CMS changes supervision rule. Rad Oncs no longer needed for daily operation of clinics. Med Students. Please read. You deserve to know implications.

[Mandelin Rain]

This is kind of buried in multiple threads, but this is a big deal.

CMS just proposed a rule change for supervision level of hospital outpatient therapeutic services from direct to general. This doesn't sound like a big deal, but it is actually a HUGE deal.

What this means functionally, is that a radiation oncologist will not need to be present to treat patients in hospital settings (i.e. the majority of jobs currently). This means a single Rad Onc can provide supervision for 2-3 hospitals simultaneously. It has been, that the vast majority of clinics have required a radiation oncologist to be present at all times during treatment. This has artificially buoyed the number of rad oncs "needed" significantly.They will no longer be needed.

Bottom lining this: The demand for rad oncs just died. Flat lined. Done.

Couple this with oversupply (doubling resident spots in a decade), wide spread hypo fractionation adoption (less demand for services), and APM (6-8% less reimbursement, optimistically) there will not be jobs for all of you. Some of you WILL be unemployed and unemployable. Locums won't be an option as linac babysitters are no longer needed. This is like the worst case scenario, perfect storm for job market collapse.

Run, don't walk away. There is still time to figure your future out.

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[medgator]

I feel so bad for the PGY4s and 5s in this specialty right now.

If we were graduating a reasonable number of residents, this wouldn't be nearly as damaging and devastating to a big group of dedicated people.

Again, this entire CF lays at the feet of the Rad Onc academia that saw fit to open programs and expand spots everywhere based on self-interest and zero data

 

[Sheldor]

Link to proposal?

 

[Burt Radnolds]

Attached the full text PDF on the final rule, interesting but lengthy read that starts on page 676. Conclusion below


After reviewing all of the public comments, we are finalizing our proposal for CY 2020 and subsequent years to change the generally applicable minimum required level of supervision for hospital outpatient therapeutic services from direct supervision to general supervision for services furnished by all hospitals and CAHs without modification. We also note all of the policy safeguards that have been in place to ensure the safety, health, and quality standards of the outpatient therapeutic services that beneficiaries receive will continue to be in place under our new policy. These safeguards include allowing providers and physicians the discretion to require a higher level of supervision to ensure a therapeutic outpatient procedure is performed without risking a beneficiary’s safety or their quality of the care, as well as the presence outpatient hospital and CAH CoPs, and other state and federal laws and regulations. We are also finalizing the accompanying changes we proposed to the regulatory text at §410.27 with several technical changes.

 

[medgator]

Link to proposal?

Direct supervision

I am trying to find an answer to rules concerning direct supervision. There is an Astro 2018 white paper stating that there is an exemption to direct supervision for CAH ( critical access hospital‘s) and rural hospitals less than 100 beds. There is a clear definition for a critical access...

forums.studentdoctor.net

Start reading the posts from today, but basically CMS is proposing changing hospital rad onc back to general from direct supervision, i.e. no rad onc needs to be physically present during IGRT.

This would be effective starting next year

 

[FrostyHammer]

For all the ASTRO bashers, be aware that they are pushing back against this PROPOSAL (on grounds of safety concerns). Also, be aware that most of these clinics will still need docs physically present to see the patients, which can't be done under another facility's supervision like IGRT can.

 

[Burt Radnolds]

For all the ASTRO bashers, be aware that they are pushing back against this PROPOSAL (on grounds of safety concerns).

This is not a proposal. This is final.

 

[FrostyHammer]

This is not a proposal. This is final.

Why's it called a proposal then? And why does ASTRO think it can push back then? Unless you don't want ASTRO to even try...

 

[Mandelin Rain]

Yeah, I guess they have already considered comments and this is the final rule.

 

[deleted941485]

This is not a proposal. This is final.

Hence the final in final rule

Well I know what my final plans will be.

Let the Hypofrac commence fourth!

It’s been a time and a half.

 

[Mandelin Rain]

ASTRO already commented. CMS passed on their comments. This is happening.

https://www.astro.org/ASTRO/media/ASTRO/Daily%20Practice/PDFs/2020HOPPSProposedRuleCommentLetter.pdf

 

[FrostyHammer]

ASTRO already commented. CMS passed on their comments. This is happening.

https://www.astro.org/ASTRO/media/ASTRO/Daily%20Practice/PDFs/2020HOPPSProposedRuleCommentLetter.pdf

Unfortunate. I think it's easy to get into doom and gloom early on like now, but again, most of these clinics will still need docs physically present to see the patients, which can't be done under another facility's supervision like IGRT can. Maybe $ gets cut, but "actual breadlines" is still far-fetched, though my words will fall on deaf ears on this forum.

 

[deleted941485]

Unfortunate. I think it's easy to get into doom and gloom early on like now, but again, most of these clinics will still need docs physically present to see the patients, which can't be done under another facility's supervision like IGRT can. Maybe $ gets cut, but "actual breadlines" is still far-fetched, though my words will fall on deaf ears on this forum.

If the goal is to chip away at Rad Onc then CMS has excelled spectacularly.

You don’t have to get to breaslines to be completely F’ed.

 

[medgator]

For all the ASTRO bashers, be aware that they are pushing back against this PROPOSAL (on grounds of safety concerns).

Considering ASTRO likely didn't even propose it to begin with, I doubt CMS just came up with this on a whim. ASTRO has done plenty in the past to warrant bashing though.

Unfortunate. I think it's easy to get into doom and gloom early on like now, but again, most of these clinics will still need docs physically present to see the patients, which can't be done under another facility's supervision like IGRT can.

Hospital based RO will be able to bill without a rad onc being there. You will only need to see the pt once a week for an OTV and at the initial consult. There's absolutely zero reason to believe this won't impact the need for rad onc labor.

 

[Mandelin Rain]

Not to offend anyone, but a resident has no idea how much excess capacity there is out in the real world, nor the desire to reduce that excess capacity to increase income.

 

[deleted573262]

Hospital based RO will be able to bill without a rad onc being there

so patient comes to main site for consult, once a week for otv, and for f/u while receiving tx at satellite? it sounds like an academic chairman's wet dream. i'm serious. the hardest part of expansion is getting faculty to live in bum**** making an academic salary. here is the solution. astro may have 'complained' and 'disagreed' but let's be realistic, it was a whimper and a whisper of a sweet nothing into the ear of big brother.

 

[Mandelin Rain]

so patient comes to main site for consult, once a week for otv, and for f/u while receiving tx at satellite? it sounds like an academic chairman's wet dream.

Yup, all those academic satellites that academicians hate staffing become less of a problem. They are now 2 day a week supervision outposts. 1 day to see consults and sim. 1 to see OTVs. No full time doc needed. SBRT/SRS still go to main campus. Someone from main site goes out there each week to cover. NP or med one handles any daily issues.

 

[deleted573262]

Oh absolutely. OTVs will probably go away with the APM as well.

Hospital admins are salivating right now. THIS is the future of radiation oncology and it is bleak.

APM + hypofrac will be the death of OTVs. Follow-ups will be considered redundant by APM and will go to surgeon or med onc. Soon rad onc won't need physicians!

 

[Mandelin Rain]

Oh absolutely. OTVs will probably go away with the APM as well.

Hospital admins are salivating right now. THIS is the future of radiation oncology and it is bleak.

Yes, I said I was more bullish short term and more bearish long term than most here. I'm revising to just bearish.

 

[medgator]

Yes, I said I was more bullish short term and more bearish long term than most here. I'm revising to just bearish.

Honestly if I were a pgy5, I'd just sign the first decent contract I came across if the geography is even remotely tolerable. Just wait until this stuff starts trickling out to pro groups and hospital admins....

 

[Mandelin Rain]

Honestly if I were a pgy5, I'd just sign the first decent contract I came across if the geography is even remotely tolerable. Just wait until this stuff starts trickling out to pro groups and hospital admins....

Yup. You just have to hope that it's honored at this point. Get in where you fit in today/tomorrow. Don't wait.

 

[Reaganite]

Hah, so wait, no rad onc required for hospital outpatient, but are we now still going to insist that the outpatient freestanding center must be overseen by a radonc? Seems this ruling would put to rest the idea that a rad onc has to supervise outpatient freestanding xrt.

 

[medgator]

Hah, so wait, no rad onc required for hospital outpatient, but are we now still going to insist that the outpatient freestanding center must be overseen by a radonc? Seems this ruling would put to rest the idea that a rad onc has to supervise outpatient freestanding xrt.

Hospitals have the best lobbyists.... I suspect it will go away in freestanding one day too once the site neutrality provisions of APM (hopefully) kick in

 

[Reaganite]

I agree. Once apm in place and everything is essentially case rate supervision goes away anyway. But I would argue this shift also informs how we interpret freestanding supervision as well. Cms guidelines never stated a rad onc had to present for freestanding (we debated this ad nauseam here) and now cms has confirmed that any docs presence is unnecessary in a hospital outpt department. I'd think freestanding providers would feel a lot more comfortable having med oncs, radiologists, etc provide supervision now.

 

[medgator]

I agree. Once apm in place and everything is essentially case rate supervision goes away anyway. But I would argue this shift also informs how we interpret freestanding supervision as well. Cms guidelines never stated a rad onc had to present for freestanding (we debated this ad nauseam here) and now cms has confirmed that any docs presence is unnecessary in a hospital outpt department. I'd think freestanding providers would feel a lot more comfortable having med oncs, radiologists, etc provide supervision now.

Personally, I'm not chancing it until I see language to that effect.

They have to be able to "furnish assistance" with IGRT and there is just too much legal precedence for my comfort level. A radiologist might make a more believable locums than a med onc though, probably, from that standpoint

 

[deleted18755]

For all the ASTRO bashers, be aware that they are pushing back against this PROPOSAL (on grounds of safety concerns). Also, be aware that most of these clinics will still need docs physically present to see the patients, which can't be done under another facility's supervision like IGRT can.

I thought this was just a proposal but anyway this is actually how it used to be “back in the day” even in non rural sites. Those old school radiation oncologists who made seven figures even pre-IMRT did it by having 1-2 doctors covering 3-4 sites. One day for consults and sims and one day for OTV’s and follow ups while a nurse or NP (we didn’t really have PA’s back then) just held it down (not sure how legal it was but in some practices the NP even did all OTV’s and follow ups so one MD could just float around 2-3 just doing consults and treatment planning).

We didn’t really have IGRT back then but treatment planning couldn’t be done remotely because it had to be done physically or on dedicated big goofy computers so one minus and one plus. There was also way more acute toxicity we had to deal with on a day to day in the 2D/3D era so that’s another plus.

I haven’t read the proposal or thought about it much but I’m very confident that with a very good PA and some creativity if I wanted to do so I could easily treat 45-50 patients across two sites within 45 minutes or so without hiring an MD or wasting money on a linac babysitter. I’m too old to think about things like this but what would stop a very intense private practice guy, hospital, or academic center from having the MD sit at a centralized location and have patients come to him all day everyday for consults from the surrounding areas then back to wherever for treatment five days/wk at a linac close to home staffed but a PA and MD 0-2 days/wk.

 

[deleted941485]

I thought this was just a proposal but anyway this is actually how it used to be “back in the day” even in non rural sites. Those old school radiation oncologists who made seven figures even pre-IMRT did it by having 1-2 doctors covering 3-4 sites. One day for consults and sims and one day for OTV’s and follow ups while a nurse or NP (we didn’t really have PA’s back then) just held it down (not sure how legal it was but in some practices the NP even did all OTV’s and follow ups so one MD could just float around 2-3 just doing consults and treatment planning.

We didn’t really have IGRT back then but treatment planning couldn’t be done remotely because it had to be done physically or on dedicated big goofy computers so one minus and one plus.

I haven’t read the proposal or thought about it much but I’m very confident that with a very good PA and some creativity if I wanted to do so I could easily treat 45-50 patients across two sites without hiring an MD or wasting money on a linac babysitter.

Yeah I dont see this helping new grads at all.

I mean back in the day is one thing because there really weren’t all that many ROs out there so it all seemed to work out at the end of the day. But now with everyone looking to open up a program in their back yard, it’s just going to make it harder for new grads to get anything.

 

[RadOncDoc21]

Don’t get me wrong, I’m not a half glass full kind of guy and I definitely think CMS and admins want to screw us but what if this is one way to control numbers? Don’t have to train as many docs due to not needing as much coverage? I understand, it sucks on the front end because we are still over supplying docs.

 

[deleted941485]

Don’t get me wrong, I’m not a half glass full kind of guy and I definitely think CMS and admins want to screw us but what if this is one way to control numbers? Don’t have to train as many docs due to not needing as much coverage? I understand, it sucks on the front end because we are still over supplying docs.

Nah residents are still cheaper than NPs and PAs so they’ll find some kind of excuse to open a few more programs.

 

[medgator]

Don’t get me wrong, I’m not a half glass full kind of guy and I definitely think CMS and admins want to screw us but what if this is one way to control numbers? Don’t have to train as many docs due to not needing as much coverage? I understand, it sucks on the front end because we are still over supplying docs.

Nah residents are still cheaper than NPs and PAs so they’ll find some kind of excuse to open a few more programs.

Yup, but on a societal level, it would save money on rad onc labor costs. It just won't jive with the agenda from some of those in academic rad onc

 

[deleted941485]

Yup, but on a societal level, it would save money on rad onc labor costs. It just won't jive with the agenda from some of those in academic rad onc

Then again I was never on board with the idea that we needed more doctors in the first place.

 

[OTN]

This is a big deal, but I wonder if it’s going to be tempered by the increased SBRT we’re doing. I usually have 5-6 cases every day, and from a medicolegal standpoint I would NEVER have a non radonc cover SBRT.

 

[medgator]

This is a big deal, but I wonder if it’s going to be tempered by the increased SBRT we’re doing. I usually have 5-6 cases every day, and from a medicolegal standpoint I would NEVER have a non radonc cover SBRT.

Theoretically you could check imaging remotely off site in real time if need be. I still think a rad onc should be around, personally, just being a devil's advocate

 

[Mandelin Rain]

If you're treating 6 SBRTs per day, chances are you're busy enough to be there every day. And you definitely SHOULD be.

This is about the hospital system with three 12-14 patient outlying hospitals and maybe one 25 person main hub. That can now be staffed with 2-3 docs rather than 4-5. All special procedures will still go to the main hub.

This is a pretty common scenario across the country. Also, of course, the case with nearly all academic departments at this point.

All those high-ish paying rural jobs that just can't find/keep someone? Guess what? Now they don't need to. Find a group within two hours willing to send someone 2 days per week. Problem solved.

 

[OTN]

Just heard about all this, being off yesterday. I emailed my regional admin to discuss. For us, it means we can put a machine in that vault in the outlying center and not have to staff it. Great for me/us, terrible for a new grad, as there goes another possible job.

 

[medgator]

All those high-ish paying rural jobs that just can't find/keep someone? Guess what? Now they don't need to. Find a group within two hours willing to send someone 2 days per week. Problem solved.

This may have been CMS's plan to "solve" rural rad onc shortages? Obviously it has caught all of us, including ASTRO, off guard.

This potentially could pour gasoline on the dumpster fire of a match that 2020 will likely be

 

[Mandelin Rain]

I agree that it's not terrible for some of us already in practice. But it will indeed be really bad for some of us. Some people will be laid off or not rehired when their contract expires. Professional services groups may be cut loose if a system thinks they can successfully employ 2-3 docs and profit of pro fees. Locums guys already begging for work? Give up. You're done.

Clear losers are current residents. Feel terrible for them. Med students have the chance to avoid the cliff, but current residents are in real trouble.

 

[radoncradonc]

Moderator,
Can we make this thread a sticky? Med students deserve to know the seismic shift that is coming.

 

[TheIllusionist]

i am blessed. programs made the choice for me. I am IM all the way.

 

[Mandelin Rain]

ASTRO has adopted a very defensive stance against this rule. There is a reason for that. They understand it will hurt the majority of their membership.

Im established in practice but I’m definitely looking at this rule with a concerned eye rather than celebrating it as an opportunity.

 

[BobbyHeenan]

I forgot... My local NCI designated CC does not accept Medicaid! Much easier to take care of the well-insured high ECOG prostate and breast patients I guess

ASTRO has adopted a very defensive stance against this rule. There is a reason for that. They understand it will hurt the majority of their membership.

Im established in practice but I’m definitely looking at this rule with a concerned eye rather than celebrating it as an opportunity.

Agree completely. It may “help” me and my practice but I think it’s bad for the field and patient care. Pro fees are a blip on the cost radar too , so it’s really not saving much money.

 

[medgator]

ASTRO has adopted a very defensive stance against this rule. There is a reason for that. They understand it will hurt the majority of their membership.

Im established in practice but I’m definitely looking at this rule with a concerned eye rather than celebrating it as an opportunity.

Agree. On top of that, this rule couldn't have come at a worse time, honestly, esp with the way academics has been asleep at the wheel with residency expansion

This will hurt many, many individuals who've put in a big chunk of their lives towards RO.

Honestly if 0/195 match in April, it'll be a good thing for the specialty. Plenty of slack that could be picked up by existing practitioners and it would give academic RO the wakeup call they've been needing all these years

 

[deleted18755]

If you're treating 6 SBRTs per day, chances are you're busy enough to be there every day. And you definitely SHOULD be.

This is about the hospital system with three 12-14 patient outlying hospitals and maybe one 25 person main hub. That can now be staffed with 2-3 docs rather than 4-5. All special procedures will still go to the main hub.

This is a pretty common scenario across the country. Also, of course, the case with nearly all academic departments at this point.

All those high-ish paying rural jobs that just can't find/keep someone? Guess what? Now they don't need to. Find a group within two hours willing to send someone 2 days per week. Problem solved.

Exactly the (honestly quite impressive) guys who have the patient volume/referrals to sustain 5-6+ SRS/SBRT per day will be fine but that’s a very small percentage of current practices.

On the opposite extreme the retired/semi-retired guys who babysit linacs from time to time will instantly be unemployed, but who cares when they were just doing it to get out of the house and make some “golfing money.”

Where are all the new graduates supposed to work now that every MD can just pop into a practice and knock out 3-4 consults in a morning, a bunch of sims and a few follow ups in the afternoon, and OTV’s the next day (with another consult or two or follow ups or whatever since there are usually only 12-15 or maybe 20 patients max under treatment at many sites) then just pack up and switch with their NP/PA and go to the next center for 2 days then maybe even swing by another for a day or just work from home the fifth day?

 

[Lawpy]

This is a bit depressing

 

[Mandelin Rain]

This is a bit depressing

Agreed. It’s real though.

 

[medgator]

This is a bit depressing

Better to get the info out now before CMS and academia hurt more individuals.

 

[deleted573262]

Better to get the info out now before CMS and academia hurt more individuals.

the whippings will continue until morale improves

 

[Lawpy]

Agreed. It’s real though.

And tragic. Here's another recent thread:

Perspective of PGY2 at "top 10" program

PGY2 at a "top 10" program here, and if I had to do it all over again, I wouldn't apply to rad onc or even consider it. It's ridiculous how little our leadership cares about the state of the field. This change in CMS supervision will not affect expansion. In fact, I still expect programs to open...

forums.studentdoctor.net

Kinda stings because radonc is a great field, and i really like the physics involved in it. But the job market has been pretty poor, and now it has gotten worse with the final rule.

It hurts. I really really feel bad for the residents since it's painful to spend the time training and working hard only to end up unemployed and struggling in a crappy job market. To see the brightest and most talented minds in a bad state hurts.

And for that, it stings but i'd need to look elsewhere (probably medonc). I just really hope the job market improves soon because it stings to see residents struggling.

 

[Neuronix]

Moderator,
Can we make this thread a sticky? Med students deserve to know the seismic shift that is coming.

Are you serious? Every thread is about the same thing. I'm currently petitioning SDN to rename this whole forum to "The rad onc job market is bad"

 

[scarbrtj]

I have been saying this for years. It will make America equivalent though to most other countries (ie no rad onc needed for direct supervision in a hospital).

Turns out the answer to "Why do we need an MD here if he literally does nothing all day?" is simple. This will, if nothing else, kill the locums market. The locums guy—who walks in the hospital door in the AM and they put him in a back office while he sits there 8am-4pm, reading, doing his one or two day gig—is no longer needed, has zero marketability, etc. So at the very least this WILL directly impact many rad oncs nationwide immediately. If you're a new resident and have a job finding difficulty, locums won't be a temporary save.

It should be noted and of historical interest at this point that, since forever, if you dive into the gargantuan Medicare fee schedule, there is a supervision code written next to every CPT code (1=general, 2=direct, 3=personal, 9=concept does not apply). For every single rad onc code except 77014 (which is "2"), including all the SRS and SBRT codes, they are affixed with number "9." I always felt this was informational if not portentous.

I'm currently petitioning SDN to rename this whole forum to "The rad onc job market is bad"

Not just bad; it's radionecrotic.