" of 31 (rad onc) U.S. citizens per year. That's 31 out of ~5200 American rad oncs. And even more starkly, it's a program designed to target (in some ways) 31 U.S. citizens out of ~330 million.


I’m sorry 230M over 5 years? Is that a joke? They spend more money on a single biologic in a year but we are the problem.
 
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Three cases on my schedule this week and I'm pretty sure in an APM world there's no way either our cancer center or this patient isn't getting hosed with APM rules. Incentives to either delay or avoid care or give appropriate care and you never get reimbursed for it.

- case 1: Breast cancer, bony mets. Palliated a rib met (kind of a big soft tissue component) 2.5 months ago (5 fractions). New acetabular met I"m about to treat.

- case 2: cholangiocarcinoma, bony mets at diagnosis. T spine met, symptomatic... palliated that in between chemo cycles. Now her hip met 8 weeks later is more symptomatic.

- case 3: Cervical cancer. Outside hospital closer to her home doing her EBRT. Referred for brachy.

The brachy thing is most scary. I see some chatter on twitter about it but I don't see anything definite about what we're going to do about this in an APM world. These cases are TONS of time and resources. We can argue about brachy boost for prostate, but if we can't figure out a way to have a viable brachy payment solution for cervix we're literally costing lives.

For the palliative cases I would find a hungry statistician after APM has been around for a while. Then try to correlate its inception with increasing opioid usage because that will happen.

You'll be a star.

For brachy, I got nothing. The wording confuses and angers me and I don't know what's what. This isn't religious scripture. It should be clear cut.
 
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They need “evidence” that APM will be successful but honestly it doesn’t matter what the data says because HHS wins either way. If it works: they save money by cutting reimbursements. If it doesn’t work: they’ll just cut FFS reimbursements anyway.

This is largely for show
Value=Quality/Cost.
Quality is difficult to measure so lowering costs automatically increases value.
 
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Some companies actually lobbying for APM:

Under Medicare’s traditional fee-for-service payment system, the estimated reimbursement using Medicare’s 2020 national rates for treatment of breast cancer include the following:
  • For intensity modulated radiation therapy (IMRT), payment values are approximately $3,147 for physicians and $23,213 for facilities
  • For external beam radiation therapy (EBRT), payment values are approximately $3,349 for physicians and $13,445 for facilities
  • For Xoft intraoperative radiation therapy (IORT), payment values are approximately $402 for physicians and $7,942 for facilities
In 2021 the estimated reimbursement for the selected 30% of the country will include the following:
  • For selected modalities (including IMRT and EBRT) under the RO Alternative Payment Model, payment values will be approximately $2,081 for physicians and $10,129 for facilities.
The Medicare proposed reimbursement for Xoft, which would apply to 100% of the market and is subject to final CMS approval, is $360 for physicians and $7,938 for facilities.

I made a graph, for breast cancer:

J5kRYsT.png
 
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So.... are oligomets really not the savior of the specialty?

Color me shocked!
 
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Guys. I thought 2020 couldn’t get any more depressing. You proved me wrong. Good luck to ASTRO trying to put this genie back in its bottle.

So much wasted effort on trivial matters. How is that urorad fight coming along, anyway? How many rad oncs have benefited from that.
 
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DUH, cardiac ablation is! Thanks, ADROP!
And you know what ASTRO will say/do when the first cardiology group buys a trubeam and hires a rad onc... post a bunch of "we are gravely concerned" web pages. I can see it now... "We must stop cardiologists from treating the cardiology patients in cardiology offices and have the cardiology patients treated in radiation oncologists' centers instead."

Good luck to ASTRO trying to put this genie back in its bottle.
C'mon. ASTRO puts genies back in bottles at, like, Michael Jordan levels... Michael Jordan homerun hitting levels.
 
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Guys. I thought 2020 couldn’t get any more depressing. You proved me wrong. Good luck to ASTRO trying to put this genie back in its bottle.

So much wasted effort on trivial matters. How is that urorad fight coming along, anyway? How many rad oncs have benefited from that.

Let me know when you get a practice survey request about this from a current PGY-3? Maybe it'll be a PGY-4 this time...
 
A little observation on the ~$3250 paid to physicians in old FFS vs ~$2081 to be paid under APM, for breast. I believe the majority of "hypofractionated" breast patients in America were receiving 21 fractions: 16 "Canadian" new style and a 5 fraction old style/old data boost. So Medicare "saw" a price differential between "standard," which was probably 25 fractions plus 8 fraction boost (33 fx's total), and hypofractionated, and "priced in" that amount into APM.

Therefore...
33 fractions at $3250, times discounted fractions at 21 divided by 33 (21/33 = 0.64), and 0.64 times $3250 equals $2080.

Coincidence?

And just by the by, look for 5 fraction breast to sell like hotcakes in APM zones.

And ALSO by the by, if we as a specialty decide to devalue treatments to a certain level, CMS now shows absolute willingness to accept that valuation.
 
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So. Is this a done deal? Signed, sealed, delivered? Or is there still a chance the rule changes before January 1st? Election aside.
 
So. Is this a done deal? Signed, sealed, delivered? Or is there still a chance the rule changes before January 1st? Election aside.
Seems like ASTRO has some hope. They went bust-o over supervision, and that didn't even involve CMS forgoing some dinero. Now that money's on the line we think they're more apt to be successful?
 
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