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

[OTN]

With new rules would Radiation Oncologist need to be in the building for SBRT treatments and simulations?

Professional component to sim billing, so presence needed for now.

I don’t think any smart organization would allow no MD presence for SBRT.

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[scarbrtj]

Professional component to sim billing, so presence needed for now.

There's a professional component to planning. A professional component to basic dose calcs. To complex treatment devices. To cone beam CT. To almost every rad onc code besides the treatments. (One can also note that many of these codes can be rationally charged without the patient being in the building, thus hard to say the physician should be in building if patient is not; another topic maybe.) So by this logic, by Medicare saying general supervision applies to *all* outpatient therapeutic procedures... their express declaration is toothless/moot. But it's not just direct (ie in the building), it's gotta be personal supervision? Maybe there is no "supervision" crisis here. But in reality I almost never (get to) bill the sim charge nowadays anyways. On the other hand... ~95% of all hospitals "fraudulently" do the sim charges. Reading a CT has a professional code for radiologists, but they don't have to be in the building FWIW.

 

[XRT_doc]

Does this mean I can hire PA to be at the clinic talking to patients while I'm at a different facility? This would be good for clinic owners but bad for new grads.

 

[OTN]

There's a professional component to planning. A professional component to basic dose calcs. To complex treatment devices. To cone beam CT. To almost every rad onc code besides the treatments. (One can also note that many of these codes can be rationally charged without the patient being in the building, thus hard to say the physician should be in building if patient is not; another topic maybe.) So by this logic, by Medicare saying general supervision applies to *all* outpatient therapeutic procedures... their express declaration is toothless/moot. But it's not just direct (ie in the building), it's gotta be personal supervision? Maybe there is no "supervision" crisis here. But in reality I almost never (get to) bill the sim charge nowadays anyways. On the other hand... ~95% of all hospitals "fraudulently" do the sim charges. Reading a CT has a professional code for radiologists, but they don't have to be in the building FWIW.

True, but I interpret the simulation professional charge as "I physically looked at the setup of the patient on the table", and I do think there's value to physically being there to check the setup in 3d space. The other stuff you mentioned- planning, image review- happens only in a virtual space.

 

[medgator]

True, but I interpret the simulation professional charge as "I physically looked at the setup of the patient on the table", and I do think there's value to physically being there to check the setup in 3d space. The other stuff you mentioned- planning, image review- happens only in a virtual space.

Exactly how I interpret it and why I feel totally comfortable signing a plan while on vacation, but treat igrt and CT sim differently as the pt is actually present

 

[scarbrtj]

True, but I interpret the simulation professional charge as "I physically looked at the setup of the patient on the table", and I do think there's value to physically being there to check the setup in 3d space. The other stuff you mentioned- planning, image review- happens only in a virtual space.

Double true (Maybe. Big maybe. Again CMS said *all* HOPPS outpatient. CMS clear-cut clarified and here we are debating?!?). But we can't charge sims on IMRT or 3DCRT patients. How often does that mean we can charge a sim? For me, less than 5-10% of the time.

 

[medgator]

Double true (Maybe. Big maybe. Again CMS said *all* HOPPS outpatient. CMS clear-cut clarified and here we are debating?!?). But we can't charge sims on IMRT or 3DCRT patients. How often does that mean we can charge a sim? For me, less than 5-10% of the time.

You can charge sims on 3D pts I thought? At least in the freestanding setting....

 

[scarbrtj]

You can charge sims on 3D pts I thought? At least in the freestanding setting....

No, never. I don't believe freestanding or hospital has anything to do with it (and obv we've just been talking about supervision in hosp anyways). And in theory lots of people/centers are at risk of whistleblowing or getting hounded for refund etc. 'cause we've all been taught since time immemorial that you have to do a 77290 even to be able to do a 77295. A lot of centers/docs had to make some quiet refunds some time after the same such announcement (no sims) was made for IMRT.

 

[medgator]

No, never. I don't believe freestanding or hospital has anything to do with it (and obv we've just been talking about supervision in hosp anyways). And in theory lots of people/centers are at risk of whistleblowing or getting hounded for refund etc. 'cause we've all been taught since time immemorial that you have to do a 77290 even to be able to do a 77295. A lot of centers/docs had to make some quiet refunds some time after the same such announcement (no sims) was made for IMRT.

That document says "hospital" all over it

 

[BobbyHeenan]

Professional component to sim billing, so presence needed for now.

I don’t think any smart organization would allow no MD presence for SBRT.

No, never. I don't believe freestanding or hospital has anything to do with it (and obv we've just been talking about supervision in hosp anyways). And in theory lots of people/centers are at risk of whistleblowing or getting hounded for refund etc. 'cause we've all been taught since time immemorial that you have to do a 77290 even to be able to do a 77295. A lot of centers/docs had to make some quiet refunds some time after the same such announcement (no sims) was made for IMRT.

This was the OIG rec to CMS (ie CMS should bundle 77290 into 3D like they do for IMRT). I may be wrong here, but I haven't seen where CMS issued their ruling. CMS says specifically in their response there are differences in 3D and IMRT and they're basically going to look into it more. I think CT sims are probably dead soon, but I don't think this report says you can't bill a CT sim with a 3D plan.

If you're not billing a CT sim with 3D plan I think that's fine, but I think you're going to be in the minority as you've mentioned until CMS makes a ruling here.


From the summary: "CMS will consider whether implementing billing requirements in the future to prevent payments for additional planning services when reported with three-dimensional conformal radiation therapy would be appropriate. "

From what I can tell, current CMS billing guidelines still just say don't bill 77290 on same day as 3D plan.

https://downloads.cms.gov/medicare-coverage-database/lcd_attachments/34652_13/L34652_RAD014_BCG.pdf

 

[medgator]

This was the OIG rec to CMS (ie CMS should bundle 77290 into 3D like they do for IMRT). I may be wrong here, but I haven't seen where CMS issued their ruling. CMS says specifically in their response there are differences in 3D and IMRT and they're basically going to look into it more. I think CT sims are probably dead soon, but I don't think this report says you can't bill a CT sim with a 3D plan.

If you're not billing a CT sim with 3D plan I think that's fine, but I think you're going to be in the minority as you've mentioned until CMS makes a ruling here.


From the summary: "CMS will consider whether implementing billing requirements in the future to prevent payments for additional planning services when reported with three-dimensional conformal radiation therapy would be appropriate. "

Current CMS billing guidelines still just say don't bill 77290 on same day as 3D plan.

That's what we do.

 

[BobbyHeenan]

That's what we do.

Us too.


I am really thankful for scarb and others always pointing these things out though. We looked at it with our billers, group, hospital, and attorney and they said to keep billing it for now but keep a look out.

 

[deleted774703]

Since many sites look for ASTRO, ASCO, ACRO, ACR etc accreditation, I wonder if those guidelines will include having a radonc around to check images

If so is it possible that maybe centers could bypass CMS rule?

 

[deleted1002574]

Centers are going to be happy with the rule. Why would they want to increase their costs by hiring more doctors ?

 

[deleted774703]

Centers are going to be happy with the rule. Why would they want to increase their costs by hiring more doctors ?

I mean I don’t understand the urge to be randomly accredited by these organizations to begin with, but they do it

Could ASTRO etc could help us out by having radoncs on site for image checks as a criteria for accreditation?

Or would that cause them to lose facilities from choosing accreditation option ?

 

[deleted1002574]

In contrarian view... just for discussion purposes.

Yes, the rule saves jobs.

But, from patient care / safety view - does direct supervision improve care ? Does it lead to better outcomes ? Does it improve health? Does it do anything measurable ? Could any of the major misadministrations or egregious cases of malpractice have been avoided with direct supervision ?

I want to with my heart say direct supervision matters. But, other than SBRT/SRS (which could have been carved out), do you really think we could ever have evidence that it improves outcomes, reduces toxicity, or reduces costs? If something in medicine doesn’t do one of those things, does it deserve to exist ?

 

[medgator]

In contrarian view... just for discussion purposes.

Yes, the rule saves jobs.

But, from patient care / safety view - does direct supervision improve care ? Does it lead to better outcomes ? Does it improve health? Does it do anything measurable ? Could any of the major misadministrations or egregious cases of malpractice have been avoided with direct supervision ?

I want to with my heart say direct supervision matters. But, other than SBRT/SRS (which could have been carved out), do you really think we could ever have evidence that it improves outcomes, reduces toxicity, or reduces costs? If something in medicine doesn’t do one of those things, does it deserve to exist ?

Isn't that exactly what CMS's argument was to get rid of the 2-tiered approach to supervision regulations?

If you read the commentary, essentially they said they saw no detriment to patients treated under "general supervision" at small rural and critical access hospitals (CAH), so they saw no point of keeping the 2-tiered system going forward.

It's not CMS's responsibility to support the RO job market in the first place or find jobs for the excess number of grads that have been entering practice the last several years via prolonging enforcement of unnecessary supervision regulations

 

[thecarbonionangle]

This is a disaster.

50% unmatched this year. Programs will fill with desparate unqualified warm bodies that will destroy the field and reputation.
Significant exodus of matched PGY-1s and current PGY-2s and 3s.
Bail to IM, rads, whatever.

I can't imagine people coming out with significant loan burden into this.
Combined with our ridiculous board certification process, there is no safety net. If you don't get through the board certification process, you're done. Period. 13 years of education after high school before you start your very first real job. Don't pass boards? Hope you like doing medicare physicals, prison doc work, babysitting psych wards in the middle of nowhere for 100k/year. The option of being a locums making $2000/day as a worst case scenario is gone.

The bottom just fell out. As a med student or even an early rad onc resident, I didn't understand how the business works or why this would have been so bad. Med students, listen to everybody. This is real. You should not apply to this field unless you are independently wealthy and just want to work as a rad onc for any cost.

We aren't as bad as nuc med where the speciality basically disappeared and everyone had to retrain.
But we just became worse than pathology.

it is overwhelmingly clear that the field is in a a very tough spot. Anybody early on in a midtier or mediocre program should consider based on their risk tolerance to switch a different specialty. Current employed rad oncs should save even more and prepare to potentially be out of a job. This is particularly worrisome to anybody who just joined and is not yet partner. Guess what? They don’t need you or like you THAT much.

Anybody sitting on a decent contract in a tolerable location where you will not hang yourself, should strongly consider signing it and praying it is honored and not taken back. You have very little power this year.

It is funny how some of the usual “positive” posters (Find repulsive) on here are SHOOK. Some people are just clueless and cannot see the light, like that thing they put on horses eyes so they walk straight. Some people are just BLIND!. That is SAD.

Trump, or as the right calls him “daddy” absolutely did ruin RO with his crony Azar. For those expecting known Trump high money doner Hahn to save us, you will be waiting for a while.

 

[XRT_doc]

it is overwhelmingly clear that the field is in a a very tough spot. Anybody early on in a midtier or mediocre program should consider based on their risk tolerance to switch a different specialty. Current employed rad oncs should save even more and prepare to potentially be out of a job. This is particularly worrisome to anybody who just joined and is not yet partner. Guess what? They don’t need you or like you THAT much.

Anybody sitting on a decent contract in a tolerable location where you will not hang yourself, should strongly consider signing it and praying it is honored and not taken back. You have very little power this year.

It is funny how some of the usual “positive” posters (Find repulsive) on here are SHOOK. Some people are just clueless and cannot see the light, like that thing they put on horses eyes so they walk straight. Some people are just BLIND!. That is SAD.

Trump, or as the right calls him “daddy” absolutely did ruin RO with his crony Azar. For those expecting known Trump high money doner Hahn to save us, you will be waiting for a while.

How did Azar ruin RO?

 

[medgator]

How did Azar ruin RO?

Azar Announces Mandatory Oncology Payment Model Is Coming

The announcement is an about-face from earlier efforts that scrapped a cardiac care bundled payment program originally developed during the Obama administration.

www.ajmc.com

Only way to spend more on drugs is ring cost savings out of the RO turnip. Azar has his priorities and it ain't radonc.

Kinda like cutting PBS, NIH and PP funding to get some pennies to throw into the Pentagon/defense budget

 

[beamseyeview]

Anybody sitting on a decent contract in a tolerable location where you will not hang yourself, should strongly consider signing it and praying it is honored and not taken back. You have very little power this year.

Truth. See my data point here. To Medical Students Considering Rad Onc - Perspectives on the Future by an Optimist

 

[thecarbonionangle]

Truth. See my data point here. To Medical Students Considering Rad Onc - Perspectives on the Future by an Optimist

only speaking truth here brotha. Those who don't want to listen are gonna find out the hard ways. Listen up folks and PAY ATTENTION, you ain’t seen nothing yet.

the truth is now any contract you get moving forward will be half as good. Don’t let people smell your fear and desperation, they will eat you alive. This is the alligator/shark Modus operandi.

 

[Chartreuse Wombat]

ASTRO pushes back but no change likely.

 

[nkmiami]

Should our workforce have ever hinged on a piece of legislation that did not historically exist and is not present in the rest of the world, or should need be driven by patient demand?

 

[Chartreuse Wombat]

 

[medgator]

Sticky!!!

 

[pikachu]

In contrarian view... just for discussion purposes.

Yes, the rule saves jobs.

But, from patient care / safety view - does direct supervision improve care ? Does it lead to better outcomes ? Does it improve health? Does it do anything measurable ? Could any of the major misadministrations or egregious cases of malpractice have been avoided with direct supervision ?

I want to with my heart say direct supervision matters. But, other than SBRT/SRS (which could have been carved out), do you really think we could ever have evidence that it improves outcomes, reduces toxicity, or reduces costs? If something in medicine doesn’t do one of those things, does it deserve to exist ?

I'll attempt to answer this while agreeing with your point that direct supervision is not likely to prevent a major misadministration, since the MD is not verifying site, side, MUs, etc. in real-time before each beam-on. You are absolutely correct that we have to prove our value to daily care - while it may not make much difference to CMS, a strong case for why we are needed on site daily could provide the professional and accreditation societies with justification for making daily on-site MD presence a condition for accreditation AND demonstrate to practices why they may be taking on needless risk by running treatments without an MD present.

Here are some instances where direct supervision (which I'm taking to mean as MD on-site for all treatments) probably DOES make a difference.
-the H&N patient getting concurrent chemorads with severe mucositis, limited PO intake, on the path to dehydration/renal insufficiency/electrolyte imbalance etc. MD is called to see patient, gets labs, catches renal failure or other problems early, provides appropriate nutritional/fluid support to let the patient continue with treatment. We can extrapolate that this type of support may avoid prolonged treatment breaks and therefore improve outcomes. Flip side of this is that the MD is there to say, yes this patient needs a break - in this case the benefit is preventing severe long-lasting skin/mucosal toxicity or other problems. Such situations are quite common in H&N and anal patients and to a lesser extent in conventional lung (esophagitis), gastric (nausea/poor PO), rectal (mucositis/diarrhea), comprehensive breast (skin), and likely other sites as well. To my knowledge this type of E&M is not within the scope of RN/RTT care (YET). Such problems don't always wait until your on-treat day to present, either, so relying on the once-weekly on-treat visit is not sufficient to address them.
-poor setup due to weight loss, abdominal bloating, pain/discomfort, or any number of additional factors where MD can be on hand to address the problem immediately. We operate on the premise that fewer breaks --> better disease control, so any delay in addressing patient factors that affect setup can be presumed to affect outcomes.

 

[scarbrtj]

I'll attempt to answer this while agreeing with your point that direct supervision is not likely to prevent a major misadministration, since the MD is not verifying site, side, MUs, etc. in real-time before each beam-on. You are absolutely correct that we have to prove our value to daily care - while it may not make much difference to CMS, a strong case for why we are needed on site daily could provide the professional and accreditation societies with justification for making daily on-site MD presence a condition for accreditation AND demonstrate to practices why they may be taking on needless risk by running treatments without an MD present.

Here are some instances where direct supervision (which I'm taking to mean as MD on-site for all treatments) probably DOES make a difference.
-the H&N patient getting concurrent chemorads with severe mucositis, limited PO intake, on the path to dehydration/renal insufficiency/electrolyte imbalance etc. MD is called to see patient, gets labs, catches renal failure or other problems early, provides appropriate nutritional/fluid support to let the patient continue with treatment. We can extrapolate that this type of support may avoid prolonged treatment breaks and therefore improve outcomes. Flip side of this is that the MD is there to say, yes this patient needs a break - in this case the benefit is preventing severe long-lasting skin/mucosal toxicity or other problems. Such situations are quite common in H&N and anal patients and to a lesser extent in conventional lung (esophagitis), gastric (nausea/poor PO), rectal (mucositis/diarrhea), comprehensive breast (skin), and likely other sites as well. To my knowledge this type of E&M is not within the scope of RN/RTT care (YET). Such problems don't always wait until your on-treat day to present, either, so relying on the once-weekly on-treat visit is not sufficient to address them.
-poor setup due to weight loss, abdominal bloating, pain/discomfort, or any number of additional factors where MD can be on hand to address the problem immediately. We operate on the premise that fewer breaks --> better disease control, so any delay in addressing patient factors that affect setup can be presumed to affect outcomes.

It's easy to conflate things in these discussions. From a very legal perspective what you're talking about is not direct supervision. You're talking about MD being around when something comes up for which a patient can benefit from face-to-face time w/ MD. Direct supervision is strictly a regulatory/legal term which means a doctor is in building (along w/ patient by definition) when an outpatient therapeutic tx is administered, for which a billing code is attached, so that it may be properly billed. It's a bunch of discrete quanta of all-or-nothing compliance taking place throughout the day versus an elongated clinical scenario that you vividly & accurately portray for which, if taking place separate from the OTV, there is no MD code for. Direct supervision is not really a rational term to apply for when the MD literally "sees" the patient; personal supervision would more accurately apply. (Direct vs personal... confusing, I know. Direct is not really direct, it's indirect, yada yada.) But there are zero rad onc codes which require personal supervision (a lot of the interventional radiology codes require personal supervision e.g.). There was a brief period of time where kV X-ray IGRT (CBCT never did) literally required personal supervision.

"We operate on the premise that fewer breaks --> better disease control." You can make the argument, and I think some did outside the rad onc sphere to CMS, that a direct-to-general switch makes tx breaks less likely (ie therapy of any sort less likely to be interrupted).

 

[deleted1002574]

1) Taking care of side effects, even of HNC, can be managed by PA or NP or medonc. I.e. - does not have to be a rad-onc. I'm not sure the physics boards is necessary for this I'm not sure how sitting at machine all day makes sense. Maybe you would need to come M,W,F to check on your very sick patients? And be available Tu, Th if your nurse says "Mr. So and So is crumping"?

2) Reviewing set up and CBCT that shows weight loss can be done at machine, at desk, or in living room

 

[RickyScott]

It's easy to conflate things in these discussions. From a very legal perspective what you're talking about is not direct supervision. You're talking about MD being around when something comes up for which a patient can benefit from face-to-face time w/ MD. Direct supervision is strictly a regulatory/legal term which means a doctor is in building (along w/ patient by definition) when an outpatient therapeutic tx is administered, for which a billing code is attached, so that it may be properly billed. It's a bunch of discrete quanta of all-or-nothing compliance taking place throughout the day versus an elongated clinical scenario that you vividly & accurately portray for which, if taking place separate from the OTV, there is no MD code for. Direct supervision is not really a rational term to apply for when the MD literally "sees" the patient; personal supervision would more accurately apply. (Direct vs personal... confusing, I know. Direct is not really direct, it's indirect, yada yada.) But there are zero rad onc codes which require personal supervision (a lot of the interventional radiology codes require personal supervision e.g.). There was a brief period of time where kV X-ray IGRT (CBCT never did) literally required personal supervision.

"We operate on the premise that fewer breaks --> better disease control." You can make the argument, and I think some did outside the rad onc sphere to CMS, that a direct-to-general switch makes tx breaks less likely (ie therapy of any sort less likely to be interrupted).

In all fairness, treatment

1) Taking care of side effects, even of HNC, can be managed by PA or NP or medonc. I.e. - does not have to be a rad-onc. I'm not sure the physics boards is necessary for this I'm not sure how sitting at machine all day makes sense. Maybe you would need to come M,W,F to check on your very sick patients? And be available Tu, Th if your nurse says "Mr. So and So is crumping"?

2) Reviewing set up and CBCT that shows weight loss can be done at machine, at desk, or in living room

I guess you could also speak to pt on phone or videoconference if nurse finds issue?

I don’t know what I am going to do with all my free time in a couple years?Don’t like golf etc.

 

[medgator]

I don’t know what I am going to do with all my free time in a couple years?Don’t like golf etc.

Do you even lift, bro? Jk. I'll probably have plenty more gym time myself....

 

[pikachu]

It's easy to conflate things in these discussions. From a very legal perspective what you're talking about is not direct supervision. You're talking about MD being around when something comes up for which a patient can benefit from face-to-face time w/ MD. Direct supervision is strictly a regulatory/legal term which means a doctor is in building (along w/ patient by definition) when an outpatient therapeutic tx is administered, for which a billing code is attached, so that it may be properly billed. It's a bunch of discrete quanta of all-or-nothing compliance taking place throughout the day versus an elongated clinical scenario that you vividly & accurately portray for which, if taking place separate from the OTV, there is no MD code for. Direct supervision is not really a rational term to apply for when the MD literally "sees" the patient; personal supervision would more accurately apply. (Direct vs personal... confusing, I know. Direct is not really direct, it's indirect, yada yada.) But there are zero rad onc codes which require personal supervision (a lot of the interventional radiology codes require personal supervision e.g.). There was a brief period of time where kV X-ray IGRT (CBCT never did) literally required personal supervision.

"We operate on the premise that fewer breaks --> better disease control." You can make the argument, and I think some did outside the rad onc sphere to CMS, that a direct-to-general switch makes tx breaks less likely (ie therapy of any sort less likely to be interrupted).

Interesting,...yes it is easy to elide these terms and I'll be honest with you I never paid close attention to these regulations until now. I still think that these scenarios and others make a case for having an MD on site throughout the treatment day even if it doesn't fall under the strict legal definition of direct supervision for treatments.

How does the direct to general switch make treatment break less likely? Are you referring to scenario where machine cannot treat because an MD cannot be on site?

1) Taking care of side effects, even of HNC, can be managed by PA or NP or medonc. I.e. - does not have to be a rad-onc. I'm not sure the physics boards is necessary for this I'm not sure how sitting at machine all day makes sense. Maybe you would need to come M,W,F to check on your very sick patients? And be available Tu, Th if your nurse says "Mr. So and So is crumping"?

2) Reviewing set up and CBCT that shows weight loss can be done at machine, at desk, or in living room

Are the physics boards the only thing that makes you a radiation oncologist? Again, this is about making the case to professional societies and practices that having a board certified RO on site mitigates risk and improves patient care. I don't think an NP, PA, or even a med onc should be making the call about whether to break/continue a patient with severe toxicity, stop treatment all together, make decision about whether to resim, etc. All of these are decisions we are called to make frequently and they are far more difficult to make if you cannot evaluate the patient in person. We can't complain about decreasing demand for radiation oncologists and then turn around and say it's ok to push off our professional responsibilities onto other specialties or even to physician extenders. And yes I am aware that this has been going on in rural clinics for ever...but that doesn't mean that is the best way to practice.

As far as the setup review, yes, you can look at that CBCT off site and realize that the setup sucks, but recognizing and addressing the underlying problem that's causing the crap setup requires a face to face evaluation of the patient imo.

 

[deleted1002574]

Okay. So, I guess the main point is that you do believe an on site rad onc for all treatments benefits patients and improves quality. And, I think it’s more selective than that. Getting lunch while a imrt lung or prostate gets treated shouldn’t land me in trouble with the Feds (my opinion).

Interesting,...yes it is easy to elide these terms and I'll be honest with you I never paid close attention to these regulations until now. I still think that these scenarios and others make a case for having an MD on site throughout the treatment day even if it doesn't fall under the strict legal definition of direct supervision for treatments.

How does the direct to general switch make treatment break less likely? Are you referring to scenario where machine cannot treat because an MD cannot be on site?



Are the physics boards the only thing that makes you a radiation oncologist? Again, this is about making the case to professional societies and practices that having a board certified RO on site mitigates risk and improves patient care. I don't think an NP, PA, or even a med onc should be making the call about whether to break/continue a patient with severe toxicity, stop treatment all together, make decision about whether to resim, etc. All of these are decisions we are called to make frequently and they are far more difficult to make if you cannot evaluate the patient in person. We can't complain about decreasing demand for radiation oncologists and then turn around and say it's ok to push off our professional responsibilities onto other specialties or even to physician extenders. And yes I am aware that this has been going on in rural clinics for ever...but that doesn't mean that is the best way to practice.

As far as the setup review, yes, you can look at that CBCT off site and realize that the setup sucks, but recognizing and addressing the underlying problem that's causing the crap setup requires a face to face evaluation of the patient imo.

 

[medgator]

Interesting,...yes it is easy to elide these terms and I'll be honest with you I never paid close attention to these regulations until now. I still think that these scenarios and others make a case for having an MD on site throughout the treatment day even if it doesn't fall under the strict legal definition of direct supervision for treatments.

How does the direct to general switch make treatment break less likely? Are you referring to scenario where machine cannot treat because an MD cannot be on site?

Theoretically you could treat.... Just don't bill CMS a cent.

 

[medgator]

Okay. So, I guess the main point is that you do believe an on site rad onc for all treatments benefits patients and improves quality. And, I think it’s more selective than that. Getting lunch while a imrt lung or prostate gets treated shouldn’t land me in trouble with the Feds (my opinion).

Or going to a tumor board, seeing an inpatient consult etc

 

[pikachu]

Okay. So, I guess the main point is that you do believe an on site rad onc for all treatments benefits patients and improves quality. And, I think it’s more selective than that. Getting lunch while a imrt lung or prostate gets treated shouldn’t land me in trouble with the Feds (my opinion).

My points aren't meant to argue that the federal regulations should change, as that's very unlikely at this point. Also, I agree that one benefit of the rule change is that people will be free to go to tumor boards, see inpatients, whatever, during the treatment day. Rather we need to make the case within practices and hospital systems for why radiation clinics should have a radiation oncologist on site rather than regressing to the bare bones staffing levels that are apparently now the minimum allowed by law. Again, the only way to do this is to show that we provide valuable services that improve outcomes, improve patient satisfaction, and mitigate risk. We are all part of practices that will need to decide staffing levels for clinics or convince larger systems that we are needed in clinics regardless of what the feds say. Everyone who is ringing the alarm bells about the job market should want to identify ways in which we as ROs are indispensable to the safe and effective administration of radiation treatments - assuming the goal is to prevent the gutting of the field.

 

[deleted1002574]

I agree. We are making two different points. The federal regulation to begin with that did not improve safety/quality.

A lot of these things need to be internally regulating - by docs, hospitals, national organizations, credentialing organizations.

The way it stood, to punish practicing docs that were signing off on films off site or whatever did not do anything good for patients or docs.

I'm not suggesting have 5 clinics for 1 doc, and 1 day at each. The supervision rule never made sense. It was 1) just medicare patients (??) 2) Just IMRT (??) 3) Some centers exempt 4) Some centers with 'different' rules 5) Even if people paid back money, they were at risk of treble penalties. It grabbed some low hanging fruit and it ensnared some probably decent human beings into nonsense because of nefarious staff members who were trying to collect whistle blower money. I bet zero of these cases would have happened if they didn't have that 20% rule.

Federal overreach is something physicians should always try to deflect. A good specialty makes good rules for itself instead of having the government slap down rules that make zero sense.

 

[Krukenberg]

My points aren't meant to argue that the federal regulations should change, as that's very unlikely at this point. Also, I agree that one benefit of the rule change is that people will be free to go to tumor boards, see inpatients, whatever, during the treatment day. Rather we need to make the case within practices and hospital systems for why radiation clinics should have a radiation oncologist on site rather than regressing to the bare bones staffing levels that are apparently now the minimum allowed by law. Again, the only way to do this is to show that we provide valuable services that improve outcomes, improve patient satisfaction, and mitigate risk. We are all part of practices that will need to decide staffing levels for clinics or convince larger systems that we are needed in clinics regardless of what the feds say. Everyone who is ringing the alarm bells about the job market should want to identify ways in which we as ROs are indispensable to the safe and effective administration of radiation treatments - assuming the goal is to prevent the gutting of the field.

varian is selling a halcyon package designed for adaptive therapy based on CBCT. Could be a good way to maintain rad onc value while not slowing down treatments as much as MR linac

 

[Neuronix]

varian is selling a halcyon package designed for adaptive therapy based on CBCT. Could be a good way to maintain rad onc value while not slowing down treatments as much as MR linac

It's a joke for most disease sites imo. Adaptive radiotherapy lite.

 

[medgator]

It's a joke for most disease sites imo. Adaptive radiotherapy lite.

Didn't Tomo try something similar? Not sure I want to plan off anything less than a decent diagnostic CT with contrast if appropriate

 

[RickyScott]

It's a joke for most disease sites imo. Adaptive radiotherapy lite.

Machine seems like a good idea. Wish I had one.

 

[RadOncDoc21]

Machine seems like a good idea. Wish I had one.

I’ll buy 5 if it gets urology to send me some patients!

 

[taserlaser]

Didn't Tomo try something similar? Not sure I want to plan off anything less than a decent diagnostic CT with contrast if appropriate

You know, it’s funny how much I’ve heard in the past few weeks, “When we still had a tomo unit, this was never an issue...“ haha. I dug out some old plans, and actually some of the stuff it could do is quite impressive(or at least to me who has never used one before, or deal knee breaking ).

 

[medgator]

I’ll buy 5 if it gets urology to send me some patients!

Can't treat my electron/skin patients. It's really a hospital based imrt/vmat workhorse, ideal as a second linac imo, not for a single vault practice

 

[scarbrtj]

Didn't realize that chemotherapy in the hospital was governed by direct supervision (by a med onc, I am sure) all this time. I don't know how much effort or sweat medical oncology put into meeting those requirements. Also evidently the reg's now include specific guidance to allow NPs/PAs to be the general supervisors for radiation therapy/chemo; an MD not needed at all to meet regulations.

The 2020 HOPPS final rule brings major changes to physician supervision—and more—for cancer programs

 

[elementaryschooleconomics]

Didn't realize that chemotherapy in the hospital was governed by direct supervision (by a med onc, I am sure) all this time. I don't know how much effort or sweat medical oncology put into meeting those requirements. Also evidently the reg's now include specific guidance to allow NPs/PAs to be the general supervisors for radiation therapy/chemo; an MD not needed at all to meet regulations.

The 2020 HOPPS final rule brings major changes to physician supervision—and more—for cancer programs

Well this is a terrifying table from @scarbrtj's link:

 

[medgator]

Well this is a terrifying table from @scarbrtj's link:

View attachment 286611

That's going to tighten medical oncology hiring as well.

Fwiw, I know several med oncs in my area that have hired extenders/NPs in the last 2-3 years without hiring a new partner. They can help see patients in the hospital, cover chemo (at a lower rate), etc.

This will accelerate that trend

 

[BobbyHeenan]

That's going to tighten medical oncology hiring as well.

Fwiw, I know several med oncs in my area that have hired extenders/NPs in the last 2-3 years without hiring a new partner. They can help see patients in the hospital, cover chemo (at a lower rate), etc.

This will accelerate that trend

This is incredibly common in my neck of the woods.

I think it is not great for patient care (just as I think the rad onc new rule isn't great for patient care), as I have many patients seeing med onc NP's wwaaayyy too often without having seen their oncologist in too long.

I also get med onc NP's calling me quite a bit about decision making on chemo (obviously not asking me for chemo orders, just "can you look at this guy?" type of calls) and/or to see a borderline sick patient because they know I'm at the hospital 5 days/week, and often their supervising med onc isn't there.

This is the reality though of today, and it's not going away. So IMO the strategy is to teach/train the mid levels you're working with as best as you can, because they're not going away.

 

[w00tz]

This is incredibly common in my neck of the woods.

I think it is not great for patient care (just as I think the rad onc new rule isn't great for patient care), as I have many patients seeing med onc NP's wwaaayyy too often without having seen their oncologist in too long.

I also get med onc NP's calling me quite a bit about decision making on chemo (obviously not asking me for chemo orders, just "can you look at this guy?" type of calls) and/or to see a borderline sick patient because they know I'm at the hospital 5 days/week, and often their supervising med onc isn't there.

This is the reality though of today, and it's not going away. So IMO the strategy is to teach/train the mid levels you're working with as best as you can, because they're not going away.

Have worked with some really capable mid-levels who can almost operate at an attending level (contouring, even H&N, doing 90% of a consult). And I always thought, man, if they could have toughed out a few more years of training (okay, maybe more like 7 more years), they could be make 3-5 times what they are making now. But they usually just did not have the means to do more training.

Have also worked with some crappy mid-levels. Just not good attitudes or mindset compared with the good ones.

 

[evilbooyaa]

Have worked with some really capable mid-levels who can almost operate at an attending level (contouring, even H&N, doing 90% of a consult). And I always thought, man, if they could have toughed out a few more years of training (okay, maybe more like 7 more years), they could be make 3-5 times what they are making now. But they usually just did not have the means to do more training.

Have also worked with some crappy mid-levels. Just not good attitudes or mindset compared with the good ones.

I will never allow a midlevel to do contours/plan evaluation. They are there to do notes for me. The job market is bad enough as it is, I do not want NPs/PAs replacing MDs in the technical aspect of the field. I think if you are a physician who is having NPs/PAs do contours that is not good practice. Worse than having a dosimetrist do your GTV/CTV/PTV contours.