The proposed CMS alternative payment model has arrived

[OTN]

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.

I wouldn't describe it as overnight. CMMI has been signaling about this for a few years now, ASTRO has been pushing for it, and several large private practices (one in NY I'm thinking of) already have bundled payment contracts with private payers.

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[SneakyBooger]

This thread is flaming.

Is there a GoFundMe page for the COA suit?

 

[medgator]

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.

Care to back that up with any kind of proof? Successful pp still exists, the best are the ones in multi specialty groups

 

[deleted941485]

Care to back that up with any kind of proof? Successful pp still exists, the best are the ones in multi specialty groups

Most markets have undergone massive consolidation and these groups have been eliminated as a result. My comment pretty much sums up the dynamic especially in areas where most people live.

The only successful private groups I’ve seen are the ones that saw the writing in the wall and sold out to big hosp or US Onc or IoN or whatever.

Granted there are still boutique practices like a certain CK facility in Manhatten run by a rather infamous fellow but I mean is that really what we’re gonna hold up as a successful PP.

Even when I was a Med student, it was obvious that these small practices were struggling to keep up.

It’s very obvious who has the money in the healthcare landscape and who does not. It’s also obvious who is able to hire new attendings and who is not. And while I wouldn’t begrudge anybody from seeking out these great multi specialty groups it seems that they simply are not hiring.

I’m sorry I don’t share your enthusiasm for that particular practice model. I simply view them the way I view snowflakes. Pretty, delicate, and ultimately doomed.

 

[medgator]

I’m sorry I don’t share your enthusiasm for that particular practice model. I simply view them the way I view snowflakes. Pretty, delicate, and ultimately doomed.

Insurance companies are hungry for options in monopolistic hospital controlled markets. It's a fact.

I think tigerstangs second post in this thread summed it up well. Site neutrality will finally be a win for the freestanding community. Only time will tell how much it levels the playing field and restores balance to the system

 

[Krukenberg]

Insurance companies are hungry for options in monopolistic hospital controlled markets. It's a fact.

I think tigerstangs second post in this thread summed it up well. Site neutrality will finally be a win for the freestanding community. Only time will tell how much it levels the playing field and restores balance to the system

I’d like to point out that all of this is contingent on CMMI resisting the lobbying the AHA will do. ASTRO will probably lobby to remove site neutrality if the PP Astro members don’t speak up and tell ASTRO you want it left in. This is where being an Astro member is worth it so you at least can voice your opinion and influence lobbying. Otherwise the only voices at the table are the academic centers.

 

[RickyScott]

I’d like to point out that all of this is contingent on CMMI resisting the lobbying the AHA will do. ASTRO will probably lobby to remove site neutrality if the PP Astro members don’t speak up and tell ASTRO you want it left in. This is where being an Astro member is worth it so you at least can voice your opinion and influence lobbying. Otherwise the only voices at the table are the academic centers.

ASTRO is as likely to come out in favor of site/proton neutrality as much as they would come out against residency expansion. It is simply not an organization that represent the interests of the majority of it members.

 

[scarbrtj]

For $199 ASTRO will give us all some more info re: APM. I know what my "next steps" are gonna be...

 

[scarbrtj]

Kavanaugh's Red Journal commentary, believe it or not, sounds like it might have been written by SDNers (but maybe with a bit more kinder tone).
1) Rad onc's $$$ went up like crazy in the early days of IMRT
2) For about 10+ years rad onc's $$$ has been going down
3) People have worried about the $$$ going down so maybe APM will stop the bleeding
4) On the other hand, the $$$ is still too damn high and we need more hypofx to save even more damn $$$ and weed out bad, high-fx care

Radiation Oncology APM: Why us? Why now?

 

[firewicket]

Has anyone actually ran these reimbursement numbers by their billing department...I have and these rates are about 50% if not less than standard CMS rates we are getting reimbursed for currently.

Anyone with similar confirmation of this?

 

[Reaganite]

Has anyone actually ran these reimbursement numbers by their billing department...I have and these rates are about 50% if not less than standard CMS rates we are getting reimbursed for currently.

Anyone with similar confirmation of this?

On brief glance, it looked to be about 70ish percent. (If memory serves correctly, I saw prostate at about 20k, and I think breast around 7-8k?). Might depend on your medicare locale, but we've typically seen up to 30k for 45 fx prostate and maybe about 10-12 for a 30fx breast at 100% of Medicare. I also didn't read enough detail to check if the numbers quoted for average episode of care represented 100% of Medicare or what Medicare actually paid (i.e. 80%).

 

[Pointless]

Those who are already hypofracing prostate are probably going to get much less hurt by this compared with those giving 45 fractions. No fraction shaming here, just reality.

 

[scarbrtj]

Those who are already hypofracing prostate are probably going to get much less hurt by this compared with those giving 45 fractions. No fraction shaming here, just reality.

It would be likely that what CMS did was look at the lowest averages they were paying in rad onc in each disease site and said: this is the price. Welcome to the commoditization of rad onc. High tech, low tech, we don't give a tech... as long as it's high value. For me, the lowest price for prostate is when I do five-fraction SBRT. I think we make about 15K in that setting. We never get ~$50K for prostate SBRT or 45-fx IMRT... who are these people? And $100K+ for prostate proton therapy... bet it would be less if it were prostate proton SBRT. How's the prostate proton SBRT data looking?

 

[firewicket]

5 weeklies vs 8 weeklies for a prostate doesn’t make for a 50% professional fee difference. There are also geographical modifiers which means the actual rates will be even lower...

 

[Pointless]

5 weeklies vs 8 weeklies for a prostate doesn’t make for a 50% professional fee difference. There are also geographical modifiers which means the actual rates will be even lower...

Where did you get the actual reimbursement rates? I flipped through the CMS proposal and didn't see any specific prices, just generalities. I doubt that we are looking at an instantaneous 50% haircut in one move. That would be too disastrous even for the *****s that run this country to contemplate.

Although, Trump..... ah who knows? Hope you're wrong.

 

[scarbrtj]

Where did you get the actual reimbursement rates? I flipped through the CMS proposal and didn't see any specific prices, just generalities. I doubt that we are looking at an instantaneous 50% haircut in one move. That would be too disastrous even for the *****s that run this country to contemplate.

Although, Trump..... ah who knows? Hope you're wrong.

Whatever it is it ain't gonna be a bump up. To paraphrase one old phrase: "We're from the government and we're here to give good rad oncs a pay raise." @Reaganite knows to be skeptical of that.

 

[Pointless]

This we can agree on. I fully expect a pay cut, I just figured it would start on the order of 10-20% and mature from there. Any more than that and you run a real risk of closing down a lot of smaller, rural centers. And then where would the ASTRO career center be?????!!!!!

 

[Reaganite]

Where did you get the actual reimbursement rates? I flipped through the CMS proposal and didn't see any specific prices, just generalities. I doubt that we are looking at an instantaneous 50% haircut in one move. That would be too disastrous even for the *****s that run this country to contemplate.

Although, Trump..... ah who knows? Hope you're wrong.

I think one of the pages had an average cost of care by diagnosis. Those numbers were around 70ish % of medicare for standard fx in my neck of the woods. If they make cuts based on these numbers...yikes.

 

[Pointless]

I think one of the pages had an average cost of care by diagnosis. Those numbers were around 70ish % of medicare for standard fx in my neck of the woods. If they make cuts based on these numbers...yikes.

I wonder if they are quoting what is BILLED to Medicare or what is PAID by Medicare. Big difference and hopefully represents the disparity.

 

[Reaganite]

I wonder if they are quoting what is BILLED to Medicare or what is PAID by Medicare. Big difference and hopefully represents the disparity.

I didn't read the fine print, but would be surprised if billed since most billing companies usually reflexively charge way over medicare allowable.

 

[firewicket]

FYI: CMS reimbursement rates (actual money distributed) are available to anyone. You can look it up by a providers NPI and by year of billing. Just takes some googling.

 

[RickyScott]

Those who are already hypofracing prostate are probably going to get much less hurt by this compared with those giving 45 fractions. No fraction shaming here, just reality.

I am employed/salaried with small performance incentive and use a lot of hypofractrionation. Will definitely be hurt, not so much by billing but a worsening of the job market as ultimately salary and mobility set by supply and demand.

 

[deleted941485]

I am employed/salaried with small performance incentive and use a lot of hypofractrionation. Will definitely be hurt, not so much by billing but a worsening of the job market as ultimately salary and mobility set by supply and demand.

There is definitely a ripple effect that I don’t think a lot of people are grasping. But Hey 200 plus grads is A Okay!

 

[Old rad onc]

A 30% cut would be the end of our field as overhead is about 60-70 percent now. I had heard 4% but we used to get info on cuts with proposals in July and final hard proposals in November. Now , we get very little information and nothing until it is final almost after the fact. I have heard January or April 2020 is the start and it will be Manditory for 5 years on 17 different cancers. If 30 % were indeed true then mass chaos will ensue.......

 

[scarbrtj]

A 30% cut would be the end of our field as overhead is about 60-70 percent now. I had heard 4% but we used to get info on cuts with proposals in July and final hard proposals in November. Now , we get very little information and nothing until it is final almost after the fact. I have heard January or April 2020 is the start and it will be Manditory for 5 years on 17 different cancers. If 30 % were indeed true then mass chaos will ensue.......

We will probably just suck it up buttercup and take it.

 

[Irradi8or]

Folks need to understand that as proposed, the ROAPM would only apply to traditional medicare (no MA programs). This does limit most practice's exposure to the ROAPM even if in the selected CBSA. Additionally, expected cuts could be closer to 5-6% in the model, but with the more limited traditional medicare population typically representing a smaller portion of payer mix, CMS expects that those overall cuts are ameliorated to closer to 1-2% potentially. However, need to see more hard data on the trend factors, case mix, historical experience, etc to know more about your individual practice.

 

[scarbrtj]

Folks need to understand that as proposed, the ROAPM would only apply to traditional medicare (no MA programs). This does limit most practice's exposure to the ROAPM even if in the selected CBSA. Additionally, expected cuts could be closer to 5-6% in the model, but with the more limited traditional medicare population typically representing a smaller portion of payer mix, CMS expects that those overall cuts are ameliorated to closer to 1-2% potentially. However, need to see more hard data on the trend factors, case mix, historical experience, etc to know more about your individual practice.

I predict, as has been the case since time immemorial, everyone... MA, private payors... eventually will follow Medicare.

 

[fiji128]

The entire point APM is to spend less overall on care, otherwise it would serve no purpose. The pic below was pulled off of #radonc on Twitter. Nice to see prostates is the highest billable site, lol. I have no idea if these would actually be the final numbers or how many years it would take to implement this but if it does come to pass a lot of smaller community based practices would no longer be economicaly viable and those large academic departments may stop being cash cows for thier hospitals.

 

[Irradi8or]

I predict, as has been the case since time immemorial, everyone... MA, private payors... eventually will follow Medicare.

Eventually there will be increasing movement toward APMs but not right away and not immediately to this same model. Take the OCM for example - we are several years into it and most non Medicare payers have not moved to an identical model. In fact some of the new commercial APMs for Med Onc have been materially different from OCM (in some better and worse ways). We’ll need to continue to advocate for Rad Onc many more times along the way and ideally help define some of these new models.

 

[Mandelin Rain]

Those payments make sense. I've never seen a prostate patient that isn't 10% more time consuming than a head and neck patient.

 

[RickyScott]

I predict, as has been the case since time immemorial, everyone... MA, private payors... eventually will follow Medicare.

exactly

 

[xrthopeful]

Those payments make sense. I've never seen a prostate patient that isn't 10% more time consuming than a head and neck patient.

I get the part about prostate consults taking a long time but after that the contours and the toxicity management are no contest more work for head and neck

 

[medgator]

I get the part about prostate consults taking a long time but after that the contours and the toxicity management are no contest more work for head and neck

That was the rationale for Astro to try and split imrt into simple and complex codes a few years ago (also to try and screw urorads centers)

 

[SneakyBooger]

Just scheduled my 3rd arthritis consult for next week.

 

[Tigerstang]

And here goes ASTRO again, trying to undo all the government's good work...

 

[scarbrtj]

And here goes ASTRO again, trying to undo all the government's good work...

View attachment 273652

"All animals are equal, but some animals are more equal than others."
- George Orwell, honorary ASTRO member (actually he'd be kicked out)

 

[Gfunk6]

And here goes ASTRO again, trying to undo all the government's good work...

View attachment 273652

Of course, if ASTRO is proposing that freestanding centers are reimbursed at the same rate as hospital-based clinics, I'm all for it. Somehow, I don't think the feds will bite either way.

 

[medgator]

Of course, if ASTRO is proposing that freestanding centers are reimbursed at the same rate as hospital-based clinics, I'm all for it. Somehow, I don't think the feds will bite either way.

Would love to see ASTRO justify how hospital based radiation would be "disadvantaged"

 

[RickyScott]

Would love to see ASTRO justify how hospital based radiation would be "disadvantaged"

Did anyone pay 199$ to hear the ASTRO update?

 

[Irradi8or]

I'm suspecting that with the way CMS is going to adjustment the national base rate based on a practice's historical reimbursements, this may continue to hurt the historically lower cost practices.

 

[deleted941485]

I'm suspecting that with the way CMS is going to adjustment the national base rate based on a practice's historical reimbursements, this may continue to hurt the historically lower cost practices.

No good deed goes unpunished.

 

[deleted941485]

Did anyone pay 199$ to hear the ASTRO update?

No. My personal payment policy dictates that my ASTRO update is bundled with my ASTRO dues.

 

[imhopeful432]

I'm suspecting that with the way CMS is going to adjustment the national base rate based on a practice's historical reimbursements, this may continue to hurt the historically lower cost practices.

There is an efficiency adjustment as well. So practices that have been more "efficient" in the past (so their total expected cost of care has been lower than what their case mix predicted per the model) will be able to "make up" some of the money they make from the historical practice adjustment. Overall, I think its a good balance between trying to reward practices that have been historically efficient without completely throwing under the bus practices that end up having historical reimbursements higher than what was predicted

 

[Irradi8or]

Well, that's the way it should work, but I don't think necessarily will. However, start playing around with the numbers for yourself. A 0.9 efficiency factor is still a discount for efficient practices, since their historical experience adjustment will be a negative number. Inefficient practices have a positive historical experience adjustment so even a decreased efficiency factor 0.9, 0.85, 0.8, etc doesn't actually end up making that difference all that much smaller between the two types of practices. Please run the numbers for yourself to confirm...

 

[Irradi8or]

There is an efficiency adjustment as well. So practices that have been more "efficient" in the past (so their total expected cost of care has been lower than what their case mix predicted per the model) will be able to "make up" some of the money they make from the historical practice adjustment. Overall, I think its a good balance between trying to reward practices that have been historically efficient without completely throwing under the bus practices that end up having historical reimbursements higher than what was predicted

Well, that's the way it should work, but I don't think necessarily will. However, start playing around with the numbers for yourself. A 0.9 efficiency factor is still a discount for efficient practices, since their historical experience adjustment will be a negative number. Inefficient practices have a positive historical experience adjustment so even a decreased efficiency factor 0.9, 0.85, 0.8, etc doesn't actually end up making that difference all that much smaller between the two types of practices. Please run the numbers for yourself to confirm...

 

[scarbrtj]

I'm watching the Dem debates. Here's my APM for radiation oncology:
$10,000* per patient with cancer. $3,000 per patient for benign disease.
Doesn't matter the diagnosis. Doesn't matter if it's SRS or SBRT or protons or IMRT or 3DCRT or TBI.
One side effect of this: there will be no more new proton centers. There will be no massive uptake of new MRI-linac tech. Certainly no carbon ion centers.
$10,000 per patient. At any treatment center in America, academic or private.
(*And if there's Medicare-for-all, there needs to be, within reason, linac-for-all for every new rad onc grad: you go practice somewhere that's needed, and the govt gives you a linac and a pat on the back. Maybe a tax break too...)

 

[Irradi8or]

I'm watching the Dem debates. Here's my APM for radiation oncology:
$10,000* per patient with cancer. $3,000 per patient for benign disease.
Doesn't matter the diagnosis. Doesn't matter if it's SRS or SBRT or protons or IMRT or 3DCRT or TBI.
One side effect of this: there will be no more new proton centers. There will be no massive uptake of new MRI-linac tech. Certainly no carbon ion centers.
$10,000 per patient. At any treatment center in America, academic or private.
(*And if there's Medicare-for-all, there needs to be, within reason, linac-for-all for every new rad onc grad: you go practice somewhere that's needed, and the govt gives you a linac and a pat on the back. Maybe a tax break too...)

Well, just about any model you can think of is more clear than the RO APM Model that’s been proposed. The kaiser model for paying non kaiser centers is quite straight forward (not the best pay rates but highly predictable).

 

[scarbrtj]

Well, just about any model you can think of is more clear than the RO APM Model that’s been proposed. The kaiser model for paying non kaiser centers is quite straight forward (not the best pay rates but highly predictable).

When I have had to treat inpatients at a freestanding center (because the hospital didn't have rad onc), you have to negotiate pay rates with the hospital because at the freestanding center you can't bill inpatients for RT. And in those situations, we have set a set price for the RT. E.g., $5000 per patient no matter what (usually palliative and these are good prices). It's worked out very well. The hospital does the billing for our RT, and can get less, or more, in certain situations than that $5000.

 

[medgator]

When I have had to treat inpatients at a freestanding center (because the hospital didn't have rad onc), you have to negotiate pay rates with the hospital because at the freestanding center you can't bill inpatients for RT. .

I learned from my billing company that apparently that's only the case for straight Medicare patients, not Medicare advantage, some Medicaid and commercial insurance

 

[deleted941485]

They’ve been working on this for at least the last 5 years. ASTRO has been begging for it and this is the best CMS could do? But Of course they’ll fight for protons lol.