Changes you would like to make to your practice if you are 'chosen' for APM

[GI_RadOnc]

I'm interested in seeing if anyone's practices are discussing, as a group, changes to their treatment guidelines if/when APM comes. As a below-the-diaphragm GI-radonc; I'm at 5 fractions for most things besides anal cancer and post-operative treatments; but I am really interested in the following:

Managerial - any private groups/employed groups/academic groups having meetings, lectures, etc on this?

Organ sites:
Prostate - 5 fraction? 7 fraction (Danish)? Any hypofrac for post-operative patients?
Breast - 30 Gy / 5 fractions? Any hypofrac with comprehensive patients
Locally advanced lung?
Esophagus?
Head and Neck?
More?
Setting up single fraction bone met clinic?

{Not taking any sides on the good/bad of APM... to me I have the same control over it as I do COVID-19!}

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[scarbrtj]

One thing I'd like to know. Can MDs just practice medicine now w/ APM? Will we have to document "everything." What is everything under APM? There will no longer in theory be a note for every code. Will I see a patient every 7 days, rain or shine, side effects or no, under APM? I would think not. Will I write detailed notes describing why I'm planning, e.g., IMRT for a treatment? (This always struck me as goofy as a surgeon writing a huge note saying why he/she was planning a particular surgical approach for a particular case where it's already decided a patient is getting surgery... "Why I'm choosing a pylorus-sparing Whipple... five paragraphs on why I think it's cool to preserve pyloruses...") What would be the point? Would I allow myself 48 hrs instead of 24 hrs in between checking films?

(BTW... we should already have a single fx bone met clinic. And in this clinic, paperwork/dictation hassles should be mild, and you can sim/plan/treat all in same day and not worry about codes "bumping" or any silliness.)

 

[BobbyHeenan]

Agree with what's posted above -
?Do I still need to dictate a treatment planning note or concurrent chemo note?

For prostate I may consider more SBRT. I do some now but don't push it too hard.

I'm not going to change esophagus or head/neck, not aware of any hypofrac data

For breast I already do hypofrac whole breast and 30/5 APBI, so not going to change anything there.

 

[evilbooyaa]

It will eliminate my need to do OTV notes in otherwise asymptomatic patients.

It will eliminate all notes during RT besides consult and treatment summary. (Side note, what is a concurrent chemo note?)

It will push me to offer 1 or 5 fraction more often than I currently do instead of 10.

May allow me to offer hypofrac PMRT/RNI in more patients.

Offer 5 x 5 to everything that has data, like rectal/sarcoma/etc.

 

[Gfunk6]

To be clear, even if the APM is implemented soon and even if you are selected:

1. You still can't do things outside of published Medicare guidelines (e.g. SBRT to the breast lumpectomy cavity).
2. You still have to bill all charges accurately (even though it would no longer be fee for servce)
3. Your documentation requirement is not changed.

Since APM will be a "randomized, non-blinded" clinical trial, CMS needs to know what caused the losing arm to "die" faster. That means having accurate billing/clinical data for anlysis.

 

[taserlaser]

It will eliminate my need to do OTV notes in otherwise asymptomatic patients.

It will eliminate all notes during RT besides consult and treatment summary. (Side note, what is a concurrent chemo note?)

It will push me to offer 1 or 5 fraction more often than I currently do instead of 10.

May allow me to offer hypofrac PMRT/RNI in more patients.

Offer 5 x 5 to everything that has data, like rectal/sarcoma/etc.

As an aside, 5x5 in sarcoma does have slightly higher relapse rates compared to standard fractionation. If you want a hypofrac option, can consider Eiber’s latest 30/5 but that’s still premature on outcome data, but 2yr toxicity was just published. YMMV

 

[evilbooyaa]

As an aside, 5x5 in sarcoma does have slightly higher relapse rates compared to standard fractionation. If you want a hypofrac option, can consider Eiber’s latest 30/5 but that’s still premature on outcome data, but 2yr toxicity was just published. YMMV

Fair - I'm not well versed in the 5 frac data for sarcoma, just the twitter comment I saw on it. Don't see a ton of Sarcoma and everything gets std fx now from the attendings at my current institution.

 

[Aphtalyfe]

To be clear, even if the APM is implemented soon and even if you are selected:

1. You still can't do things outside of published Medicare guidelines (e.g. SBRT to the breast lumpectomy cavity).
2. You still have to bill all charges accurately (even though it would no longer be fee for servce)
3. Your documentation requirement is not changed.

Since APM will be a "randomized, non-blinded" clinical trial, CMS needs to know what caused the losing arm to "die" faster. That means having accurate billing/clinical data for anlysis.

Just wanted to reiterate what Gfunk said... you still should be billing for what you're doing. CMS updates their reimbursements based on what is billed. Also private insurers likely won't be going to APM any time soon. Probably shouldn't be changing documentation/billing based on what insurance a patient has!

 

[Burt Radnolds]

As noted above, there is zero up front upside if you are selected for APM. There is increased burden placed on your department as you learn how to implement their convoluted system, you will likely make less money no matter what you do (and will be penalized MORE if you were already a hypofractionater as they use an individual historical data factor to decide each clinic's reimbursement), and you will still need to prior authorize treatment and cannot just go rogue doing whatever you feel. I was previously cautiously optimistic that there may be a silver lining somewhere, but after being thoroughly educated, I don't see it.

 

[scarbrtj]

(Side note, what is a concurrent chemo note?)

STP

 

[evilbooyaa]

To be clear, even if the APM is implemented soon and even if you are selected:

1. You still can't do things outside of published Medicare guidelines (e.g. SBRT to the breast lumpectomy cavity).
2. You still have to bill all charges accurately (even though it would no longer be fee for servce)
3. Your documentation requirement is not changed.

Since APM will be a "randomized, non-blinded" clinical trial, CMS needs to know what caused the losing arm to "die" faster. That means having accurate billing/clinical data for anlysis.

Are they really branding this as the bolded?

I thought it was a partial roll out to make sure there weren't huge catastrophical issues with the program and to make tweaks before it was rolled out (mostly) nationwide.

Seems like a loss on both ends if you 1) need to sacrifice a portion of your earnings to the APM gods and 2) still do all the same crap billing/excessive notes/get prior auth for justification as you did in FFS.

If they're going to make it APM then make it free rein to do whatever... not 'you get paid like APM but have to justify and document like FFS'

 

[Chartreuse Wombat]

The decision to select 40% of practices is back calculated from the hoped for savings as a percentage of the "total pie".

Scarb can provide the math I am sure

 

[Gfunk6]

Are they really branding this as the bolded?

I thought it was a partial roll out to make sure there weren't huge catastrophical issues with the program and to make tweaks before it was rolled out (mostly) nationwide.

Seems like a loss on both ends if you 1) need to sacrifice a portion of your earnings to the APM gods and 2) still do all the same crap billing/excessive notes/get prior auth for justification as you did in FFS.

If they're going to make it APM then make it free rein to do whatever... not 'you get paid like APM but have to justify and document like FFS'

Of course not, don't be silly! It's just my cynical way of looking at it.

 

[KHE88]

Is there a way I can get out of mindlessly waiting for a million Calypso and VisionRT and other documents to load and sign off on for 15 minutes at the end of each day??!

 

[deleted941485]

Move the practice lol

 

[RickyScott]

One thing I'd like to know. Can MDs just practice medicine now w/ APM? Will we have to document "everything." What is everything under APM? There will no longer in theory be a note for every code. Will I see a patient every 7 days, rain or shine, side effects or no, under APM? I would think not. Will I write detailed notes describing why I'm planning, e.g., IMRT for a treatment? (This always struck me as goofy as a surgeon writing a huge note saying why he/she was planning a particular surgical approach for a particular case where it's already decided a patient is getting surgery... "Why I'm choosing a pylorus-sparing Whipple... five paragraphs on why I think it's cool to preserve pyloruses...") What would be the point? Would I allow myself 48 hrs instead of 24 hrs in between checking films?

(BTW... we should already have a single fx bone met clinic. And in this clinic, paperwork/dictation hassles should be mild, and you can sim/plan/treat all in same day and not worry about codes "bumping" or any silliness.)

This was exactly my sentiment. I have no doubt that billing consultants etc will come up reasons for documentation.

 

[medgator]

Move the practice lol

I've heard that it is location/zip specific, so those of us in multi site practices might be able to shift CMS patients to other centers/linacs when feasible

 

[deleted941485]

I've heard that it is location/zip specific, so those of us in multi site practices might be able to shift CMS patients to other centers/linacs when feasible

Maybe hospital systems will consider the same. perhaps a prudent response to an otherwise involuntary enrollment.

Shunt the Medicare patients at least.