RO-APM Podcast Episode (from The Accelerators)

[TheWallnerus]

View attachment 345792

Nothing to see here

View attachment 345793

Probably a coincidence that Anderson faculty are consulting with CMS on APM and Anderson faculty have partnership in a company with an EMR add-on to comply with the required APM documentation.

Folks here's what we know so far.

1) MDACC gets the highest extra amount of upcharge from Medicare for being PPS exempt versus any of the other 10 exempt places in the country
2) MDACC has faculty "advising" Medicare on the rollout of the Alternative Payment Model; this faculty (and MDACC) will never face APM mandates
3) MDACC is in close, many-years cahoots with an EMR company that stands to profit off the APM and has been designing algorithms with seeming foreknowledge of what APM would require
4) There are MDACC faculty with "equity" in the EMR company that seems best situated to benefit from the APM rollout

Any questions

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[evilbooyaa]

I mean Aileen Chen isn't making money off of it I guess?

 

[OTN]

Folks here's what we know so far.

1) MDACC gets the highest extra amount of upcharge from Medicare for being PPS exempt versus any of the other 10 exempt places in the country
2) MDACC has faculty "advising" Medicare on the rollout of the Alternative Payment Model; this faculty (and MDACC) will never face APM mandates
3) MDACC is in close, many-years cahoots with an EMR company that stands to profit off the APM and has been designing algorithms with seeming foreknowledge of what APM would require
4) There are MDACC faculty with "equity" in the EMR company that seems best situated to benefit from the APM rollout

Any questions

 

[TheWallnerus]

I mean Aileen Chen isn't making money off of it I guess?

I mean I guess it's possible the government is paying her nothing for advising them on how to save $230m+ 2022-26, and then minimum $150m+/year thereafter if what she advised them on works. It's possible. I don't know if it would make me more mad/sad that she volunteered, or they're paying her $100K a year. Or if she leaves academia after this and gets a sweet industry job somewhere. (I have to be honest with myself and sometimes admit I am jealous.)

 

[thecarbonionangle]

Folks here's what we know so far.

1) MDACC gets the highest extra amount of upcharge from Medicare for being PPS exempt versus any of the other 10 exempt places in the country
2) MDACC has faculty "advising" Medicare on the rollout of the Alternative Payment Model; this faculty (and MDACC) will never face APM mandates
3) MDACC is in close, many-years cahoots with an EMR company that stands to profit off the APM and has been designing algorithms with seeming foreknowledge of what APM would require
4) There are MDACC faculty with "equity" in the EMR company that seems best situated to benefit from the APM rollout

Any questions

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[BobbyHeenan]

I'm sure an EMR built at MDA will have a really good chance of being integrated seamlessly into everything that goes on at non-MDA cancer centers. I mean their model and set up there for work flow, clinic, and the average patient that goes there really looks a lot like what we all see and do out in practice.

 

[thecarbonionangle]

“Brocade” definetely sounds hell-pitty like some terrible nasty “punch” at a frat party. The hang over will be fantastic on this folks!

 

[Mandelin Rain]

Folks here's what we know so far.

1) MDACC gets the highest extra amount of upcharge from Medicare for being PPS exempt versus any of the other 10 exempt places in the country
2) MDACC has faculty "advising" Medicare on the rollout of the Alternative Payment Model; this faculty (and MDACC) will never face APM mandates
3) MDACC is in close, many-years cahoots with an EMR company that stands to profit off the APM and has been designing algorithms with seeming foreknowledge of what APM would require
4) There are MDACC faculty with "equity" in the EMR company that seems best situated to benefit from the APM rollout

Any questions

The right way, the wrong way, and the MD Anderson way.

 

[communitydoc13]

All EMR systems like this main purpose is to make it look like you did a lot of work when you didn't. Because billing. Because money.

EMR is that thing that hurts me the most because it eats my day, doubles my work time, keeps me from family and books and is filled with misinformation to boot. EMR is what makes me confident that the present day visionaries, who have gotten disproportionately rich and influential working towards automation, cloud based solutions, virtual platforming, data sharing, health analytics, big-data and every other damn tech-focused initiative of the past 20 years, don't have any interest in human values.

What are human values in the workforce?

1. Trust (you could say trust but verify). Bill by visit/time, CMS can look for outliers. Requiring granular data entry is silly. ROS and PE (not to mention med reconciliation) next to meaningless these days. An old school hand written note with Vitals, pertinent positives only and NED is more valuable than the 3 page surgical note printouts that we get nowadays. The excessive documentation simply a window to excessive liability. Humans don't process hundreds of list items in a 15 minute visit.

2. Emphasis on training.

3. Respect for individual decision making among those who meet the high standards of training certification (see #2).

4. Prioritizing things that impact outcomes in real time. (These are procedures, face to face counseling, examination and in person communication) Not granular documentation.

5. Understanding that humans are inherently bad documenters and while big trends and order of magnitude truths may be exposed with your big data enterprises, marginal truths and insights derived from detailed differences in outcome are always going to rely on experimentation (experimentation is a human enterprise).

6. Fix big problems with big not detailed solutions. Details should be left to people who do the work. Things like: reasonable pricing, reasonable taxation, insistence on transparency.

 

[BobbyHeenan]

Folks here's what we know so far.

1) MDACC gets the highest extra amount of upcharge from Medicare for being PPS exempt versus any of the other 10 exempt places in the country
2) MDACC has faculty "advising" Medicare on the rollout of the Alternative Payment Model; this faculty (and MDACC) will never face APM mandates
3) MDACC is in close, many-years cahoots with an EMR company that stands to profit off the APM and has been designing algorithms with seeming foreknowledge of what APM would require
4) There are MDACC faculty with "equity" in the EMR company that seems best situated to benefit from the APM rollout

Any questions

The whole situation reads like a chapter in Skin in the Game.
Hidden asymmetries.

 

[TheWallnerus]

RO-APM hosting a zoom that's starting in 20 minutes if anyone wants to jump on

Maybe lemmiwinks should jump on and raise some hell

The Page Cannot be found

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mathematicaevents.webex.com

 

[Mandelin Rain]

I would be happy to co-author a red journal paper outlining the inherent conflicts of interests taking place at MDA vis a vis the RO-APM.

All darkness should be brought into the light

Or.... it could just be Twitter blasted. That's likely more effective.

 

[TheWallnerus]

Here were Chen's slides

(For post-MRM RT e.g. you have to state if your PRIMARY target is CW or nodes... can only choose one! "Nodes" is not an option in lung so I guess a nodal relapse RT is out)

(there are MANY data elements per patient that MUST recorded and logged https://innovation.cms.gov/media/document/ro-model-clin-data-elements-guide-nov2021 ... YOU MUST REPORT DATA ELEMENTS ON EVERY SINGLE PATIENT YOU TREAT, MEDICARE OR NOT... ALL YOUR PATIENT BELONG CMS NOW)

STARTING IN YEAR 3 PATIENT SURVEY RESPONSES WILL PARTIALLY DETERMINE PAYMENTS

 

[evilbooyaa]

It's quite bold to make certain unchosen Radiation Oncologists not only accept a paycut, but require them to do additional work on TOP of that.

I'd imagine the latter is going to lead to more closure of rural centers than the former.

 

[RickyScott]

Dr. Benjamin Smith has done more damage to this field than anyone else in its entire history, and it's not even close. Given all that he's "accomplished", it's very likely he will be able to hold the crown for all of eternity.

I have close colleague from residency whose charts were reviewed by MDACC several years ago because hospital was entering affiliation. In reviewing breast plans, BS basically commented that IMRT has no role in breast cancer and implied it is only used for financial benefit (despite fact these are employed docs).

 

[elementaryschooleconomics]

These are all from the last 24 hours. I'm glad the folks over at CMS have decided we need to get paid less and do more work.

I think I'm taking a Twitter break for today.

 

[metallica81788]

I listened to this podcast over a long drive about a week or two after this thread was started. Having already been scared by APM and the future even without being in the zipcode... the deep dive into the information terrified me.

 

[WanderingRad3]

Someone on twitter made the good point it may just make sense to take the 3% cut on our Medicare FFS patients and not submit clinical data elements. Hiring an FTE or spending my own time filling out info that’s not going to improve patient care to avoid a 3% cut on 20-30% of my patients? No thanks.

 

[TheWallnerus]

Someone on twitter made the good point it may just make sense to take the 3% cut on our Medicare FFS patients and not submit clinical data elements. Hiring an FTE or spending my own time filling out info that’s not going to improve patient care to avoid a 3% cut on 20-30% of my patients? No thanks.

It is my understanding you’ll be having to keep data on ALL patients. The extent of that for non Medicare I don’t know, but CMS (and the MD Anderson faculty) stressed multiple times yesterday that data has to be collected on all patients. It’s seemingly a lot more data on the Medicare patients though. The data is worth 2% penalty. The not making patients fill out surveys is worth 1% penalty.

 

[BobbyHeenan]

It is my understanding you’ll be having to keep data on ALL patients. The extent of that for non Medicare I don’t know, but CMS (and the MD Anderson faculty) stressed multiple times yesterday that data has to be collected on all patients. It’s seemingly a lot more data on the Medicare patients though. The data is worth 2% penalty. The not making patients fill out surveys is worth 1% penalty.

I believe this is correct.

For MIPS/MACRA stuff you're sending in scores on all patients, not just medicare patients. I'd assume for APM it is the same.

We had to hire an outside company to help us with this. What a HUGE waste of time and resources. Our group spent tens of thousands on it....not one iota of improvement in patient care by figuring out how to streamline pain scores, flu shot documentation, medical reconciliation, etc.

 

[medgator]

Someone on twitter made the good point it may just make sense to take the 3% cut on our Medicare FFS patients and not submit clinical data elements. Hiring an FTE or spending my own time filling out info that’s not going to improve patient care to avoid a 3% cut on 20-30% of my patients? No thanks.

Have enough FTEs dealing with prior auth let alone this

 

[elementaryschooleconomics]

While we haven't explicitly decided yet, I imagine my department will opt to take the loss as well rather than sink the time and resources into collecting/submitting data.

Strong work, CMS. You guys are really crushing it with these Oncology models. Who's working over there? High School students getting AP credit? You're really making a positive impact on the health and lives of the American citizens. I hope you have fun at prom this spring!

 

[Gfunk6]

View attachment 345856



These are all from the last 24 hours. I'm glad the folks over at CMS have decided we need to get paid less and do more work.

I think I'm taking a Twitter break for today.

First they came for the rural radiation oncologists, and I did not speak out—because I was not a rural radiation oncologist

Then they came for 30% of all radiation oncologists in the US, and I did not speak out— because I was not one of those 30%.

Then they came for me—and I retired . . .

 

[Mandelin Rain]

"Government Programs for $400, Alex."

"RO-APM"

"What is boondoggle?"

"Correct. Still your board."

 

[thecarbonionangle]

Younger rad oncs are sort of like Hodor, just holding door open while bums sneak out the back door to leave us to be eaten by goons. The grifters got paid and have millions in the bank and dont give a damn about you.

 

[deleted941485]

I mean seriously my employed practice is already in APM. Endless meeting about MIPS and MACRA. They cornered me to today and asked if id be willing to start administering oral chemo and putting in fiducials. I haven't put fiducials in awhile and chemo wtf?! Dont get me wrong I want to get into systemics but wtf do I know about the day to day admin? The practice bean counters think that even with my current patient load of 25 should compensate for the drop in revenue for getting f'd in the ass by CMS and probably also takes the heat off them hiring another med onc. people ruin everything.

 

[TheWallnerus]

I mean seriously my employed practice is already in APM. Endless meeting about MIPS and MACRA. They cornered me to today and asked if id be willing to start administering oral chemo and putting in fiducials. I haven't put fiducials in awhile and chemo wtf?! Dont get me wrong I want to get into systemics but wtf do I know about the day to day admin? The practice bean counters think that even with my current patient load of 25 should compensate for the drop in revenue for getting f'd in the ass by CMS and probably also takes the heat off them hiring another med onc. people ruin everything.

If anyone with a basic business sense looked at the effort/human capital expended over MIPS and MACRA and upcoming APM activities versus what is not lost 1) at the CMS level and 2) at the total practice revenue level, I don’t see how any doctor could financially justify it unless she sees 100 or more Medicare patients per year. The median number of Medicare patients per MD per year is 50. If one adds in loss of psychological QoL, it’s REALLY not worth it.

 

[deleted941485]

If anyone with a basic business sense looked at the effort/human capital expended over MIPS and MACRA and upcoming APM activities versus what is not lost 1) at the CMS level and 2) at the total practice revenue level, I don’t see how any doctor could financially justify it unless she sees 100 or more Medicare patients per year. The median number of Medicare patients per MD per year is 50. If one adds in loss of psychological QoL, it’s REALLY not worth it.

CMS cannot make any of this worth an MDs time. They just cant but they sure as hell can nickel and dime you to death.

 

[Lamount]

Finally, mainstream press catches on

 

[TheWallnerus]

Finally, mainstream press catches on

That article written by a black Republican. I wonder if ASTRO is for Republicans it was previously against as long as they are against Biden who is for cutting cancer reimbursement? (Picturing ASTRO PAC furiously calling Republican congressmen... "Hey, about that whole 'Cancer is nonpartisan' thing...")

 

[imhopeful432]

That article written by a black Republican. I wonder if ASTRO is for Republicans it was previously against as long as they are against Biden who is for cutting cancer reimbursement? (Picturing ASTRO PAC furiously calling Republican congressmen... "Hey, about that whole 'Cancer is nonpartisan' thing...")

Not sure what you're getting at. ASTRO PAC does donate to lots of republicans (they're usually 50/50). And if you're getting at ASTRO statement on Jan 6th in particular, the GOP author of that article (Michael Steele) has been up there pretty much with Liz Cheney on slamming other republicans on the Jan 6th/election issue...

 

[TheWallnerus]

Not sure what you're getting at. ASTRO PAC does donate to lots of republicans (they're usually 50/50). And if you're getting at ASTRO statement on Jan 6th in particular, the GOP author of that article (Michael Steele) has been up there pretty much with Liz Cheney on slamming other republicans on the Jan 6th/election issue...

I'm getting at one time ASTRO PAC said we are going to "de-donate" politicians for their political choices with which ASTRO PAC strongly disagreed. Now, we need those same politicians to make political choices in rad onc's favor. I was afraid ASTRO PAC's previous decision to de-donate might come back to bite us when we would need help. But if it was a decision that could only hurt the politicians and have zero consequence or ramification for rad onc, then great.

 

[fiji128]

In the realm of the DC Swamp concerned with medical issues/spending and the vast sums of money sloshing around does any politician really care what tiny Astro PAC has to say about anything one way or the other?

Look at this fund raising, tiny!

But everyone's fav, Ben Smith is at top donor at the $2,500 to $4,999 level.

ASTRO PAC - American Society for Radiation Oncology (ASTRO) - American Society for Radiation Oncology (ASTRO)

After overwhelming sentiments expressed by ASTRO members that the Society should become more involved in the political process, the Board of Directors created ASTRO PAC, a federal political action committee (PAC).

www.astro.org

 

[TheWallnerus]

In the realm of the DC Swamp concerned with medical issues/spending and the vast sums of money sloshing around does any politician really care what tiny Astro PAC has to say about anything one way or the other?

Politicians can be VERY petty and have long memories about these minor slights.

 

[fiji128]

Politicians can be VERY petty and have long memories about these minor slights.

Completely bone headed move by Astro PAC in the first place. Why does Astro PAC need to publicly comment on anything other then issue that are germane to cancer and radiation therapy?

 

[Mandelin Rain]

Politicians can be VERY petty and have long memories about these minor slights.

Just ask Rosie O'Donnell

 

[TheWallnerus]

Completely bone headed move by Astro PAC in the first place. Why does Astro PAC need to publicly comment on anything other then issue that are germane to cancer and radiation therapy?

The fix for APM, and prevention of rad onc pmt cuts in general, must come from Congress. When you are an organization that makes a move to "defund" 147 Republican congresspeople and 0 Democrats, and give vocal anti-Republicans a platform, eventually the Republicans might get a sense "Hey I don't think the rad oncs like us." And if Republicans don't have total undying love forever and always for ASTRO and rad onc, it could mean not great things could happen. But what do I know.

 

[Mandelin Rain]

To quote the GOAT, "Republicans buy sneakers too."

Self-inflicted wounds is what ASTRO is about.

 

[WanderingRad3]

To quote the GOAT, "Republicans buy sneakers too."

Self-inflicted wounds is what ASTRO is about.

ASTRO was not some kind of leader in this area. Many (most?) major medical PACs such as the AMA, AAP, etc made the same announcement of pulling money in light of Jan 6th (in addition to lots of corporate PACs, etc). I happen to agree with the decision as an important signal both to legislators and to donors to the PAC (such as me), but even if you don’t, it’s not as if ASTRO was going out on a limb here…if anything, they were taking the “safer” route

 

[TheWallnerus]

it’s not as if ASTRO was going out on a limb here…if anything, they were taking the “safer” route

As long as APM and rad onc cuts are a "go," I will maintain niggling suspicions that it was not the safer route. What signal does it send when you cease donations in times of disagreement with a politician but later return to them for a favor. I guess you really weren't that serious about the original "signal."

 

[BobbyHeenan]

ASTRO was not some kind of leader in this area. Many (most?) major medical PACs such as the AMA, AAP, etc made the same announcement of pulling money in light of Jan 6th (in addition to lots of corporate PACs, etc). I happen to agree with the decision as an important signal both to legislators and to donors to the PAC (such as me), but even if you don’t, it’s not as if ASTRO was going out on a limb here…if anything, they were taking the “safer” route

I'm way out of my element here (I know nothing about lobbying and really need to re-watch the Schoolhouse rock cartoon "how a bill is made"), but I prefer having a laser focus on radiation issues as the most (?only?) important issue. You don't have to "signal" about every issue unrelated to cancer care. I know it feels right or better to do so, but it is advancing the mission of ASTRO?

Kendi is a big name in political circles too. Having him speak at ASTRO did not help.

I like the Coinbase approach instead.

Coinbase is a mission focused company

There have been a lot of difficult events in the world this year: a global pandemic, shelter in place, social unrest, widespread protests…

blog.coinbase.com

 

[fiji128]

ASTRO was not some kind of leader in this area. Many (most?) major medical PACs such as the AMA, AAP, etc made the same announcement of pulling money in light of Jan 6th (in addition to lots of corporate PACs, etc). I happen to agree with the decision as an important signal both to legislators and to donors to the PAC (such as me), but even if you don’t, it’s not as if ASTRO was going out on a limb here…if anything, they were taking the “safer” route

No one is really looking to Astro to take sides on the whole Dem vs Rep thing. Not anymore complicated then that. Stick to advancing issues in regards to cancer and radiation therapy.

Now you have a Dem administration looking to aggressively defund the specialty so where does that leave you?

 

[thecarbonionangle]

ASTRO should take a stand in Taiwanese independence. They scared and in pockets of the Chinese? Cmon folks!

 

[Mandelin Rain]

ASTRO was not some kind of leader in this area. Many (most?) major medical PACs such as the AMA, AAP, etc made the same announcement of pulling money in light of Jan 6th (in addition to lots of corporate PACs, etc). I happen to agree with the decision as an important signal both to legislators and to donors to the PAC (such as me), but even if you don’t, it’s not as if ASTRO was going out on a limb here…if anything, they were taking the “safer” route

I'm definitely not a Republican, but was it the objecting to certification of election ASTRO had a problem with as claimed in the statement? Or was their quarrel REALLY with those who incited the insurrection attempt, i.e. Trump and Guiliani et al. but just had no power to send a signal to?

Because if it's the former, I don't recall any public statement by ASTRO-PAC on defunding after a handful of house Dems objected to certification of multiple states after Trump's victory in 2016. And if it's the latter, it was just misdirected virtue signaling.

Either way, bad look for a "non-partisan" organization.

If ASTRO-PAC's goal is to defund every congress person who votes party line for some nonsensical issue, there'll be no one left.

 

[medgator]

As long as APM and rad onc cuts are a "go," I will maintain niggling suspicions that it was not the safer route. What signal does it send when you cease donations in times of disagreement with a politician but later return to them for a favor. I guess you really weren't that serious about the original "signal."

APM started by trumps HHS czar and continued under current admin... I don't understand the last few posts

Very analogous to the flawed idea that bailouts occurred under Obama, ignoring the TARP and even auto bailouts started under dubya

 

[TheWallnerus]

APM started by trumps HHS czar and continued under current admin... I don't understand the last few posts

My point is when someone in an admin does something with which you disagree and your niche PAC has been donating to them, usually it means you should donate to them more not less. Unless you just want to relegate yourself to total inconsequentiality. I guess that's why I'm not a lobbyist though. Political action committee people must be prepared for strange bedfellows if they want any action, even bedfellows who seem to have severe electile dysfunction.

 

[Chartreuse Wombat]

APM started by trumps HHS czar and continued under current admin... I don't understand the last few posts

Very analogous to the flawed idea that bailouts occurred under Obama, ignoring the TARP and even auto bailouts started under dubya

I think it is a mischaracterization that APM started with Trump appointee. The groundwork was laid in legislation passed in 2015 when the Trumpster was only a candidate. Highlighted portion in attachment.

 

[TheWallnerus]

I think it is a mischaracterization that APM started with Trump appointee. The groundwork was laid in legislation passed in 2015 when the Trumpster was only a candidate. Highlighted portion in attachment.

I don’t mean to harp on ASTRO PAC, but it’s not even about who’s right or who’s wrong. If we are arguing we are losing. Here’s what ASTRO PAC should do…

When a congressman votes to not certify an election, ASTRO PAC should call his chief of staff and say “We do not agree” and make a donation.

When a congressman votes to drill for oil in Alaska, or against gun rights, or for the silly Texas law on the thing, ASTRO PAC should do the same.

When a congressman votes to hurt rad onc in some way, ASTRO PAC should call his chief of staff and say “We very very strongly disagree” and send double the donation. And the next time he votes your way, you send triple. Only if he hurts rad onc over and over do you stop donating. If the congressman hurts your delicate sensibilities over and over you still might need his vote for rad onc one day. (That is assuming that rad onc is ASTRO PAC’s only focus.)

 

[Lamount]

I don’t mean to harp on ASTRO PAC, but it’s not even about who’s right or who’s wrong. If we are arguing we are losing. Here’s what ASTRO PAC should do…

When a congressman votes to not certify an election, ASTRO PAC should call his chief of staff and say “We do not agree” and make a donation.

When a congressman votes to drill for oil in Alaska, or against gun rights, or for the silly Texas law on the thing, ASTRO PAC should do the same.

When a congressman votes to hurt rad onc in some way, ASTRO PAC should call his chief of staff and say “We very very strongly disagree” and send double the donation. And the next time he votes your way, you send triple. Only if he hurts rad onc over and over do you stop donating. If the congressman hurts your delicate sensibilities over and over you still might need his vote for rad onc one day. (That is assuming that rad onc is ASTRO PAC’s only focus.)

I get that there is a lot of history to contend with… but that wasn’t the point of my sharing the article.

It’s the right message. Those of us who have loud voices should do their best to amplify it.

 

[communitydoc13]

When a congressman votes to not certify an election, ASTRO PAC should call his chief of staff and say “We do not agree” and make a donation.

When a congressman votes to drill for oil in Alaska, or against gun rights, or for the silly Texas law on the thing, ASTRO PAC should do the same.

I don't know about this. Admittedly, I'm pretty gung ho on reminding everyone about the significance of 1/6. I can't imagine this (and the muted response by the GOP) as going down as anything but a catastrophe for our democracy in the long run....but who cares. That is not why I am not sure about the donation thing.

The main reason why ASTROs response is not all that unreasonable is that for a very small field with a very niche PAC, signaling is likely much more effective than the type of money donations available, which I believe must be nominal at best. Signaling can get press releases and can enter into a politician's consciousness. That Beau Biden (and innumerable other VIPs) was treated at MDACC (and not in Delaware) has a much bigger impact on how the present administration is going to pick winners and losers in our field than anything ASTRO can do. That Ron Rivera got proton therapy at Bajaj's shop does more for the preferential treatment of affluent Washingtonians with proton therapy than any randomized data will.

ASTRO PAC just picking a winner and signaling to it. Not brave (for two reasons, they were just following suit and I suspect the position is not very controversial with the overwhelming majority of their membership). But reasonable and political.

My guess is Joe would take a call from MDACC and that call could mean something regarding upcoming radiation cuts and APM. My guess is that call is not coming.