The proposed CMS alternative payment model has arrived

[medgator]

Lean practices hire less. Getting leaner makes that worse. APMs will make that even worse. Site neutrality, APM, and proton cuts will literally turn academic centers into just another treatment center. It’s the trifecta of death. I’m not a fan of academic or big hospital Corp but these beasts are pretty much the only ones hiring.

Maybe we will see freestanding and private practices come back when the playing field is finally level

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[deleted941485]

No but that's what APM is trying to do. It will probably be more of a pay cut if you:

1). Prescribe too many fractions unnecessarily

And/or

2) practice at an expensive site of service.

Not sure how either of those is a "bad" pay cut

Do we know how the APM is structured yet? Have the details been looked at.

It’s nice to think only the bad Rad oncs will be punished and the good ones will be rewarded but honestly didn’t we already go down that road with MIPS and other nonsense metrics supposedly designed to show what quality healthcare providers we are?

Every RO will be punished the guilty with the innocent because honestly Medicare doesn’t care. It’s interested in cutting costs across the board. If proton therapy was cheaper than photons nobody would give a damn.

How did the drug companies make out this year? Oh right! They abandoned the Medicare negotiation for drug prices! Cuts to 340b program? Nope. Lol! Well I guess you know where all those cuts to RO are going now.

 

[deleted941485]

Maybe we will see freestanding and private practices come back when the playing field is finally level

I’d bet on the rapture happening in my lifetime before I see the dissolution of corporate medicine.

 

[medgator]

I’d bet on the rapture happening in my lifetime before I see the dissolution of corporate medicine.

There's no reason for CMS to be complicit in paying them more for the exact same service. And RO is the tip of the iceberg there....

 

[deleted941485]

There's no reason for CMS to be complicit in paying them more for the exact same service. And RO is the tip of the iceberg there....

I certainly understand that but the damage has already been done. We can have an ethical or moral debate about it but the fact remains.

Why should Dr. Solo get less money for a new patient while Dr. Mega Med gets more? It’s all about leverage and the power to force the issue.

The bottom line is you can’t get a fair shake from the govt or from commercial payers on your own or even in a small group. There are simply too many docs to make it work well where you get to be independent and fairly reimbursed. So we gave up independence but going corporate. Now it seems we’re gonna give up reimbursement too.

 

[Krukenberg]

Academic practices especially the ones that have proton facilities are pretty much lining up to shut down any discussion of bundling proton for Medicare patients. Its a joke. That is literally all they care about. It’s helping to prop up a lot of depts. and helps free up their attendings for “academic” work and generate money for the hospital.

A lot of depts are working overtime in building efficiency in their EMR workflow. Automated contouring, Departmental pathway algorithms, etc. it adds up to really less hiring and crappy contracts for the new attendings. And just a crappy job altogether.

In 5 years it’s gonna be basically you literally will click a diagnosis code stage them and the computer will spit out a treatment. If you don’t follow it then you’ll just fill out more paperwork. Which overtime no one will do because it just adds unnecessary time. They will slowly just stop caring.

APMs are gonna end up being just another Paycut to your Dept and ultimately to you. they’re just gonna make their existing workforce pick up the slack and give them the tools to do it.

Your clinical gestalt and experience becomes irrelevant.

These are a lot of assumptions for a resident to be making

 

[deleted941485]

These are a lot of assumptions for a resident to be making

Please illuminate me

 

[deleted947887]

These are a lot of assumptions for a resident to be making

Pesky resident. How dare he speak to you in that way?

 

[deleted941485]

Please illuminate me

Quite an assertion from an attending.

Pesky resident. How dare he speak to you in that way?

It’s alright. Kruk has it all figured out.

 

[Krukenberg]

Quite an assertion from an attending.


It’s alright. Kruk has it all figured out.

I apologize, thought you were a resident. Regardless those are some big assumptions to be making of the field. It’s just as reasonable to say that APM finally gives rad onc payment stability which makes practices more confident about hiring. Uncertainty in regulations/income makes all businesses hesitant to hire.

 

[deleted941485]

I apologize, thought you were a resident. Regardless those are some big assumptions to be making of the field. It’s just as reasonable to say that APM finally gives rad onc payment stability which makes practices more confident about hiring. Uncertainty in regulations/income makes all businesses hesitant to hire.

I agree uncertainty is bad. But what does stability in RO mean these days? The last 10 years RO has been through the ringer. So forgive my pessimistic attitude for not seeing this is a life jacket and more like a coup de grace. I’ve watched enough practices die off and get bought out because of stuff like this.

 

[medgator]

I agree uncertainty is bad. But what does stability in RO mean these days? The last 10 years RO has been through the ringer. So forgive my pessimistic attitude for not seeing this is a life jacket and more like a coup de grace. I’ve watched enough practices die off and get bought out because of stuff like this.

They were getting bought out because the hospital could charge more for the exact same service. Site-neutral payments will help put a halt that, and not only just in RO

 

[xrthopeful]

Well not just that right - if the big hospitals keep buying out all the regional hospitals with their respective breast surgeons, urologists, etc etc etc - these people now refer to the big hospital rad onc group, and the independent practitioner has to join or die.

 

[SneakyBooger]

Well, given that this "innovation" is part of The Affordable Care Act, I wonder will it go away if ACA is ruled invalid by the Supreme Court.

 

[thecarbonionangle]

Well, given that this "innovation" is part of The Affordable Care Act, I wonder will it go away if ACA is ruled invalid by the Supreme Court.

Zero chance of that happening. Roberts will not let that nonsense happen in his court.

 

[deleted941485]

Well not just that right - if the big hospitals keep buying out all the regional hospitals with their respective breast surgeons, urologists, etc etc etc - these people now refer to the big hospital rad onc group, and the independent practitioner has to join or die.

My take on it has been that since the ACA. There really is much more downside risk than upside to an independent provider in most cases either because you can’t crack into the hospital referral pattern or you’ll never be able to pay yourself and your staff adequately.

I think in general most independent providers would have been just as happy being that way but it was literally out of necessity to join the the hospital.

 

[xrthopeful]

Yep. This goes into why old people AKA scarbtj say ‘don’t go into medicine’.

For me as a ‘young person’ I’m comfortable being ‘employed’. I guess I never went into medicine with the expectation of being able to hang my own shingle. That’s not what medicine was about in my head. But yes - this is the reality of modern medicine. You are likely to be an employee.

 

[nkmiami]

I apologize, thought you were a resident. Regardless those are some big assumptions to be making of the field. It’s just as reasonable to say that APM finally gives rad onc payment stability which makes practices more confident about hiring. Uncertainty in regulations/income makes all businesses hesitant to hire.

Knowing with more certainty that your practice is going to take in less income, and deliver less fractions is going to make you more confident to hire? And that comment got 2 likes.

 

[medgator]

Knowing with more certainty that your practice is going to take in less income, and deliver less fractions is going to make you more confident to hire? And that comment got 2 likes.

Better than taking endless cuts, which was pretty much the status quo until the recent rate freezes a few years ago while payment reform was being looked at.

Right now, you are penalized in all settings for delivering less fractions in bone mets and breast cancer, where hypofx has the most data and consensus.

And you are penalized for owning a linac outside of a hospital or PPS exempt/NCI designated cancer center.

So basically those of us "choosing wisely" in the freestanding setting are getting penalized twice under the current CMS reimbursement system

 

[Krukenberg]

Knowing with more certainty that your practice is going to take in less income, and deliver less fractions is going to make you more confident to hire? And that comment got 2 likes.

Well known in the business world that uncertainty leads to less investing and hiring. Many practices will either be breakeven or make more money from this APM, and more payment stability could stimulate hiring. Just saying it could go both ways

 

[scarbrtj]

Yep. This goes into why old people AKA scarbtj say ‘don’t go into medicine’.

For me as a ‘young person’ I’m comfortable being ‘employed’. I guess I never went into medicine with the expectation of being able to hang my own shingle. That’s not what medicine was about in my head. But yes - this is the reality of modern medicine. You are likely to be an employee.

I’m your huckleberry. I haven’t paid much attention to what you’ve ever said (written), but please show me where I said “don’t go into medicine.” You have my full permission never to misquote me again.

 

[SneakyBooger]

Zero chance of that happening. Roberts will not let that nonsense happen in his court.

Perhaps so.

But until now Roberts' Court has been reluctant to address the severability issue.

They ruled in 2012 the individual mandate constitutional as there was no penalty, instead there was a tax. Therefore, they didn't have to address severability.

There is no longer a tax (since 2017) and therefore the mandate is no longer constitutionally protected as one cannot have a tax without revenue.

If Congress would have enacted the constitutional parts of the law without the unconstitutional parts, the unconstitutional parts are severable. But the individual mandate is part of that law.

The DOJ previously stated the mandate was severable. Recently the DOJ reversed their position and now state the individual mandate is inseverable.

Congress has upon 3 times stated the individual mandate is "essential" to the ACA.

Can Roberts delay the issue any longer?

It will be interesting to see.

And if the entire ACA is blown up, will insurance companies all go bankrupt? Are they not "too big to fail"?

 

[medgator]

Perhaps so.

But until now Roberts' Court has been reluctant to address the severability issue.

They ruled in 2012 the individual mandate constitutional as there was no penalty, instead there was a tax. Therefore, they didn't have to address severability.

There is no longer a tax (since 2017) and therefore the mandate is no longer constitutionally protected as one cannot have a tax without revenue.

If Congress would have enacted the constitutional parts of the law without the unconstitutional parts, the unconstitutional parts are severable. But the individual mandate is part of that law.

The DOJ previously stated the mandate was severable. Recently the DOJ reversed their position and now state the individual mandate is inseverable.

Congress has upon 3 times stated the individual mandate is "essential" to the ACA.

Can Roberts delay the issue any longer?

It will be interesting to see.

And if the entire ACA is blown up, will insurance companies all go bankrupt? Are they not "too big to fail"?

Hospital stocks are back in the gutter over the last few years. They got a boost after the ACA was passed. Tough to run a hospital when you have an unfunded mandate like emtala.

I guess Republicans stopped believing in personal responsibility and insurance mandates once RomneyCare became Obamacare, and are happy to watch uninsured deadbeats continue to get free care in hospital ERs.

 

[SneakyBooger]

Wasn't Romneycare a state program and Obamacare a federal one?

Does it matter as to whether states decide how to individually manage health insurance or should the federal government decide for them? And if the choice is the latter, then why have states at all? Should we just make the USA a single state like China or the former Soviet Union?

And if Obamacare is a better program then why can't Texas figure that out on their own? What is Texas' issue? Is it appropriate for New York City to command Dallas how to manage health insurance? If people in Dallas think New York City has a better health insurance system can they not move to NY?

If medical care is now run by corporations whose primary responsibility is to shareholders instead of patients, who does one trust to have the patients' best interests at heart? Do corporations have a heart? Do physicians have a heart?

On a side note, Hamilton is one of the greatest shows to hit Broadway. Man, I love that play!

 

[Mandelin Rain]

Haven't looked into this at all, but can anyone explain how this impacts those of us with pro services agreements, i.e. are the tech/facilities bundled with the pro or do they remain separate, but bundled pots?

 

[SneakyBooger]

Haven't looked into this at all, but can anyone explain how this impacts those of us with pro services agreements, i.e. are the tech/facilities bundled with the pro or do they remain separate, but bundled pots?

pro and tech separate still

 

[BobbyHeenan]

Haven't looked into this at all, but can anyone explain how this impacts those of us with pro services agreements, i.e. are the tech/facilities bundled with the pro or do they remain separate, but bundled pots?

There is a table in there with initial starting point estimates for what the pro and tech (as noted above, separate) reimbursements would be before all the little modifiers/multipliers are factored in.

Some of our questions still are what we do with our cervix cases where I do their brachy but the outside smaller hospital that refers in is doing their EBRT.

 

[evilbooyaa]

Let's try and minimize the politics discussion going forward.

Let's avoid playing the hierarchy game/giving into the appeal to authority fallacy if we can.

 

[OTN]

There is a possible legal challenge to the "mandatory" part of it all, as the CMMI's charter doesn't allow for mandatory programs.

 

[nkmiami]

Better than taking endless cuts, which was pretty much the status quo until the recent rate freezes a few years ago while payment reform was being looked at.

Right now, you are penalized in all settings for delivering less fractions in bone mets and breast cancer, where hypofx has the most data and consensus.

And you are penalized for owning a linac outside of a hospital or PPS exempt/NCI designated cancer center.

So basically those of us "choosing wisely" in the freestanding setting are getting penalized twice under the current CMS reimbursement system

But now the hard data show you are in the minority, in terms of delivering appropriate and cost effective care in a freestanding center- and so I would imagine are the vast majority of regular posters on this board. Those in community practice who are receiving medicare (at least) 10% more per episode (than hospital inpatient center), despite lower reimbursement rates for the freestanding centers, will be clearly squeezed with essentially mandated cuts in utilization, are not going to be looking to hire (radoncs).
Historically, across specialties, doctors when faced with cuts in reimbursement tended to compensate with "increased utilization." This wont be possible or very difficult in a bundled payment system. If freestanding centers should be charging at least 10% less, but instead are charging 10% more per episode than hospital based centers, this indicates that today, right now, there is already an oversupply of at least 20% radoncs among freestanding centers. Someone better at math and reasoning than me like scarbtj, please weigh in.

BTW I think medicare reimburses freestanding much less than 10% less than hospital centers for the same code....

 

[RickyScott]

Residents/students really should rotate through a 21C or vantage or maybe us oncology practice to get a sense of how much excess/superfluous radiation is out there so they will get a sense of what it means for the job market when this is taken away by payment reform. There is a huge bubble here.

 

[deleted941485]

The APM is going to be a double whammy for the RO job market and compensation. In my region alone (2 hospital systems and 1 small PP) we are seeing record numbers of new consults and treats BUT despite this no new hiring will be taking place at least for the next 18-24months. Prior to the CMS proposal at least the 2 hospital systems were slated to be approved for 2 new FTEs to deal with the volume at each center. One reason is the APM uncertainty, admin knows it’s gonna be a cut but if you can run your staff lean you might be able to work and maybe turn a profit. However, this is all contingent on NOT HIRING new staff attendings, physicists, everything. Oh and one of them is looking to open up a new rad Onc residency program.

 

[medgator]

Residents/students really should rotate through a 21C or vantage or maybe us oncology practice to get a sense of how much excess/superfluous radiation is out there so they will get a sense of what it means for the job market when this is taken away by payment reform. There is a huge bubble here.

Really dependent on time out from training for those physicians, but otherwise totally agree.

For those of us keeping up with guidelines, Hypofx has allowed many of us to see and treat more patients a year.... Not what you want to hear if you're graduating soon.

 

[deleted941485]

Really dependent on time out from training for those physicians, but otherwise totally agree.

For those of us keeping up with guidelines, Hypofx has allowed many of us to see and treat more patients a year.... Not what you want to hear if you're graduating soon.

APMs will be the biggest FU to new grads since the ABR failure dare I say scandal bloodbath from last year. And despite all this, I’m still catching Med students in my Dept. Some people never learn and some people refuse to learn.

 

[nkmiami]

"Our analysis also showed that, on average, freestanding radiation therapy centers furnished (and billed for) a higher volume of RT services within such episodes than did HOPDs. Based on our analysis of Medicare FFS claims data from that time period, episodes of care in which RT was furnished at a freestanding radiation therapy center were, on average, paid approximately $1,800 (or 11 percent) more by Medicare than those episodes of care where RT was furnished at a HOPD. We are not aware of any clinical rationale that explains for these differences,
which persisted after controlling for diagnosis, patient case mix (to the extent possible using data available in claims), geography, and other factors. These differences also persist even though Medicare payments are lower per unit in freestanding radiation therapy centers than in HOPDs."

My point is the excess capacity can be quantified/reflected to some extent by looking at the delta - basically adding the 11% more episode plus the average difference between codes for freestanding and hospital based departments.

 

[RickyScott]

APMs will be the biggest FU to new grads since the ABR failure dare I say scandal bloodbath from last year. And despite all this, I’m still catching Med students in my Dept. Some people never learn and some people refuse to learn.

I disagree, this is so much worse than the ABR for new grads.

 

[deleted941485]

I disagree, this is so much worse than the ABR for new grads.

And yet they just keep pumping them out left and right. There are so many headwinds working against these residents that I think if they actually paused and thought about it they might actually be more than a little angry.

 

[medgator]

I disagree, this is so much worse than the ABR for new grads.

Yup, this will be with you for life once you get through the ABR shenanigans

 

[deleted941485]

There is a possible legal challenge to the "mandatory" part of it all, as the CMMI's charter doesn't allow for mandatory programs.

ASTRO has been asking for this for years but of course not for protons. What organization would even challenge it?

 

[RickyScott]

At some point, one option would be for disenchanted younger docs to withhold astro dues, given the complicity of its leadership in residency expansion.

 

[deleted941485]

At some point, one option would be for disenchanted younger docs to withhold astro dues, given the complicity of its leadership in residency expansion.

How about the outright rape of the field?

It should be clear to anyone by this point that ASTRO and the Govt are in the process of killing rad Onc.

We are being sacrificed for the sake of Med Onc and their pharma backers.

 

[medgator]

At some point, one option would be for disenchanted younger docs to withhold astro dues, given the complicity of its leadership in residency expansion.

I plan on doing so. Pretty much anyone outside of academics should.

 

[medgator]

Honestly can’t believe anyone wants to enter the field at this point. It’s been inching towards a cliff for years, and the APM is going to be the push that sends the job market tumbling. Within 5 years I think we’ll be at a place where 20-30% of a graduating class can’t find a job and thinking about either re-training or moving out of the country, and a further 20-30% are begging for table scraps, taking the equivalent of a fellowship or instructor position for 100-200k. Maybe the top 30-40% of well connected residents from good residencies are able to eke out decent careers at 1/3rd or less what their radonc ancestors were making 10 years ago.

Those who forget history are doomed to repeat it. It's amazing (and sad) how incredulous the current crop of academic leadership in RO is to the current and future state of the field.

A few decades ago, a different generation of academic leadership addressed this problem, nowadays the current crop seem to happy to poke a few more holes in the Titanic....

 

[deleted941485]

Honestly can’t believe anyone wants to enter the field at this point. It’s been inching towards a cliff for years, and the APM is going to be the push that sends the job market tumbling. Within 5 years I think we’ll be at a place where 20-30% of a graduating class can’t find a job and thinking about either re-training or moving out of the country, and a further 20-30% are begging for table scraps, taking the equivalent of a fellowship or instructor position for 100-200k. Maybe the top 30-40% of well connected residents from good residencies are able to eke out decent careers at 1/3rd or less what their radonc ancestors were making 10 years ago.

All on down the line from RO attendings to the people that service the machines. This place is going to crater. Students information on a specialty is usually about 2-3 years old at any given time. The ones who apply this time around are just flat out delusional even the top performing ones.

 

[deleted941485]

Those who forget history are doomed to repeat it. It's amazing (and sad) how incredulous the current crop of academic leadership in RO is to the current and future state of the field.

A few decades ago, a different generation of academic leadership addressed this problem, nowadays the current crop seem to happy to poke a few more holes in the Titanic....

Oh but this time they’ll be evidence based holes!

 

[OTN]

ASTRO has been asking for this for years but of course not for protons. What organization would even challenge it?

COA is planning a legal challenge.

Home - Community Oncology Alliance

W2NvbnRhY3QtZm9ybS03IGlkPSIyNTcyNyIgdGl0bGU9IlN1cHNjcmlwdGlvbiJdClttYWlsbXVuY2gtZm9ybSBpZD0iNjg3MDAwIl0K

www.communityoncology.org

Other thoughts:
- As far as the job stuff goes, this certainly will affect the job market, but not nearly as much as residency expansion has.
- I'm not worried about my job or the radonc market as a whole, as we're not going anywhere when it comes to cancer treatment. Aging population will work in our favor as well.
- The numbers so far on the APM don't look like a complete disaster for our field, and are better than the 24% cut (8% per year x 3 years) we were scheduled to undergo.
- Site payment parity is well overdue and hopefully will help limit hospital expansion (both academic and non-academic) moving forward.
- Smaller groups having limited bargaining power in the market has been evident for at least 10 years now- it's why I didn't look to join smaller groups when I was coming out of residency then, and I wouldn't recommend it now. You'll get squeezed on both the equipment side and the payer side, making it a lot tougher than if you have a large organization to do your bargaining for you. They'll also have the IT and HR support to increase efficiency, which will be critical to success in the future.
- I haven't been an ASTRO member for several years now. We are ACRO accredited.

 

[deleted941485]

COA is planning a legal challenge.

Home - Community Oncology Alliance

W2NvbnRhY3QtZm9ybS03IGlkPSIyNTcyNyIgdGl0bGU9IlN1cHNjcmlwdGlvbiJdClttYWlsbXVuY2gtZm9ybSBpZD0iNjg3MDAwIl0K

www.communityoncology.org

Other thoughts:
- As far as the job stuff goes, this certainly will affect the job market, but not nearly as much as residency expansion has.
- I'm not worried about my job or the radonc market as a whole, as we're not going anywhere when it comes to cancer treatment. Aging population will work in our favor as well.
- The numbers so far on the APM don't look like a complete disaster for our field, and are better than the 24% cut (8% per year x 3 years) we were scheduled to undergo.
- Site payment parity is well overdue and hopefully will help limit hospital expansion (both academic and non-academic) moving forward.
- Smaller groups having limited bargaining power in the market has been evident for at least 10 years now- it's why I didn't look to join smaller groups when I was coming out of residency then, and I wouldn't recommend it now. You'll get squeezed on both the equipment side and the payer side, making it a lot tougher than if you have a large organization to do your bargaining for you. They'll also have the IT and HR support to increase efficiency, which will be critical to success in the future.
- I haven't been an ASTRO member for several years now. We are ACRO accredited.

That’s great but...community oncology is just another thing govt has killed. They pissed and moaned with the give forced them at random to participate in certain infusions drug programs years ago.

Let me ask. If a hospital is the only place you can get RT treatments in your area then isn’t it site neutral by virtue of the fact that no one is offering it on the freestanding side? All comparisons become meaningless and totally theoretical.

 

[medgator]

That’s great but...community oncology is just another thing govt has killed. They pissed and moaned with the give forced them at random to participate in certain infusions drug programs years ago.

Let me ask. If a hospital is the only place you can get RT treatments in your area then isn’t it site neutral by virtue of the fact that no one is offering it on the freestanding side? All comparisons become meaningless and totally theoretical.

Without another option to compete against, hospitals love to jack up prices and insurance companies have no leverage in the contracting process.

California sues hospital giant Sutter Health, where study found prices 25% higher

California Attorney General Xavier Becerra announced a lawsuit against Sutter Health, alleging anticompetitive conduct that drove up prices.

www.usatoday.com

 

[deleted941485]

Without another option to compete against, hospitals love to jack up prices and insurance companies have no leverage in the contracting process.

California sues hospital giant Sutter Health, where study found prices 25% higher

California Attorney General Xavier Becerra announced a lawsuit against Sutter Health, alleging anticompetitive conduct that drove up prices.

www.usatoday.com

So basically the choice has become work for the health system that actively price gauges and get paid a reasonable salary or work for the community oncology practice that is 5 minutes away from utter financial ruin and spend most of your time fighting with insurance and getting paid peanuts. Like most of American politics these days there is simply no middle ground anymore.

 

[deleted941485]

I don’t disagree that expansion is worse, but it’s also been slow moving. Markets react and better to slow changes. Here, we’re talking about a massive nationwide incentive to adopt hypofractionated treatment overnight.

Every practice in the country will be strongly incentivized to go from 40->20 (or 5) on prostate, 30->15 on breast, 10-> 1 on bone mets overnight. There is the potential for HUGE financial gain here. There will be some mitigating factors like oligomets, aging pop, etc., but clinical volumes and hiring will utterly tank while all the excess is wrung out of the system.

Oligomets will never compensate for the shear drop in number of fx about the occur.

I have been saying this all along. The savy chairs have already started wringing their hands. Not only is there a pure profit motive at work here but think of all those trainees who will now apply from 1,2,3 year fellowships in SBRT. The army of cheap rad oncs that will be doing the bulk of the work on these cases. The cost of labor goes down too. They profit on both ends now.