RO Model Update July 2021

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If we can jettison IMRT in favor of 2D, jettison fractions and whole weeks of treatment, who thinks you can't jettison an OTV here or there.

I have said before: a per-5-fraction OTV was never evidence based medicine. It was to fluff the billing most times let's be honest. Especially in my BID patients where I was seeing them 2 times a week; not my call on that but "the house's."
 
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Why can’t we just run the machines 3 or 4 days a week if we are hypofractionating everything. Aren’t we 5x/week based on “old school” fractionation?
 
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What's sad/scary, among a great many things: incoming RO residents who are either oblivious to the APMocalypse or self-gaslighting about it.
 
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TheWallnerus said:
What's sad/scary, among a great many things: incoming RO residents who are either oblivious to the APMocalypse or self-gaslighting about it.
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A us MD who chooses to match into radonc is likely to be dumb as f. And a future president of Astro in 25 years.
 
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MegaVoltagePhoton said:
Brachy is an important part of my cervical cancer practice. I was worried that if brachy was included, it would incentivize omission of brachy. Maybe that is ok, but I have not seen convincing data that SBRT is good enough. So that's a positive here.
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Timmerman published a trial in the last 2 years. SBRT was inferior to brachy. It’s not going anywhere for GYN.

When people say brachy is dying what they really mean is prostate brachy is dying. Considering it use to be the lions share of the overall volume I can see where people are coming from. The only reason I do a lot of prostate brachy is I run a busy HDR program (mostly Gyn) and have all of the logistics and support staff in place. Start to finish our prostate HDR cases (so no pre planning) are around 2.5 hours. Literally everyone has to be good at their role or its a huge time sink which is precisely what happens without repetition. I could make an “argument” it’s better than SBRT but I can also “argue” platinum is more valuable than diamonds.
 
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TheWallnerus said:
What's sad/scary, among a great many things: incoming RO residents who are either oblivious to the APMocalypse or self-gaslighting about it.
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All the elite RO residents at PFS except centers wont know what hit them when they end up as a COG in community practice that isn't exempt lol.

I Love when one of these neurotic interviewees makes it to my desk desperately try to impress me with nonsense about set-up for breast patient that "they like" (more accurately the attending they trained with) and has about as much implications for the outcome as a butterfly flapping its wings.

I basically have to explain to them that nobody really cares about your professional opinion. It isnt really values by anyone but you are the gatekeeper of anyone on treatment thats it. your job as far as your employer is concerned is to put meat on the machine. The future of an RO dept is AI, a nurse, a physicist, and maybe you working from home. They eventually stop talking and leave me alone.
 
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Since OTV charge is such an important part of reimbursement, admins that I’ve worked with were too focused on capturing it… hounding me to see this and that patient “within 5 fx block” :) good riddance
 
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ramsesthenice said:
Timmerman published a trial in the last 2 years. SBRT was inferior to brachy. It’s not going anywhere for GYN.

When people say brachy is dying what they really mean is prostate brachy is dying. Considering it use to be the lions share of the overall volume I can see where people are coming from. The only reason I do a lot of prostate brachy is I run a busy HDR program (mostly Gyn) and have all of the logistics and support staff in place. Start to finish our prostate HDR cases (so no pre planning) are around 2.5 hours. Literally everyone has to be good at their role or its a huge time sink which is precisely what happens without repetition. I could make an “argument” it’s better than SBRT but I can also “argue” platinum is more valuable than diamonds.
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Wouldn't brachy in gyn be mostly cervical. We can get our hackles up about cervical brachy all we want, but eventually there are going to be very few practitioners of that dying art left. The few left may be busy, granted, but widespread access to cervical brachy is just not going to make sense financially. The incidence is falling and will go under 10K per year (that's about 3 cases per U.S. county per year) this decade.

ROI3Evx.png
 
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ramsesthenice said:
Timmerman published a trial in the last 2 years. SBRT was inferior to brachy. It’s not going anywhere for GYN.

When people say brachy is dying what they really mean is prostate brachy is dying. Considering it use to be the lions share of the overall volume I can see where people are coming from. The only reason I do a lot of prostate brachy is I run a busy HDR program (mostly Gyn) and have all of the logistics and support staff in place. Start to finish our prostate HDR cases (so no pre planning) are around 2.5 hours. Literally everyone has to be good at their role or its a huge time sink which is precisely what happens without repetition. I could make an “argument” it’s better than SBRT but I can also “argue” platinum is more valuable than diamonds.
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Thankfully I have a limited brachy practice. If I have a cervix, ill do the EBRT and refer to large academic center for the rest which is exempt anyway. Most of these patients are 50's to early 60's have no insurance, dont go to doctors, and are high risk. It wasn't worth my time before and it likely still isn't worth it now. I saw alot of cervix in residency but seriously but when these millennials and beyond start turning 50 you aint gonna see it anymore.

Also another question, due to APM. Is anyone gonna push their patients to get SAVI - APBI or build a SAVI program because of this?
 
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seper said:
Since OTV charge is such an important part of reimbursement, admins that I’ve worked with were too focused on capturing it… hounding me to see this and that patient “within 5 fx block” :) good riddance
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And if you miss it under APM, you just don't submit a zero-claim CPT for it. If you don't do it, don't bill it. If you do it, bill it, but you won't get paid for it. The radiation oncology eschaton has been immanentized.
 
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TheWallnerus said:
And if you miss it under APM, you just don't submit a zero-claim CPT for it. If you don't do it, don't bill it. If you do it, bill it, but you won't get paid for it. The radiation oncology eschaton has been immanentized.
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You probably should stil bill for it because itll probably factor into how much they cut the bundle year to year. Oh you see them less often? Well the bundle technically covers x number of visits...cut. Oh you treated with 20 as opposed to 28 fx for prostate across the system...cut. Honestly probably shouldn't change anything you do. hypofracing may only hasten the demise.
 
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RadsWFA1900 said:
Will result in the largest year to year drop in reimbursement in RO...hard pass
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Does that mean if we all go back to 6+ week breast regimens we will get pay raises. The APM mentioned 3 week breast A LOT. If we do like the UK and convert 2/3 of our breast patients to 5 fractions will APM cut us even more.
 
TheWallnerus said:
Does that mean if we all go back to 6+ week breast regimens we will get pay raises. The APM mentioned 3 week breast A LOT. If we do like the UK and convert 2/3 of our breast patients to 5 fractions will APM cut us even more.
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No thats lost forever. The only choice you have really is how fast do you want the whole thing to collapse. 2 years...5 years? 10?
 
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TheWallnerus said:
Wouldn't brachy in gyn be mostly cervical. We can get our hackles up about cervical brachy all we want, but eventually there are going to be very few practitioners of that dying art left. The few left may be busy, granted, but widespread access to cervical brachy is just not going to make sense financially. The incidence is falling and will go under 10K per year (that's about 3 cases per U.S. county per year) this decade.

ROI3Evx.png
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Don’t get me wrong, I would love to see HPV related cancers fall to nothing which they should. But I have always questioned some of the projections. Look around and ask who is getting vaccinated as a whole? It’s highly concentrated among people who regularly engage with the healthcare setting and preventative care. As if we need anymore reminders, access barriers and vaccine hesitancy are very real. I personally see cervical and H&N cancer diverging. Both will go down but I think whereas HPV+ H&N rates (predominantly seen in affluent(ish) males) will continue to fall, cervical is going to level off. It’s already predominately a disease of patients with poor access and/or minutes healthcare engagement. At least the advanced cases we radiate. Again, I would love to be wrong. And hey, these public health/epi folks know a lot more than me about the topic.
 
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ramsesthenice said:
Don’t get me wrong, I would love to see HPV related cancers fall to nothing which they should. But I have always questioned some of the projections. Look around and ask who is getting vaccinated as a whole? It’s highly concentrated among people who regularly engage with the healthcare setting and preventative care. As if we need anymore reminders, access barriers and vaccine hesitancy are very real. I personally see cervical and H&N cancer diverging. Both will go down but I think whereas HPV+ H&N rates (predominantly seen in affluent(ish) males) will continue to fall, cervical is going to level off. It’s already predominately a disease of patients with poor access and/or minutes healthcare engagement. At least the advanced cases we radiate. Again, I would love to be wrong. And hey, these public health/epi folks know a lot more than me about the topic.
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Are hpv vaccines required for schooling?
 
RickyScott said:
Are hpv vaccines required for schooling?
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That would be very hard for me to believe. Vaccination requirements are typically set at the institutional level but can be over ridden by state legislatures. I work for a large state medical center tied to a well known institution and our state Supreme Court decided we can’t require seasonal flu vaccination. We technically can’t even ask about it. It is beyond disappointing to know we have solutions and under utilize them.
 
ramsesthenice said:
That would be very hard for me to believe. Vaccination requirements are typically set at the institutional level but can be over ridden by state legislatures. I work for a large state medical center tied to a well known institution and our state Supreme Court decided we can’t require seasonal flu vaccination. We technically can’t even ask about it. It is beyond disappointing to know we have solutions and under utilize them.
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Meanwhile, some of us are on staff at local community hospitals that mandate annual flu vaccines as part of maintaining staff privileges...
 
medgator said:
Meanwhile, some of us are on staff at local community hospitals that mandate annual flu vaccines as part of maintaining staff privileges...
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I am personally of the belief in the absence of a legitimate exception we all should. When patients go to see a provider (intentional choice of words because I don’t just mean doctors) I feel like they should have the expectation that said person has done everything reasonable to minimize their risk of exposure to common infectious diseases that are also likely to find their way in on other patients. Taking a seasonal vaccine for influenza (and possible soon COVID it’s looking like) falls solidly in the reasonable category to me.

Talking to patients about vaccines often feels like watching bugs fly into a bug lamp nanoseconds after watching their buggie friend get evaporated on the hot surface. I had a 58 y/o female with anal cancer (p16+) who’s husband was also treated for an HPV+ oropharyngeal SCC a few years back bring her 27 y/o son to a follow up appointment. Kid was concerned about his cancer risk and wanted to know if there was anything he could do to reduce his risk since both of his parents got cancer fairly young. I obviously wouldn’t be telling you this story if he accepted the vaccine. No, I got the line of bull crap about how vaccines also have risk and basically he was really looking for validation that diet and exercise would be enough ☹️
 
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A dear friend of mine in Pathology and I were recently lamenting the fact that we seem to be unable to convince some people to get the COVID vaccine.

He quipped, "Well, that problem will take care of itself."
 
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Gfunk6 said:
A dear friend of mine in Pathology and I were recently lamenting the fact that we seem to be unable to convince some people to get the COVID vaccine.

He quipped, "Well, that problem will take care of itself."
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"All bleeding stops eventually"
 
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Gfunk6 said:
A dear friend of mine in Pathology and I were recently lamenting the fact that we seem to be unable to convince some people to get the COVID vaccine.

He quipped, "Well, that problem will take care of itself."
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Take care of itself? While some may joke and even secretly wish for a thinning of the lower IQ heard through mass casualties, it’s not going to play out like that.

A fraction of a percent of the non immune will die, the rest will recover with immunity until the virus mutates and reinfects those without adequate immunity, lower percentages of people will die as people are left with partial immunity to yet another endemic pathogen humanity has to coexist with. New vaccines will be introduced periodically conferring varying levels of protection that people choose to take based on their own risk tolerances. The vulnerable will die as they always have from something (as is the nature of being vulnerable and eventually becoming so as a mortal species — a fact some have a hard time grappling with), the rest will live and adapt and the species will survive and proposer.

Why any physician who didn’t sleep through epidemiology and immunology class would believe otherwise astounds me.

Or… everybody gets a specific vaccine this one time and wears surgical masks designed to prevent large droplet and splash infections and this stupidly infectious virus riding on 1 micron aerosols will suddenly go away. And when this miraculous outcome doesn’t materialize with a sudden George Bush “mission accomplished” moment, the above inevitable situation will occur and be blamed on a specific group of people and used for to justify horrible things and power grabs as has always happened since basically the history of human civilization.

Maybe I’ll check back in 2 years and tell me how stupid I was when everything is “back to normal.” Hopefully my rants about not getting swindled out of pro fees helped a few new grads at least understand the scam even if they can’t do anything about it.

Good luck to all my fellow hungry rad onc rats.
 
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Turaco said:
Take care of itself? While some may joke and even secretly wish for a thinning of the lower IQ heard through mass casualties, it’s not going to play out like that.

A fraction of a percent of the non immune will die, the rest will recover with immunity until the virus mutates and reinfects those without adequate immunity, lower percentages of people will die as people are left with partial immunity to yet another endemic pathogen humanity has to coexist with. New vaccines will be introduced periodically conferring varying levels of protection that people choose to take based on their own risk tolerances. The vulnerable will die as they always have from something (as is the nature of being vulnerable and eventually becoming so as a mortal species — a fact some have a hard time grappling with), the rest will live and adapt and the species will survive and proposer.

Why any physician who didn’t sleep through epidemiology and immunology class would believe otherwise astounds me.

Or… everybody gets a specific vaccine this one time and wears surgical masks designed to prevent large droplet and splash infections and this stupidly infectious virus riding on 1 micron aerosols will suddenly go away. And when this miraculous outcome doesn’t materialize with a sudden George Bush “mission accomplished” moment, the above inevitable situation will occur and be blamed on a specific group of people and used for to justify horrible things and power grabs as has always happened since basically the history of human civilization.

Maybe I’ll check back in 2 years and tell me how stupid I was when everything is “back to normal.” Hopefully my rants about not getting swindled out of pro fees helped a few new grads at least understand the scam even if they can’t do anything about it.

Good luck to all my fellow hungry rad onc rats.
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Any physician that didn't sleep through epidemiology/immunology would know that all problems will eventually resolve from a planetary POV. Hence, this problem will take care of itself. Same for small pox. Perhaps there's a better way. It's funny how I gotta look at a confederate statue on the way to work everyday and hear about not forgetting history from the same people that don't know it,
 
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Ray D. Ayshun said:
Any physician that didn't sleep through epidemiology/immunology would know that all problems will eventually resolve from a planetary POV. Hence, this problem will take care of itself. Same for small pox. Perhaps there's a better way. It's funny how I gotta look at a confederate statue on the way to work everyday and here about not forgetting history from the same people that don't know it,
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Those same people literally don’t care if other people who look or think differently from them live or die.
 
RadOncDoc21 said:
Those same people literally don’t care if other people who look or think differently from them live or die.
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I kinda wish we had never instituted masks or created the vaccine so I could have the true number of how many would've died for no other reason than to use in conversation with KHE. 600,000 does sound kinda paltry. I think 5,000,000 would've been a good round number to be able to throw around. I get the same pushback from some patients with NED. "Well, maybe I didn't need the RT..."
 
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Ray D. Ayshun said:
I kinda wish we had never instituted masks or created the vaccine so I could have the true number of how many would've died for no other reason than to use in conversation with KHE. 600,000 does sound kinda paltry. I think 5,000,000 would've been a good round number to be able to throw around. I get the same pushback from some patients with NED. "Well, maybe I didn't need the RT..."
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Also, those numbers are likely under reported. I know where I’m at, the hospital stopped testing people soon after Memorial Day and the docs would get reprimanded if they ordered a test.
 
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Mandelin Rain said:
If you're on the model, you won't HAVE to do them.

This job is going to look nothing like the job I signed up for.
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I’m beginning to see hints that ASTRO is going to say that since you still have to submit a zero-pay claim for every CPT you do on an APM patient, that OTVs are still necessary. Necessary because that’s what we did before and we need to show CMS nothing’s going to change, and necessary because if you aren’t doing them you should be submitting CPTs for them anyway so that means you have to do them. If you don’t do them now but did them in the past it will be suspicious for fraud. At least this is the form of the convoluted logic I predict. Call it “have to justify our jobs somehow.” ASTRO has made some pretty circular arguments before but APM is going to make them set a world record for significant digits of pi.
 
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Mandelin Rain said:
If you're on the model, you won't HAVE to do them.

This job is going to look nothing like the job I signed up for.
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I think you need to double check this.

I *think* as part of the evaluation of the model, you are still basically supposed to do all the same things and "bill" the same way so that they (CMS) can figure out the difference in payouts between what APM is paying and what FFS pays.

So for example if you do a breath hold breast you're still supposed to submit charges (and document appropriately) to CMS for the breath hold, weekly visits, etc.

I think eventually that all goes away, but for now I don't think you're supposed to change anything.
 
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BobbyHeenan said:
for example if you do a breath hold breast you're still supposed to submit charges (and document appropriately) to CMS for the breath hold
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Me: I am not going to do breath hold anymore.
Biller: That’s fine. We just won’t submit a claim.

Moi: I am going to do OTVs every two weeks.
Biller: That’s fraud.
Moi: But why is that not just like me wanting not to do breath hold anymore.
Biller: Because I am smart. And you are dumb.
Moi: This makes no sense. I can’t change my practice habits based on your arbitrary feelings about what I should or shouldn’t do based on a past where reimbursements were different?
Biller: I know you are, but what am I?
 
Mandelin Rain said:
If you're on the model, you won't HAVE to do them.

This job is going to look nothing like the job I signed up for.
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Technically you won't have to do them, just like you don't have to do them now if you don't want to collect 77427, but you'll screw yourself and everyone else in the future. The professional component of the bundled payment is designed to cover your work, based on assumption of what was historically done: planning, OTV, and other management services. If you stop documenting and charging all things like OTVs, don't be surprised that CMS will adjust (lower) you professional component payments in the next cycle when they do their regular assessments. Then you really set yourself up to work for Uber for the rest of your professional life.
 
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cancer_doc said:
Technically you won't have to do them, just like you don't have to do them now if you don't want to collect 77470, but you'll screw yourself and everyone else in the future. The professional component of the bundled payment is designed to cover your work, based on assumption of what was historically done: planning, OTV, and other management services. If you stop documenting and charging all things like OTVs, don't be surprised that CMS will adjust (lower) you professional component payments in the next cycle when they do their regular assessments. Then you really set yourself up to work for Uber for the rest of your professional life.
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77427 i believe. It's 77435 if we are talking SBRT
 
BobbyHeenan said:
I think you need to double check this.

I *think* as part of the evaluation of the model, you are still basically supposed to do all the same things and "bill" the same way so that they (CMS) can figure out the difference in payouts between what APM is paying and what FFS pays.

So for example if you do a breath hold breast you're still supposed to submit charges (and document appropriately) to CMS for the breath hold, weekly visits, etc.

I think eventually that all goes away, but for now I don't think you're supposed to change anything.
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This is how this goes:
CMS, who already has decades of data about what each disease site bills/costs, initiates APM. They say that, based on the data they already have, they are going to reimburse us X dollars per prostate patient. However, they still want us to bill the same way.

We stop obsessing about getting every OTV, every medical physics consult, every special treatment procedure, every port and treat. We become more willing to hypofractionate, even when it may not be totally appropriate. After 5 years, CMS says "oh wow, based on the billings over the last 5 years, we're actually OVERpaying for radiation services" and institute cuts to the already designated APM prices.

Long term, this is bad news. Make hay while the sun shines and hopefully we will have enough saved when the cuts come and the bottom falls out from under us.
 
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cancer_doc said:
Technically you won't have to do them, just like you don't have to do them now if you don't want to collect 77427, but you'll screw yourself and everyone else in the future. The professional component of the bundled payment is designed to cover your work, based on assumption of what was historically done: planning, OTV, and other management services. If you stop documenting and charging all things like OTVs, don't be surprised that CMS will adjust (lower) you professional component payments in the next cycle when they do their regular assessments. Then you really set yourself up to work for Uber for the rest of your professional life.
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How is this different from the argument if we all go from 4 week breast to 1 week breast we are screwing ourselves also. I mean historically the one week hasn’t been done.
 
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TheWallnerus said:
How is this different from the argument if we all go from 4 week breast to 1 week breast we are screwing ourselves also. I mean historically the one week hasn’t been done.
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Changing fractionation schemes is a natural reaction to APM as this is the original intent of APM- to mitigate over-fractionation. But changing how you actively manage a patient on treatment, regardless of fractionation scheme, is vastly different in my professional opinion. Changing the latter would serve to CMS the validation that doctors are less valuable and less necessary in RO treatment. With all this talk about over saturation of RO market, finding more excuses to remove yourself further from patient management does not add up.

If you shorten treatment course AND change your management / documentation patterns, then you're just double-fisting yourself a world of pain in both financial and potentially quality measures....
 
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