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

[medgator]

there should be a way to allow both. mandate doc on site 4 days a week, but they dont have to be there during every treatment? Im fully for flexibility. we just have to think of the downstream/future effects.

for those would say that we have these rules now and nothing bad has happened - I would say that these have only been the current rules for a few years, multiple of those years were peak of covid, and we already see Bridge Oncology come out ofter woodworks. If the current rules became permanent is without some sort of guardrails, I do worry about the medium and long term future implications.

That was the whole point of their first webinar. It was an open forum, certainly more than some contrived "town hall"that you have to be a member of to even speak at

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[MidwestRadOnc]

I do not believe a hospital outpatient setting can bill any CPT code with professional or TC modifiers without using those modifiers. That is to say, a global billing is only available to freestanding settings. Doesn’t matter if physician is employed or does his own professional billing.

But, I never said an MD didn’t have to be there at all during image acquisition. Well, I did sort of: CMS approves of an NP, PA, etc, supervising the IGRT instead of an MD. (Right now, virtual supervision provides this level of direct supervision; if it goes away, an MD or APP would need to be there for IGRT image acquisitions, but not for other radiation therapy activities… like treatments.)

So then it’s moot?

If virtual direct goes away, and we are left with general for hospitals, and an APP is required to bill, this basically chains the MD there 5 days a week if they can’t/wont hire an APP, no? Because you can’t bill the TC of the igrt and the hospital is not going to just forego those codes?

 

[TheWallnerus]

So then it’s moot?

If virtual direct goes away, and we are left with general for hospitals, and an APP is required to bill, this basically chains the MD there 5 days a week if they can’t/wont hire an APP, no? Because you can’t bill the TC of the igrt and the hospital is not going to just forego those codes?

Yes, maybe, but… there’s even more to the calculus. For example, a hospital CANNOT bill the IGRT technical for IMRT. So they’re already “foregone” in a great many instances, supervision or no.

 

[Reaganite]

Yes, maybe, but… there’s even more to the calculus. For example, a hospital CANNOT bill the IGRT technical for IMRT. So they’re already “foregone” in a great many instances, supervision or no.

What does virtual direct have to do with general hospital supervision? Seems like this is entirely a freestanding issue as you mentioned before. Why would Midwest need an APP to supervise IGRT in the setting of general supervision?

 

[MidwestRadOnc]

So igrt is bundled in certain cases. Why can’t hospital bill TC in the other cases?

 

[TheWallnerus]

What does virtual direct have to do with general hospital supervision? Seems like this is entirely a freestanding issue as you mentioned before. Why would Midwest need an APP to supervise IGRT in the setting of general supervision?

Many believe he would not need an APP, or MD, physical presence. I believe this has actually been tested in court now (elementary school may have a link?). But if we accept that IGRT is a diagnostic test (big if), hospitals would “need” APP or MD supervision if IGRT technical is billed. (But it’s never billed for IMRT, SBRT, etc.)

“What does virtual direct have to do with general hospital supervision?”…. The only thing it has to do with it is what ASTRO said: it wants direct for every service in ALL sites of service, and it (misguidedly?) thinks virtual supervision rollback gets it that.

 

[TheWallnerus]

So igrt is bundled in certain cases. Why can’t hospital bill TC in the other cases?

They sure can. They sure do.

 

[MidwestRadOnc]

They sure can. They sure do.

So the hospital is billing TC for igrt on 3d cases when no provider of any kind is there even though you’ve demonstrated the regulations say they are needed. And this is ok? I mean i don’t see a compliance admin letting this fly. More likely they would just not bill for the TC in these cases if they can’t make you come in.

 

[TheWallnerus]

So the hospital is billing TC for igrt on 3d cases when no provider of any kind is there even though you’ve demonstrated the regulations say they are needed

I was leaving the hospital routinely (well, a day or two every other week) from about 2013 onward. CEO of hospital put in place collaborative agreement that if rad onc not there, med onc or radiology was supervising. Case law has been clear that a supervising MD doesn’t have to be aware they’re supervising. Many ways around “the regulations” for hospital providers that freestanding centers don’t have. Having NP or PA flexibility, in hospital, after 2021, made it even better. Some here smarter than I will say I’m wrong about IGRT being a diagnostic test, and it’s general supervision even for IGRT in a hospital. Keep in mind I’m just giving you MY opinions. YMMV.

 

[MidwestRadOnc]

I have worked in a place where med onc adamantly refused to be supervising.

 

[TheWallnerus]

I have worked in a place where med onc adamantly refused to be supervising.

Listen starting about 18:30, refuting the IGRT direct supervision idea:

 

[Reaganite]

Jason's podcast is awesome. That last case he dissects really gets to the heart of the insanity that astro and the D man have brought to rad onc supervision and billing. For those who don't listen, the last notable qui tam case involved many of the issues we've discussed here, and the gist of the ruling was that much of the supervision policy endorsed by Astro is basically made up (any doctor can supervise, for example), and you're not committing fraud if you bill under the wrong "doctor of the day" as long as the services were legitimately performed by someone in the group and would have been paid either way.

 

[TheWallnerus]

Jason's podcast is awesome. That last case he dissects really gets to the heart of the insanity that astro and the D man have brought to rad onc supervision and billing. For those who don't listen, the last notable qui tam case involved many of the issues we've discussed here, and the gist of the ruling was that much of the supervision policy endorsed by Astro is basically made up (any doctor can supervise, for example), and you're not committing fraud if you bill under the wrong "doctor of the day" as long as the services were legitimately performed by someone in the group and would have been paid either way.

So you’re right. And Jason is right. And it all has led me to a rather odd conclusion:

The rad onc job market is not propped up by supervision. It is propped by a mass delusion. If CEOs, compliance admins, and rad oncs en masse believed what the rules actually literally say, and how judges have ruled, we would need half the rad oncs we have in America. (The retort to this is other rad onc qui tam SETTLEMENT cases, which is not a good retort.) But I guess… fortunately?… for rad oncs and rad oncs in training, I don’t think anyone in rad onc is ever going to much follow the rules or the court rulings. They prefer their own interpretations, those of ASTRO, and those of Ron D.

 

[RickyScott]

So you’re right. And Jason is right. And it all has led me to a rather odd conclusion:

The rad onc job market is not propped up by supervision. It is propped by a mass delusion. If CEOs, compliance admins, and rad oncs en masse believed what the rules actually literally say, and how judges have ruled, we would need half the rad oncs we have in America. (The retort to this is other rad onc qui tam SETTLEMENT cases, which is not a good retort.) But I guess… fortunately?… for rad oncs and rad oncs in training, I don’t think anyone in rad onc is ever going to much follow the rules or the court rulings. They prefer their own interpretations, those of ASTRO, and those of Ron D.

Radiation is a black box to most administrators and they will move cautiously, but def see one doc supervising multiple centers in our future.

 

[Mandelin Rain]

Radiation is a black box to most administrators and they will move cautiously, but def see one doc supervising multiple centers in our future.

I agree. It's a cash cow and a black box for the hospital. Hard to want to upset the apple cart as long as the money is flowing.

However, it'll only take one or two CEOs of large health systems to make a change before it rapidly spreads nationwide.

That's why relying on this artificial supervision demand for our service is so incredibly short sighted.

 

[NotJasonBeckta]

So you’re right. And Jason is right. And it all has led me to a rather odd conclusion:

The rad onc job market is not propped up by supervision. It is propped by a mass delusion. If CEOs, compliance admins, and rad oncs en masse believed what the rules actually literally say, and how judges have ruled, we would need half the rad oncs we have in America. (The retort to this is other rad onc qui tam SETTLEMENT cases, which is not a good retort.) But I guess… fortunately?… for rad oncs and rad oncs in training, I don’t think anyone in rad onc is ever going to much follow the rules or the court rulings. They prefer their own interpretations, those of ASTRO, and those of Ron D.

For those unwilling/unable to dedicate the...700 hours my podcast episodes require (one day...shorter)...

Here's the most recent Court Opinion from the Relators third appeal (that's right, this thing has been going since 2016, and all I can think is "new definition of disgruntled"):

https://figshare.com/ndownloader/files/45129988

 

[Mandelin Rain]

Following a few crumbs, a not so bold prediction:

CMS laughs, ASTRO redirects as it did with APM. Direct supervision ends up in ROCR as a requirement for payment.

THIS is your comment period before that happens.

 

[communitydoc13]

It is propped by a mass delusion. If CEOs, compliance admins, and rad oncs en masse believed what the rules actually literally say, and how judges have ruled

What rules literally say and how judges have ruled don't always seem to be connected in a fully rational way. This is the substrate of all of law.

I am not familiar enough with case history to say that we have certain legal precedents that protect us regarding supervision...please send case names if there are some.

But in malpractice (and most of everything) there is this vague "standard of reasonableness". This is a double edged sword. It allows for the defense of a diversity of practices in any given clinical scenario. It also means that outlier behavior is particularly vulnerable to prosecution.

Mass delusion may actually be enforceable?

 

[Gfunk6]

Following a few crumbs, a not so bold prediction:

CMS laughs, ASTRO redirects as it did with APM. Direct supervision ends up in ROCR as a requirement for payment.

THIS is your comment period before that happens.

Exceptions are made for protons of course

 

[Mandelin Rain]

Exceptions are made for protons of course

Naturally.

 

[Gfunk6]

 

[RadOncDoc21]

View attachment 384302
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This dude needs to be president or have some type of formal leadership position in our field! Technology is here to stay and instead of trying to go back to old outdated habits, we should embrace what technology can allow for us to do. Maybe this how we become competitive again and of course decrease the number residency positions!

 

[elementaryschooleconomics]

Wow, how reasonable and rationale and logical.

Simul for President!

*checks ASTRO society rules*

Oh...wait...darn. Simul is automatically excluded because there's a strict prohibition on "reason" and "logic".

Back to the dumpster fire we go!

 

[RickyScott]

I can assure you Astro doesn’t care abt the devaluation of igrt and otv prof codes.

 

[Reaganite]

I can assure you Astro doesn’t care abt the devaluation of igrt and otv prof codes.

As wallnerus mentioned, their academic center bed buddies don't bill igrt at main campus anyway and otv codes are nothing in the context of the high multiples of medicare they get paid for treatment codes. This is about artificially propping up the job market and trying to squash freestanding.

 

[MidwestRadOnc]

This is about artificially propping up the job market and trying to squash freestanding.

Perhaps we will see a lot more "Why isn't anyone applying to my PP?" posts in the future.
Never thought we would see a world where linac ownership wasn't the ultimate goal, but here we are. Thanks ASTRO!

 

[elementaryschooleconomics]

Perhaps we will see a lot more "Why isn't anyone applying to my PP?" posts in the future.
Never thought we would see a world where linac ownership wasn't the ultimate goal, but here we are. Thanks ASTRO!

Wow, that's a good point, I hadn't thought about it through that lens yet.

Reflecting on my own personal beliefs and forecasting of the field: while "owning a linac" is sort of a long-term arc I have for myself (little more elaborate than that, but it's a reasonable analogy), I would argue I am...unusually interested and tuned in to the meta/economic side of medicine/RadOnc.

But...put a PGY5 in front of me, put a gun to my head, and there's NO WAY I would be telling your average RadOnc resident to go down that path these days. The business skills for doctors in general, and certainly RadOnc in particular, have grotesquely atrophied in the consolidation/employment era. Not that it was ever really "taught" in residency, but now it's hard to learn by experience in a private group who is strong both financially and in moral character (won't screw you).

I don't think it's possible to know with any accuracy, but I would guess that fewer than maybe...5% of Radiation Oncologists graduating residency in 2020 and later will ever have a shot at being a technical partner in a practice.

Maybe I'm wrong?

 

[thecarbonionangle]

Perhaps we will see a lot more "Why isn't anyone applying to my PP?" posts in the future.
Never thought we would see a world where linac ownership wasn't the ultimate goal, but here we are. Thanks ASTRO!

Old timer PP guys also ruined PP. Thanks late gen x/boomers!

 

[OTN]

Old timer PP guys also ruined PP. Thanks late gen x/boomers!

The impact of ASTRO/hospital lobbying is orders of magnitude larger than that of PP

 

[Gfunk6]

Not that it was ever really "taught" in residency, but now it's hard to learn by experience in a private group who is strong both financially and in moral character (won't screw you).

This rings so true for my personal journey. Like most residents, I didn't know jack about the business side of Rad Onc. I was so extremely fortunate to join a group who had the characteristics you cited. Even then, I think it was a bit of a diamond in the rough. Nowadays? Forget about it.

Even large groups like ours don't offer terms like we used to 10 years ago.

 

[OTN]

This rings so true for my personal journey. Like most residents, I didn't know jack about the business side of Rad Onc. I was so extremely fortunate to join a group who had the characteristics you cited. Even then, I think it was a bit of a diamond in the rough. Nowadays? Forget about it.

Even large groups like ours don't offer terms like we used to 10 years ago.

The writing was on the wall even 15 years ago when I was searching for pp gigs- small practices were going to continue to get squeezed by both payors and equipment providers and were never going to have the economies of scale to be able to compete with larger private practices or hospital systems/academic medical centers, who not only had access to economies of scale, but also artificially increased reimbursement rates due to crony capitalism.

I didn't anticipate the depths of cronyism and the extent to which ASTRO would be hostile to private practices, but fortunately being wary of smaller clinics helped me make the right call.

Lots of those smaller private practices are now gone or suffering. I agree that finding a good pp gig now is a matter of luck more than anything else, so I completely understand why new grads look to hospital jobs.

 

[radiation]

One of the more interesting things is how much the sentiment about direct supervision has changed on this thread. Its likely there are many outside factors at play that will determine if indirect supervision ultimately helps or hurt and clearly there are going to be some pros and cons. Agree that like the rest of medicine, telehealth is here to stay so better to embrace than reject

 

[OTN]

One of the more interesting things is how much the sentiment about direct supervision has changed on this thread. Its likely there are many outside factors at play that will determine if indirect supervision ultimately helps or hurt and clearly there are going to be some pros and cons. Agree that like the rest of medicine, telehealth is here to stay so better to embrace than reject

In my experience with doing some locums, I would rather quit radonc and retrain than have a job where I'm just sitting in an office doing nothing. If retraining wasn't a possibility, I'd rather quit medicine entirely than have to face that for a lifetime. Absolutely the worst.

That's the elephant in the room that's not being discussed. We're all highly-functioning, ambitious people or we would have never gone to medical school. None of us want to just sit and do nothing most of the time for a career.

 

[RadOncDoc21]

In my experience with doing some locums, I would rather quit radonc and retrain than have a job where I'm just sitting in an office doing nothing. If retraining wasn't a possibility, I'd rather quit medicine entirely than have to face that for a lifetime. Absolutely the worst.

That's the elephant in the room that's not being discussed. We're all highly-functioning, ambitious people or we would have never gone to medical school. None of us want to just sit and do nothing most of the time for a career.

I mean if I was to pretend to be busy working all day, that would be hell but if I’m able to watch tv, surf the web… do some day trading, I don’t think it’s that bad.

 

[Doctorer]

I mean if I was to pretend to be busy working all day, that would be hell but if I’m able to watch tv, surf the web… do some day trading, I don’t think it’s that bad.

Obviously this is widely variable, but I have a feeling that for the type of go-getter that matched radonc in the glory days, surfing the web for 30 years would be deeply unsatisfying for most.

 

[MidwestRadOnc]

Obviously this is widely variable, but I have a feeling that for the type of go-getter that matched radonc in the glory days, surfing the web for 30 years would be deeply unsatisfying for most.

Especially the 4 years of memorizing obscure trial data going back 3 decades, enduring epic chart round pimp sessions and regurgitating nuances of rad bio and physics to come out and realize I went through all that to do... this???

 

[RO28]

I mean if I was to pretend to be busy working all day, that would be hell but if I’m able to watch tv, surf the web… do some day trading, I don’t think it’s that bad.

maybe...but the depths of the internet only go so far before it starts getting weird. and I'm not the best at sitting still.

 

[RadOncDoc21]

Listen, I don’t like to be chained down either but seeing patients all day isn’t my cup of tea either. If I will get laid the same, I rather spend my hour watching sports center vs convincing a patient why he doesn’t need protons.

 

[Gfunk6]

Let's be serious, you do NOT need a physician to babysit a linac. An APP could easily do it. Hell, my local academic center has an NP who sees new RO consults on their own.

Direct supervision is not a solution to resident over-supply. It will just make the toilet flush faster.

 

[Mandelin Rain]

Listen, I don’t like to be chained down either but seeing patients all day isn’t my cup of tea either. If I will get laid the same, I rather spend my hour watching sports center vs convincing a patient why he doesn’t need protons.

What kind of clinic is this?

 

[RadOncDoc21]

What kind of clinic is this?

Got to find something to do with that free time!

 

[TheWallnerus]

Especially the 4 years of memorizing obscure trial data going back 3 decades, enduring epic chart round pimp sessions and regurgitating nuances of rad bio and physics to come out and realize I went through all that to do... this???

How many have actually already met with this realization. More than a few.

 

[OTN]

Let's be serious, you do NOT need a physician to babysit a linac. An APP could easily do it. Hell, my local academic center has an NP who sees new RO consults on their own.

Direct supervision is not a solution to resident over-supply. It will just make the toilet flush faster.

Having an NP see new radonc consults on their own is insane.

 

[TheWallnerus]

If I will get laid the same,

What kind of clinic is this?

Think Zvi Fuks ran such a clinic.

Need way more Fuks in rad onc imho.

 

[MidwestRadOnc]

What kind of clinic is this?

Maybe the one in nebraska (or was it iowa? whatever) where that guy was doing lines of coke in between otvs?

 

[RadOncDoc21]

Obviously this is widely variable, but I have a feeling that for the type of go-getter that matched radonc in the glory days, surfing the web for 30 years would be deeply unsatisfying for most.

Maybe that’s the problem with our field… too expectations. Let’s not forget that rad onc was one of the least competitive fields in the early 90’s and then exploded. Maybe it was always fool’s gold to begin with.

 

[OTN]

Maybe that’s the problem with our field… too expectations. Let’s not forget that rad onc was one of the least competitive fields in the early 90’s and then exploded. Maybe it was always fool’s gold to begin with.

I still think the field itself, the science, the tech, and the variety is super cool. The leadership at the national level has been the problem, which in hindsight makes sense, given that it was indeed very uncompetitive when those leaders entered.

 

[RadOncDoc21]

I still think the field itself, the science, the tech, and the variety is super cool. The leadership at the national level has been the problem, which in hindsight makes sense, given that it was indeed very uncompetitive when those leaders entered.

True, I literally could not see myself doing anything else in the field of medicine but with that said, I’m looking for ways to be financially independent to not have to do anything in medicine.

 

[communitydoc13]

Think Zvi Fuks ran such a clinic.

Need way more Fuks in rad onc imho.

No more Fuks to give

 

[thecarbonionangle]

What kind of clinic is this?

Freudian slip