I have no clue what started the need for the letter. And I also don't know who actually has the ear of CMS. Seemingly the people that are most involved (again, maybe this is just conjecture based on social media) are ASTRO, Ron, Jordan/Bridge, and ACRO.
I would argue no other "outsider" (separate from ASTRO or some big letter organization) knows the history (not immediately related to the letter, just the history of supervision) on this issue better than Jason Bekta though.
*best Lurch impression*
"You rang?"
I genuinely don't believe there's a singular narrative/"red thread" that brought us to this point.
However, what's happening now is exactly what I expected would have happened in 2020 if the pandemic hadn't taken place.
What's lost in this conversation is the relatively "newness" of the Supervision rules themselves. So, taking a very high-level view of the timeline over the last 30 years, here's my best guess:
1) The majority of the people in traditional/establishment "leadership" positions today are in the 55 to 75-year-old age range. These people did their RadOnc residencies in the late 80's and the 1990's. At that time, there were severe concerns about oversupply as well, and RadOnc was very uncompetitive. Unlike today, programs responded by significantly reducing spots.
2) CMS introduced supervision rules for freestanding centers in the late 90s/early 2000s. There were more practices billing freestanding radiotherapy than today, but it doesn't appear to have caused a huge uproar like it does now. However, this could just be an artifact of the immature internet and lack of digital "stuff"/archives.
3) Early 2000s, IMRT, gravy train. RadOnc jumped into hyperspace by accident, not through planned/coordinated leadership.
4) In 2007-2009, the political landscape focused on Healthcare. The ACA ("Obamacare") was passed. This was the time of the "UroRads Troubles" and the attempt at using Stark Law to fend them off.
5) CMS issued a "clarification" in 2009 that the Supervision rules applied to hospital outpatient departments too. Everyone lost their minds. Very upset. CMS stuck to their guns and, by 2010/2011, Direct Supervision for hospital outpatient departments was clearly the law of the land.
6) The political focus on Healthcare created, in part, the "Radiation Boom" series in the New York Times. We had the high-profile MIMA (Todd) whistleblower case. Then, in 2012, we had the SGR publication making claims about how "expensive" radiotherapy was. The SGR metrics were discontinued shortly thereafter because the government realized it was dumb. Sadly, the damage was done.
7) From 2012-2015 there was intense interest in cutting/bundling radiotherapy reimbursement concurrently with the pop culture concerns about safety. ASTRO and other entities adopted a defense strategy which, in retrospect, was highly ineffective.
8) In the culture of RadOnc, all of these became dogmatically tied together. Supervision/safety/whistleblower, and then those pieces got wrapped into the reimbursement defense. Specifically today, we see the "understanding" that the OTV code was "preserved" as part of the supervision/safety/whistleblower dogma.
9) The bundling happened in 2015. Then there was a brief period of quiet. Then CMMI came out with the RO-APM proposal. Supervision and other issues took a backseat. RO-APM became the all-consuming battle.
10) Starting in 2012/2013 with the "Pendulum" aka "Bloodbath" article, the concerns about oversupply started to return. These concerns were ignored and derided.
11) ...to the detriment of everyone. We all know what happened starting in 2018.
12) The direct-to-general switch was announced in November 2019, ASTRO reacted in December 2019, it took place in January 2020.
13) Pandemic happened while RadOnc became the least desirable specialty in medicine.
14) Also, we've been in a ~14 year campaign for hypofrac/omission. Don't get me wrong, I think in many cases this is good for patients. However, it's extremely unbalanced, in that the optics of doing this appears, to the outside world, that even the radiation doctors want to get rid of radiation.
So throughout this time we've had the 22-year tenure of the now-retiring ASTRO CEO. We've had the same rotating cast of people in "leadership" positions. Where they work and their obvious biases have been discussed at length on SDN.
As I am fond of pointing out on social media and podcasts, ASTRO went on a whirlwind tour over the last ~18 months of making "unforced errors". They were on the cusp of rehabilitating their reputation during the year Eichler was ASTRO president and the Workforce Taskforce was announced.
Sadly, it turned into an unmitigated disaster.
Longwinded, I know, but it sets the stage for my hypothesis as to "why".
The current 22-year ASTRO/RadOnc era has been dominated by reaction, not action.
It was coincidence the era started with the rise in IMRT. UroRads? Reaction. Supervision and whistleblower? Reaction. New York Times? Reaction. SGR and cries of "costly radiation"? Reaction. Bundling of codes? Reaction. RO-APM? Reaction. Concerns of job market? Boards? Crash of competitiveness?
All reaction.
With the permanent tabling of RO-APM, and the country's focus on the pandemic, we've been in a period of minimal external threats to the specialty. However, the specialty is at a very low point.
The Workforce bungling, ROCR surprise, Direct Supervision necromancy...this is ASTRO taking action, unprompted. They know we're at a low point. They know something needs to be done.
They lack the skills or experience to get it done.
Because we're clearly coming to a point where CMS needs to decide whether or not Virtual Direct becomes permanent, ASTRO decided they need to throw their hat in the ring.
Because RadOnc is a bunch of W2 employees with very dogmatic views of the world, Bridge, a curious startup with a guy who struggles to maintain strong optics on social media, became a real point of fear for people.
I'm personally agnostic about Bridge. I think it has the same chances of success as any small business/startup in a highly regulated space. Startups in medicine...struggle.
Until the current echo chamber of establishment leadership steps aside or retires, I absolutely expect further "unforced errors", until/unless another external threat occurs for them to react to.
