RO APM may be implemented this year

[deleted941485]

Medicare just shoveled out to cash to anyone who billed Medicare last year, federal reserve/central bank style because of how much covid affected some practices. Won't see APM until at least 2022, I'm guessing. If that. Very good possibility APM dies with the next administration's HHS head.

CMS Suspends Advance Payment Program to Clinicians for COVID-19

CMS also said it is re-evaluating how much it will pay for pending accelerated-payment applications, with $175 billion in other funding becoming available for the medical community.

www.medscape.com

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[medgator]

CMS Suspends Advance Payment Program to Clinicians for COVID-19

CMS also said it is re-evaluating how much it will pay for pending accelerated-payment applications, with $175 billion in other funding becoming available for the medical community.

www.medscape.com

Not surprised, considering right after that was announced, they basically sent everyone money who billed Medicare last year... That'll be far more interesting to see what happens

HHS Begins Funding $30 Billion to Medicare Providers – Attestations to Be Required | McGuireWoods

First 30 Billion Tranche Public Health Social Services Emergency Fund

www.mcguirewoods.com

 

[taserlaser]

FAST-Forward out now too

DEFINE_ME

26 Gy non-inferior to 40/15

 

[deleted941485]

FAST-Forward out now too

DEFINE_ME

26 Gy non-inferior to 40/15

My prediction is You’ll be treating most of your patients breast and prostate with a five fraction regimen by the end of 2025. ROs will be begging for APM when all the OTV revenue has essentially evaporated.

At the end of the day, how many dedicated radiation oncologists are actually needed in the US?

 

[scarbrtj]

My prediction is You’ll be treating most of your patients breast and prostate with a five fraction regimen by the end of 2025. ROs will be begging for APM when all the OTV revenue has essentially evaporated.

At the end of the day, how many dedicated radiation oncologists are actually needed in the US?

“Begging for APM” ... people prob don’t appreciate how true this really is

 

[deleted941485]

“Begging for APM” ... people prob don’t appreciate how true this really is

They are going to have to start coming around to it. The whole model for RO reimbursement is collapsing partially because of the ridiculous ways it was structured to begin with and partially because the field historically did not exactly attract the brightest minds.

I mean the best thing would be to get out of this dumpster altogether but since that isn’t an option...everyone is kind of stuck

 

[RickyScott]

They are going to have to start coming around to it. The whole model for RO reimbursement is collapsing partially because of the ridiculous ways it was structured to begin with and partially because the field historically did not exactly attract the brightest minds.

I mean the best thing would be to get out of this dumpster altogether but since that isn’t an option...everyone is kind of stuck

we are approaching a point where only institutions with price gouging can profit off these compressed regimens, and none of the smaller centers or community hospitals can survive, thereby giving them a big share of the market.

 

[scarbrtj]

we are approaching a point where only institutions with price gouging can profit off these compressed regimens, and none of the smaller centers or community hospitals can survive, thereby giving them a big share of the market.

If a breast or prostate can be treated in 5 fractions, no reason in theory it can't be treated in 1-4 fractions. Five fractions, versus less (or versus 6!*), is itself a kind of "price gouging."


*Coding Question: It is my understanding that in order to treat two sites with SBRT you need to keep the treatments to five or less. If the physician has two plans and two separate lesions, but treats these on alternate days that total more than five fractions, can we bill SBRT charges?
Coding Answer: CPT instructions for CPT code 77373 (SBRT treatment delivery, per fraction to 1 or more lesions, including image guidance, entire course not to exceed 5 fractions) include the possibility of treating multiple sites of disease in one treatment course. Therefore, if the sum of the treatment days for all of the sites treated during a single course of therapy exceeds five; it is not appropriate to charge CPT code 77373 for SBRT delivery.

 

[deleted941485]

we are approaching a point where only institutions with price gouging can profit off these compressed regimens, and none of the smaller centers or community hospitals can survive, thereby giving them a big share of the market.

these large institutions can get reimbursement for a five fx regimen that is at least comparable to what a PP freestanding would get for 39fx. We’re talking the mega health systems in your community.

If you aren’t affixed to a health system at his point, I think you ought to at least consider it.

Really it’s game over for RO and the shame is even with shorter regimens we still could have made it work but NO.

 

[medgator]

we are approaching a point where only institutions with price gouging can profit off these compressed regimens, and none of the smaller centers or community hospitals can survive, thereby giving them a big share of the market.

Pt will travel much easier for 5 fx than 15-30. Maybe RW was right.... All curative xrt will happen at high volume academic centers

 

[deleted941485]

Pt will travel much easier for 5 fx than 15-30. Maybe RW was right.... All curative xrt will happen at high volume academic centers

Yeah if it’s 5fx proton or something.

 

[Burt Radnolds]

FAST-Forward out now too

DEFINE_ME

26 Gy non-inferior to 40/15

For those doing Livi 5fx APBI, does this make you want to reduce your dose? Obvious toxicity jump from 26 to 27Gy, while Livi in 30Gy.

 

[taserlaser]

For those doing Livi 5fx APBI, does this make you want to reduce your dose? Obvious toxicity jump from 26 to 27Gy, while Livi in 30Gy.

Where I trained we did 27 Gy/5 daily for APBI on trial. Where I work at now they do 30 Gy/5 every other day. Now that we have this, we’ll be going to 26 Gy/5 daily, and I personally would be comfortable with that. Not sure what we will decide for those that need boost. Have to work out the eqd2s but will may SIB those that require it rather than extend the fractionation as per FF, but that’s still an area of question.

 

[scarbrtj]

For those doing Livi 5fx APBI, does this make you want to reduce your dose? Obvious toxicity jump from 26 to 27Gy, while Livi in 30Gy.

Nah. Whole breast lower dose; APBI the higher dose. Level 1 data for both. No level 1 for <30Gy APBI EBRT AFAIK. Never had a prob w/ 30 APBI.

 

[evilbooyaa]

For those doing Livi 5fx APBI, does this make you want to reduce your dose? Obvious toxicity jump from 26 to 27Gy, while Livi in 30Gy.

Right.... but this is 26Gy/5Fx whole breast, not APBI. Toxicity = Dose x volume. FAST-Forward is treating much higher volume in most patients.

FAST Trial already showed that 5.7Gy x 5 is less toxic than 6Gy x 5 when treatment done once a week.

Similarly, 27Gy in 5 WBI may have worse toxicities when compared to 26Gy in 5.

I would not de-escalate APBI dose lower than 30Gy in 5.

*EDIT* - Scooped by scarb

 

[PhotonBomb]

Partial breast will be preferable to me when possible. Better cosmetically. I’m sticking with Livi

 

[scarbrtj]

Where I trained we did 27 Gy/5 daily for APBI on trial. Where I work at now they do 30 Gy/5 every other day. Now that we have this, we’ll be going to 26 Gy/5 daily, and I personally would be comfortable with that. Not sure what we will decide for those that need boost. Have to work out the eqd2s but will may SIB those that require it rather than extend the fractionation as per FF, but that’s still an area of question.

I personally feel the 30/5 qod vs 30/5 qd yields as much safety benefit/toxicity reduction as not giving tamoxifen during RT or not wearing deodorant during RT. But I’m crazy that way.

 

[PhotonBomb]

I personally feel the 30/5 qod vs 30/5 qd yields as much safety benefit/toxicity reduction as not giving tamoxifen during RT or not wearing deodorant during RT. But I’m crazy that way.

Def agree. Won’t fault anyone at all for doing Livi every other day but I know more than a few people are doing it daily with no issues

 

[Burt Radnolds]

Nah. Whole breast lower dose; APBI the higher dose. Level 1 data for both. No level 1 for <30Gy APBI EBRT AFAIK. Never had a prob w/ 30 APBI.

Right.... but this is 26Gy/5Fx whole breast, not APBI. Toxicity = Dose x volume. FAST-Forward is treating much higher volume in most patients.

FAST Trial already showed that 5.7Gy x 5 is less toxic than 6Gy x 5 when treatment done once a week.

Similarly, 27Gy in 5 WBI may have worse toxicities when compared to 26Gy in 5.

I would not de-escalate APBI dose lower than 30Gy in 5.

*EDIT* - Scooped by scarb

If 26 Gy is enough to control the disease, and 27Gy causes an obvious toxicity increase, then why give 30 Gy? Especially if you are treating straight through as some of you are. Just because its a smaller volume does not mean you need to give more dose to achieve the same oncologic benefit. Partial versus whole breast is a moot point to me. Its all about controlling the disease within the port and 26Gy appears to do the trick.

 

[scarbrtj]

If 26 Gy is enough to control the disease, and 27Gy causes an obvious toxicity increase, then why give 30 Gy? Especially if you are treating straight through as some of you are. Just because its a smaller volume does not mean you need to give more dose to achieve the same oncologic benefit. Partial versus whole breast is a moot point to me. Its all about controlling the disease within the port and 26Gy appears to do the trick.

The NNT for RT to "do the trick" is very high in these patient subgroups.
(It certainly ain't even in the same league as the low numbers immuno can boast, yeesh!)
About any gray may "do the trick." We can certainly say zero gray can "do the trick"... if you pick the right patient population.
I'm still of the old-school mindset that more grays do more tricks. Also of the mindset that an "obvious toxicity increase" for the 27 vs 26 is very tricky, perhaps an unfortunate statistical fluke. Why unfortunate? Because if we truly follow your logic, and truly believe it... yes, I would concur, any 5 fx regimen that goes a microgray above 26 Gy should immediately be jettisoned due to toxicity concerns.
EDIT: "Partial versus whole breast is a moot point to me." Not to me, for toxicity. Things that directly correlate to RT toxicity (in general, given equal anatomic tx sites)... tx volume, total dose, daily dose. To prove my point, I can set it up where I can give 30 Gy/1 fx to the breast* and get less toxicity than 26 Gy/5 fx.

* as long as the PTV is 1cc or less in size for the 30/1 vs whole breast 26/5, heh

 

[evilbooyaa]

If 26 Gy is enough to control the disease, and 27Gy causes an obvious toxicity increase, then why give 30 Gy? Especially if you are treating straight through as some of you are. Just because its a smaller volume does not mean you need to give more dose to achieve the same oncologic benefit. Partial versus whole breast is a moot point to me. Its all about controlling the disease within the port and 26Gy appears to do the trick.

You may be correct, but why **** with level 1 data?

 

[radoncgrad2019]

You may be correct, but why **** with level 1 data?

I don’t know about radoncmonkey but he probably works in an academic place or somewhere he’s not worried about being sued.

The only person looking at my charts is my partner who is 65 and can barely see. I’m alwhas worried about being sued. I’ll stick with treating per trial!

 

[evilbooyaa]

I don’t know about radoncmonkey but he probably works in an academic place or somewhere he’s not worried about being sued.

The only person looking at my charts is my partner who is 65 and can barely see. I’m alwhas worried about being sued. I’ll stick with treating per trial!

I don't mean it from a lawsuit perspective. Just in terms of doing what's safest for the patient.

Say 30Gy in 5 fractions treats seroma + 1cm, and 26Gy reaches out to say 1.5cm, and say 26Gy is the 'magical' dose.

Who is to say 26Gy to a 1cm margin would be oncologically safe compared to the V26 the breast normally gets with 30/5?

I mean realistically, it's probably not wrong, but this seems like pontificating for the sake of it.

Sounds just like academics!

 

[Burt Radnolds]

Hmm, we have two very large trials mapping out a potential toxicity curve, 1) UK FAST, a 915 patient multi institutional study demonstrating 30 Gy worse than 28.5 Gy whole breast once weekly and now 2) UK FAST FORWARD, a 4096 patient multi institutional study demonstrating 27 Gy worse than 26 Gy whole breast given daily. Scarb says statistical fluke but .

Forgive me for asking the question on whether or not where there is smoke there is fire? In my eternal quest to provide the most efficacy for patients at the lowest toxicity cost, I am now a disobeyer of level 1 evidence and, oh my goodness, possibly even an "academic" ?

How dare I disrespect the great Livi, and his 520 patient single institution study not even appropriately powered to prove the points it wanted to prove and 10 year results presented in abstract form? Is this even "level 1" evidence? This fractionation does not even exist in any major current guidelines.

Agree that volume is a huge driver of toxicity in radiation and please do not distort my argument into whole breast = partial breast. However, I do believe what is good for the goose is also good for the gander however and am not buying into evilbooyaa's dose gradient argument here. Choosing APBI versus whole breast risk stratification and choosing the dose necessary to control microscopic disease in the breast are two separate issues. People acted like IMPORT-LOW (with its fake IMRT ) proving that 40/15 partial breast was acceptable was some earth shattering revelation when 1) we already knew APBI was appropriate in selected patients and 2) we knew 40/15 worked very nicely to control microscopic disease.

BTW this lowly community grunt grinding in a middling city signed a 30/5 plan today, but I did drop the coverage to 95/95%. Sue me .

 

[radoncgrad2019]

Hmm, we have two very large trials mapping out a potential toxicity curve, 1) UK FAST, a 915 patient multi institutional study demonstrating 30 Gy worse than 28.5 Gy whole breast once weekly and now 2) UK FAST FORWARD, a 4096 patient multi institutional study demonstrating 27 Gy worse than 26 Gy whole breast given daily. Scarb says statistical fluke but .

Forgive me for asking the question on whether or not where there is smoke there is fire? In my eternal quest to provide the most efficacy for patients at the lowest toxicity cost, I am now a disobeyer of level 1 evidence and, oh my goodness, possibly even an "academic" ?

How dare I disrespect the great Livi, and his 520 patient single institution study not even appropriately powered to prove the points it wanted to prove and 10 year results presented in abstract form? Is this even "level 1" evidence? This fractionation does not even exist in any major current guidelines.

Agree that volume is a huge driver of toxicity in radiation and please do not distort my argument into whole breast = partial breast. However, I do believe what is good for the goose is also good for the gander however and am not buying into evilbooyaa's dose gradient argument here. Choosing APBI versus whole breast risk stratification and choosing the dose necessary to control microscopic disease in the breast are two separate issues. People acted like IMPORT-LOW (with its fake IMRT ) proving that 40/15 partial breast was acceptable was some earth shattering revelation when 1) we already knew APBI was appropriate in selected patients and 2) we knew 40/15 worked very nicely to control microscopic disease.

BTW this lowly community grunt grinding in a middling city signed a 30/5 plan today, but I did drop the coverage to 95/95%. Sue me .

Grunt

 

[radoncgrad2019]

 

[thecarbonionangle]

Hmm, we have two very large trials mapping out a potential toxicity curve, 1) UK FAST, a 915 patient multi institutional study demonstrating 30 Gy worse than 28.5 Gy whole breast once weekly and now 2) UK FAST FORWARD, a 4096 patient multi institutional study demonstrating 27 Gy worse than 26 Gy whole breast given daily. Scarb says statistical fluke but .

Forgive me for asking the question on whether or not where there is smoke there is fire? In my eternal quest to provide the most efficacy for patients at the lowest toxicity cost, I am now a disobeyer of level 1 evidence and, oh my goodness, possibly even an "academic" ?

How dare I disrespect the great Livi, and his 520 patient single institution study not even appropriately powered to prove the points it wanted to prove and 10 year results presented in abstract form? Is this even "level 1" evidence? This fractionation does not even exist in any major current guidelines.

Agree that volume is a huge driver of toxicity in radiation and please do not distort my argument into whole breast = partial breast. However, I do believe what is good for the goose is also good for the gander however and am not buying into evilbooyaa's dose gradient argument here. Choosing APBI versus whole breast risk stratification and choosing the dose necessary to control microscopic disease in the breast are two separate issues. People acted like IMPORT-LOW (with its fake IMRT ) proving that 40/15 partial breast was acceptable was some earth shattering revelation when 1) we already knew APBI was appropriate in selected patients and 2) we knew 40/15 worked very nicely to control microscopic disease.

BTW this lowly community grunt grinding in a middling city signed a 30/5 plan today, but I did drop the coverage to 95/95%. Sue me .

the data makes you super comfortable to underdose, I agree, mate

 

[theradiator]

Just a grunt here but:

1) why all the excitement about YET another non-inferiority trial from a country with socialized healthcare?
2) block randomization introduces risk of bias
3) the FAST trials taken together have 4 experimental arms - 2 of which showed greater toxicity. is this really proof of "non-inferiority" without increased toxicity with the slightly lower daily dose.
4) boost (of 5 to 8 fractions!) was allowed so extrapolation to partial breast is definitely not proven

 

[radoncgrad2019]

Just a grunt here but:

1) why all the excitement about YET another non-inferiority trial from a country with socialized healthcare?
2) block randomization introduces risk of bias
3) the FAST trials taken together have 4 experimental arms - 2 of which showed greater toxicity. is this really proof of "non-inferiority" without increased toxicity with the slightly lower daily dose.
4) boost (of 5 to 8 fractions!) was allowed so extrapolation to partial breast is definitely not proven

‘Socialized healthcare’ alert!

 

[thecarbonionangle]

Just a grunt here but:

1) why all the excitement about YET another non-inferiority trial from a country with socialized healthcare?
2) block randomization introduces risk of bias
3) the FAST trials taken together have 4 experimental arms - 2 of which showed greater toxicity. is this really proof of "non-inferiority" without increased toxicity with the slightly lower daily dose.
4) boost (of 5 to 8 fractions!) was allowed so extrapolation to partial breast is definitely not proven

OMG SOCIALIZED? the devils grass? Witch’s juice? The breakdown of society is here

 

[medgator]

Hmm, we have two very large trials mapping out a potential toxicity curve, 1) UK FAST, a 915 patient multi institutional study demonstrating 30 Gy worse than 28.5 Gy whole breast once weekly and now 2) UK FAST FORWARD, a 4096 patient multi institutional study demonstrating 27 Gy worse than 26 Gy whole breast given daily. Scarb says statistical fluke but .

Forgive me for asking the question on whether or not where there is smoke there is fire? In my eternal quest to provide the most efficacy for patients at the lowest toxicity cost, I am now a disobeyer of level 1 evidence and, oh my goodness, possibly even an "academic" ?

How dare I disrespect the great Livi, and his 520 patient single institution study not even appropriately powered to prove the points it wanted to prove and 10 year results presented in abstract form? Is this even "level 1" evidence? This fractionation does not even exist in any major current guidelines.

Agree that volume is a huge driver of toxicity in radiation and please do not distort my argument into whole breast = partial breast. However, I do believe what is good for the goose is also good for the gander however and am not buying into evilbooyaa's dose gradient argument here. Choosing APBI versus whole breast risk stratification and choosing the dose necessary to control microscopic disease in the breast are two separate issues. People acted like IMPORT-LOW (with its fake IMRT ) proving that 40/15 partial breast was acceptable was some earth shattering revelation when 1) we already knew APBI was appropriate in selected patients and 2) we knew 40/15 worked very nicely to control microscopic disease.

BTW this lowly community grunt grinding in a middling city signed a 30/5 plan today, but I did drop the coverage to 95/95%. Sue me .

You're probably the only one doing it in the community given the above. Nowhere in nccn or ASTRO that i can see as a preferred regimen whatsoever

 

[deleted941485]

Just a grunt here but:

1) why all the excitement about YET another non-inferiority trial from a country with socialized healthcare?
2) block randomization introduces risk of bias
3) the FAST trials taken together have 4 experimental arms - 2 of which showed greater toxicity. is this really proof of "non-inferiority" without increased toxicity with the slightly lower daily dose.
4) boost (of 5 to 8 fractions!) was allowed so extrapolation to partial breast is definitely not proven

1. You can’t expect much more out of them esp in the UK. Innovation is cost cutting and since radiotherapy isn’t really its own field that the clinical oncologists would rather not want to be bothered with it so cut it down to a nub.

2. Not sure how can you give examples

3. I thought the 3 arm approach was a little weird. 26 vs 27.

4. How many actually got the boost?

 

[theradiator]

Properties of permuted-block randomization in clinical trials

This article describes some of the important statistical properties of the commonly used permuted-block design, also known simply as blocked-randomiza…

www.sciencedirect.com

 

[thesauce]

Bumping this just to ask: I heard someone mention that APMs were tried and other specialties and were abandoned. Does anyone know what those specialties are?

 

[deleted941485]

Bumping this just to ask: I heard someone mention that APMs were tried and other specialties and were abandoned. Does anyone know what those specialties are?

Bundling has already happening in every specialty - they take a bunch of codes that are typically billed together and make it one code and cut it as well

Hospitals have had DRGs from the 80s. Has been a long slow decline since then.

Cardiac Surg has had them since Denton Cooley and insurance decided it was a great idea - can’t say it’s really been great for the field considering now they have come up with a billion and 1 reasons to not crack a chest

Orthopedics - Medicare has always wanted a Hip or knee bundle. They may already have it. Ortho is big money for hospitals of course but the key difference here is that they don’t have dinguses publishing papers looking for ways to “Deescalate arthroplasties” so in some ways they can still compensate for it with volume.

I also believe they were voluntary up until recently

Rad onc has none of these options. You can’t make it up in volume and you have no new indications. Bundling will screw you. Oh and it’s mandatory so if you get picked that’s it. Which I don’t think was the case with OCM

If APM is implemented you have about 5 years to get out.

 

[deleted941485]

Fields don’t flourish because of bundling they flourish in spite of it.