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

[radoncgrad2019]

lol those are some garbage statistics.

you're better than that, scarb.

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[medgator]

lol those are some garbage statistics.

you're better than that, scarb.

You're welcome to do better.

 

[RickyScott]

lol those are some garbage statistics.

you're better than that, scarb.

Really. dermatologists face geographic restrictions? Know a few who have tons of unsolicited offers of of residency. Are you lol with the essence of what scar is saying? Maybe you believe most radonc jobs are hidden, like buried treasure.(you have to “hunt” for them according to you) perhaps only accessible to those with white privelege?

 

[PhotonBomb]

Really. dermatologists face geographic restrictions? Know a few who have tons of unsolicited offers of of residency. Are you lol with the essence of what scar is saying? Maybe you believe most radonc jobs are hidden, like buried treasure.(you have to “hunt” for them according to you) perhaps only accessible to those with white privelege?

What the actual f_ck?That escalated quickly.

 

[MOHS_01]

Derm is totally different. Lot of cash paying and cosmetic procedures.

Everyone (not in derm) believes this, but cosmetic margins are **** and doesn’t really pay any better than general dermatology — unless you have a particularly strong brand in an appropriate location. It’s the myth that people want to believe more than a truth that exists.

 

[Krukenberg]

Everyone (not in derm) believes this, but cosmetic margins are **** and doesn’t really pay any better than general dermatology — unless you have a particularly strong brand in an appropriate location. It’s the myth that people want to believe more than a truth that exists.

are the NPs Independently encroaching on cosmetic or general dermatology?

 

[RickyScott]

are the NPs Independently encroaching on cosmetic or general dermatology?

I am sure they are. Yet derm still has more than 10x online jobs posted thaN xrt. And, why is this not a legitimate metric?

fyi: one of the staples of north korean propaganda is that people everywhere around the world outside of north korea are hungrier and face worse starvation.

 

[scarbrtj]

lol those are some garbage statistics.

you're better than that, scarb.

Really. dermatologists face geographic restrictions? Know a few who have tons of unsolicited offers of of residency. Are you lol with the essence of what scar is saying?

And I'm not saying anything. I just wrote down some (real) numbers, and did a calculation, and then somebody yelled "garbage!" Ah well.

 

[medgator]

And I'm not saying anything. I just wrote down some (real) numbers, and did a calculation, and then somebody yelled "garbage!" Ah well.

With nothing better to offer no less. Trolls gonna troll. Even if it is inline with what arro surveys and red journal articles seem to corroborate

 

[MOHS_01]

are the NPs Independently encroaching on cosmetic or general dermatology?

both - but they “have a passion” for cosmetic stuff quite often, apparently.

They can have those headaches as far as I’m concerned; high maintenance and low margin... sounds perfect for the half trained.

 

[scarbrtj]

With nothing better to offer no less. Trolls gonna troll. Even if it is inline with what arro surveys and red journal articles seem to corroborate

Numbers are numbers. And data is data. There are a few data points that do not contradict the hypothesis that rad onc is not oversupplied, or that the rad onc job market is not "fierce[ly]" competitive. But there are numerous data points that do. And we all know how to read data and its results. Whenever you get a p<0.00001 result, the data have to be ridiculously off for the result to be wrong (and the chances of that are small but it happens). And that's all the data "say" here: that the hypothesis that the rad onc and derm job markets are similar is rejected at p<0.00001.

 

[CyberKnife19]

Now that this has been in place for a while, are others in a hospital based setting altering their practices at all?

For example, if you are treating until 6:00 p.m., is anybody leaving at 5:00 or 5:30 if no new starts, SRS or SBRT? If you do leave a little early, would that effect your ability to get ACR or ASTRO accrediation? Thank you.

 

[evilbooyaa]

My residency hospital still requires, internally, that somebody be on site/campus while machines are on.

Can't speak for folks that are hospital-employed or PPs in hospital based settings.

 

[KHE88]

Now that this has been in place for a while, are others in a hospital based setting altering their practices at all?

For example, if you are treating until 6:00 p.m., is anybody leaving at 5:00 or 5:30 if no new starts, SRS or SBRT? If you do leave a little early, would that effect your ability to get ACR or ASTRO accrediation? Thank you.

I'm less inclined to show up at 8AM simply to babysit the linac if I don't have anything else going on until 9. But in general I prefer to be around when patients are getting treated as it's not extremely uncommon that somebody comes in hypotensive and passes out on the table or something.

My residency hospital still requires, internally, that somebody be on site/campus while machines are on.

Can't speak for folks that are hospital-employed or PPs in hospital based settings.

I think for IGRT billing, the professional component, you still have to be there.

 

[RickyScott]

I have been getting extra sleep on monst weekdays. Usually come in 30-45 minutes later than I used to. Curious as to the long term health benefits here. In Jan was 30 minutes, but feb about 45 minutes. Will keep you updated abt March.

edit- I, like 99% of us,review IGRT at the end of day. IGRT is part and parcel of modern radonc, so when cms is relaxing presence requirement, the most logical interpretation is that doc does not have to be there for IGRT as well. Astro is basically alleging conspiratorial government entrapment. Silly and desperate on so many levels

 

[scarbrtj]

I think for IGRT billing, the professional component, you still have to be there.

"If you're just tuning in..."

This is certainly ASTRO's take.
But change my mind:
1) Direct supervision means: be in the same building as the patient when the procedure is done. Direct supervision does not mean "be in the building" period.
a. No MD I know of checks the bulk of IGRT films while patient in building; instead, check films end of day
b. Not only that, "reading" a film is not a procedure... it's a professional, MD-delivered service and thus "supervision level" does not apply
c. This is why *all* professional parts of codes that have a prof/tech component are assigned supervision level "9" (which means the concept does not apply) in the Medicare physician fee schedule
2) One IGRT code e.g. is cone beam CT, 77014, ostensibly a CT code even though we call it "therapy"
a. There are many 77xxx CPT codes, most of which are radiology codes
b. Radiologists read (ie deliver professional components of prof/tech codes) remotely all the time, ie no direct supervision
3) CMS allows for outpatient hosp therapies as general supervision now. Is IGRT a part of outpatient radiation therapy, or does it stand apart? Someone would have to prove, in a court of law, that 77014 is done for diagnostic purposes instead of therapy purposes for greater-than-general to apply
4) Or one could just not bill IGRT altogether.
a. Hospitals are already not billing IGRT technical most of the times anyways.
b. MDs who bill professional on their own could choose not to bill prof if unsure

 

[metallica81788]

I am solo at a hospital-based satellite and the department at main campus (where there are multiple doctors) does not want things regarding direct supervision changing at all. MedOncs and NPs are here in the building from 7-730 and on.

It could be quite beneficial to them if I were to take time off and they wouldn't need to find locums or cover themselves, but it seems status quo for my employer.

 

[scarbrtj]

History repeats itself. Even after the Emancipation Proclamation there for a time still existed some pockets of slavery in the South. And the proclamation was just flat-out ignored in the Union-controlled border states. It wasn't until the 13th Amendment that slavery was done for outright. A lot of "supervision bigots" out there still fighting the good fight. On the plus side I don't think they'll ever get the dissatisfaction of a 13th Amendment-type moment, nor will those who disagree with the rules not changing ever get the satisfaction. 'Til then: "The government abolished direct supervision requirements" and "I don't give a damn what Lincoln said!"

 

[deleted1002574]

Dicey to compare slavery to direct supervision... Are you going to utilize Holocaust references regarding the PTV margin for brain mets next?

 

[evilbooyaa]

History repeats itself. Even after the Emancipation Proclamation there for a time still existed some pockets of slavery in the South. And the proclamation was just flat-out ignored in the Union-controlled border states. It wasn't until the 13th Amendment that slavery was done for outright. A lot of "supervision bigots" out there still fighting the good fight. On the plus side I don't think they'll ever get the dissatisfaction of a 13th Amendment-type moment, nor will those who disagree with the rules not changing ever get the satisfaction. 'Til then: "The government abolished direct supervision requirements" and "I don't give a damn what Lincoln said!"

Quoting this for posterity so I can remember the time scarb equated those who advocate for direct supervision after the mandatory requirement was removed to be similar to those who advocated for slavery after the end of the civil war.

Scarb gonna scarb.

 

[deleted1002574]

Quoting this for posterity so I can remember the time scarb equated those who advocate for direct supervision after the mandatory requirement was removed to be similar to those who advocated for slavery after the end of the civil war.

Scarb gonna scarb.

The analogy is good. The imagery / narrative ... less so.

 

[PhotonBomb]

The analogy sucks

Slavery was unequivocally wrong

Just because scarb thinks he is too good for direct supervision rules doesn’t mean the rules are inherently wrong. In fact this entire thread is built upon the concept that the end of direct supervision rules was a bad thing for the field

Do you know what an analogy is

 

[deleted1002574]

Yup. Anything that doesn't fit your world view "sucks".

The point is, ASTRO can blather all they want. They've succeeded in turning rad onc into a second tier specialty, and we can quibble about that (as 90% of the posts on this board do). They can write white papers all day long. But, the supervision change is real, and 5 years from now there will be a lot less physician presence at HOP departments.

Scarb's reading of this is logical and correctly interprets what Medicare says. Plus, they are no longer going after people. This is fact.

 

[deleted1002574]

Yes. It's not the slavery.

It's the fact that the law of the law changed, and people refuse to believe it. That's the analogy.

*EDITED BY MODS*

What do people think the rule change says? They directly state that because there has been no harm to rural centers that don't have direct supervision, they are allowing hospitals to go to general, too. Rural hospitals are treating patients without supervision. Period. End of story. That was happening and is happening. We can pretend and twist the words. But, that is what is happening. IMRT. 3D. SBRT. CBCT. All of it. IT IS HAPPENING IN THE STICKS. So, it will happen in community hospitals. That's it and that's all.

 

[Gfunk6]

Dicey to compare slavery to direct supervision... Are you going to utilize Holocaust references regarding the PTV margin for brain mets next?

I hereby invoke Goodwin's Law and declare that this thread has run its course.

 

[evilbooyaa]

Yup. Anything that doesn't fit your world view "sucks".

The point is, ASTRO can blather all they want. They've succeeded in turning rad onc into a second tier specialty, and we can quibble about that (as 90% of the posts on this board do). They can write white papers all day long. But, the supervision change is real, and 5 years from now there will be a lot less physician presence at HOP departments.

Scarb's reading of this is logical and correctly interprets what Medicare says. Plus, they are no longer going after people. This is fact.

Yes and if hospitals disagree with the MINIMUM threshold as set forth by CMS on an individual level, they can, at an institutional level, set whatever standard they would like at or above that level.

I really, really don't see the analogy here. If hospital admin are OK with not having on-site coverage given the CMS ruling, OK. If the hospital admin wants to go above the minimum threshold as set by CMS, then OK. Departmental policies will be just as or more strict than what CMS allows. I don't see the problem here.

*EDIT*
Regardless of your opinions on the matter and whether you agree or disagree with scarb, calling each other idiots in more drawn out terms is not OK. Refrain from doing so. 2 posts edited, warnings given out.

 

[KHE88]

Everybody needs to chill and stop being perma-offended by everything, especially scarb? You got big issues if you let the scarb offend you.

Have a good plate of biryani, a nice Chenin blanc, and relax...

 

[KHE88]

They directly state that because there has been no harm to rural centers that don't have direct supervision, they are allowing hospitals to go to general, too. Rural hospitals are treating patients without supervision. Period. End of story.

Curiously enough, the original CAH exception was made to allow CAHs more time to come up to speed with direct supervision requirements with the plan that they would eventually fall under direct supervision requirements too. Bizzarely they seem to have done a complete 180 and now use the success at CAHs to justify getting rid of it everywhere.

 

[scarbrtj]

Dicey to compare slavery to direct supervision... Are you going to utilize Holocaust references regarding the PTV margin for brain mets next?

It's a dicey world. Today I prescribed doxycycline to a woman. Dicey!

 

[deleted1002574]

Curiously enough, the original CAH exception was made to allow CAHs more time to come up to speed with direct supervision requirements with the plan that they would eventually fall under direct supervision requirements too. Bizzarely they seem to have done a complete 180 and now use the success at CAHs to justify getting rid of it everywhere.

Because there is no medical necessity to most linac baby sitting except protecting jobs, because ASTRO/ABR/academic medicine destroyed the market.
(Yes, we should be there for SRS, SBRT, complicated set up, blah blah blah). But, nothing bad happened before the rules and nothing bad will happen in the future. The mistakes that occur have zero to do with the MD watching Hulu in the office or from home. Sad, but true.

 

[CyberKnife19]

Thanks for the replies, but I was wondering if anyone can speak to the second part of my question, "If you do leave a little early, would that effect your ability to obtain/retain ACR or ASTRO accreditation?" Thank you.

 

[scarbrtj]

Thanks for the replies, but I was wondering if anyone can speak to the second part of my question, "If you do leave a little early, would that effect your ability to obtain/retain ACR or ASTRO accreditation?" Thank you.

According to local pontificators and prognosticators, probably not re: ACR, probably will re: ASTRO. Although who knows. To quote ASTRO: "some [supervision] flexibility is necessary for those practices that deliver care to underserved populations who may experience access to care issues." They have not gone on to define "underserved populations" or what "flexibility" means. When the "rule" came out ASTRO said it was a "blanket" rule, and "We contend that reducing the supervision of a patient during therapeutic treatment could potentially endanger patients." But now ASTRO is walking back and saying it's not really "blanket" i.e. "the supervision changes are more limited than they appear." (Reminds me of: is she pregnant? Yes. But she's less pregnant than she appears.) And what about this allowance for "flexibility" given that they initially said general supervision "endangers" patients? One could argue that ASTRO is admitting 1) either rural docs have some flexibility to give endangering care, or 2) rural patients have the flexibility to receive endangering care. Or both.

But the thing(s) ASTRO specifically points to re: supervision (APEx) read:
The documentation specifies the number of each professional discipline required to be on-site, directly involved in patient care or available remotely during operating and non-operating hours... Coverage requirements include a qualified RO to be on-call 24 hours a day and seven days a week to address patient needs and/or emergency treatments.
So is this mandating constant presence during treatment, or that the MD can be "available remotely," or just needs be on-call 168 hours/week? Guess one day soon enough someone will find out ASTRO's true, official position. But trying to divine it now is clear as mud.

 

[deleted1002574]

One could argue that ASTRO is admitting 1) either rural docs have some flexibility to give endangering care, or 2) rural patients have the flexibility to receive endangering care. Or both.

THIS. ASTRO, make some sense, bro!

 

[RollTideRadOnc]

I guess I'm a bit slow on the uptake, but can someone please help me understand this:

- Does this apply to all radiation oncology supervision? Or do it only apply to rural and "hospital based" (or some other subset entirely)? If centers need to be hospital based to be excluded from supervision, what does "hospital based" mean? Does the dept have to physically in a hospital with inpatient beds? Only affiliated with a hospital?

Sorry for the general state of my confusion and thanks for any help.

 

[deleted1002574]

Hospital out patient departments. You are either freestanding or hospital based. If you're hospital based, you fall under the new general supervision rules. If you are CAH, you fall under those same rules. If freestanding, as per usual, you are the red-headed stepchild, and SOL.

 

[PhotonBomb]

I guess I'm a bit slow on the uptake, but can someone please help me understand this:

- Does this apply to all radiation oncology supervision? Or do it only apply to rural and "hospital based" (or some other subset entirely)? If centers need to be hospital based to be excluded from supervision, what does "hospital based" mean? Does the dept have to physically in a hospital with inpatient beds? Only affiliated with a hospital?

Sorry for the general state of my confusion and thanks for any help.

Bro it’s LEAP DAY

 

[Radonc90]

I cannot believe ASTRO sent out this letter to CMS, going back to an issue that was a huge problem
for single-MD (rural or city) practice. ASTRO is completely out of touch with reality...

 

[Reaganite]

ACR Urges CMS to Extend Virtual Supervision of Diagnostic Tests

The American College of Radiology® (ACR®) met with at the Centers for Medicare and Medicaid Services (CMS) leaders Feb. 12, to provide the College’s views on virtual direct supervision of diagnostic tests. The College highlighted the importance of maintaining high patient safety by having...

www.acr.org

Wanna guess who wins this one? P.S. suck it, Michalski.

As Todd has pointed out previously, I don't believe there has ever been a supervision requirement attached to a radiation treatment delivery code. It was only the IGRT component that ASTRO decided was a diagnostic test that required supervision. Guess what? ACR thinks its perfectly fine for diagnostic tests to be supervised remotely.

 

[TheWallnerus]

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.

If we go back and look at all the doom and gloom predictions many were making way back when regarding supervision being relaxed… I think none of the predictions came true? We are still about as well or bad off now as we were Jan 1 2020. The job market is still about the same. Locums is still just as much of a thing.

This was a “bombshell” event that felt existential at the time. The reports of our death were greatly exaggerated though. (It’s still sad how many good rad oncs were ensnared over “supervision fraud.”)

It’s hard to make predictions, especially about the future. I still stick by my predictions of less new patients per year per rad onc over time! I do think that full implementation and operationalization of relaxed supervision has yet to be fully realized. When that happens, it’s impossible to predict what will happen to rad onc employment.

And maybe that will never happen? It hasn’t happened for four years.

 

[MidwestRadOnc]

I cannot believe ASTRO sent out this letter to CMS, going back to an issue that was a huge problem
for single-MD (rural or city) practice. ASTRO is completely out of touch with reality...

This is completely insane. I provide general supervision without an issue and am available via phone and FaceTime if needed to easily handle any of the specific examples mentioned. Additionally, the general supervision relaxation went into effect BEFORE COVID 19. Finally, he attempts to say that virtual direct supervision is no longer needed so we need to go back to direct supervision for all, completely sidestepping the separate issue of general supervision. How dishonest. What is the goal here? Why does he care if every rural site has a babysitter 5 days a week or not? No serious person can argue that it makes treatment delivery less safe, and if it does you have a staff and logistics problem. It is 2024. Cell phones have been a thing for 3 decades now. Smart phones for nearly 2. You need my beating heart the because……

Is anybody working on a counter to this biased ivory tower crap? Hospital lobby?

 

[TheWallnerus]

History repeats itself. Even after the Emancipation Proclamation there for a time still existed some pockets of slavery in the South.

This is completely insane. I provide general supervision without an issue and am available via phone and FaceTime if needed to easily handle any of the specific examples mentioned

You need my beating heart there because……

"Once a [rad onc] man has tasted freedom he will never be content to be a slave."

- Walt Disney

 

[RadOncDoc21]

"Once a [rad onc] man has tasted freedom he will never be content to be a slave."

- Walt Disney

Nobody ever told me that as a rad onc, I would be married to the LINAC. One time, I stepped out to get some fresh air, I swore I saw one of the therapist staring at me through the window. I think she was ready to be a whistle blower and get paid.. I made sure I had one foot still inside the building.

God forbid how many lives would have been lost that day if my other foot was outside the door!

 

[Mandelin Rain]

If we go back and look at all the doom and gloom predictions many were making way back when regarding supervision being relaxed… I think none of the predictions came true? We are still about as well or bad off now as we were Jan 1 2020. The job market is still about the same. Locums is still just as much of a thing.

This was a “bombshell” event that felt existential at the time. The reports of our death were greatly exaggerated though. (It’s still sad how many good rad oncs were ensnared over “supervision fraud.”)

It’s hard to make predictions, especially about the future. I still stick by my predictions of less new patients per year per rad onc over time! I do think that full implementation and operationalization of relaxed supervision has yet to be fully realized. When that happens, it’s impossible to predict what will happen to rad onc employment.

And maybe that will never happen? It hasn’t happened for four years.

However, relaxed supervision did singlehandedly usher in COVID-19. So.... still, not great.

 

[Mandelin Rain]

Seriously though, that black swan event could've encouraged/forced widespread adoption of VERY relaxed supervision, but it didn't really happen. If a global pandemic isn't enough to convince admins that 3 days/week or whatever is okay, I'm not sure what will. (spoiler: it will be money. it will always be money.)

 

[TheWallnerus]

Seriously though, that black swan event could've encouraged/forced widespread adoption of VERY relaxed supervision, but it didn't really happen. If a global pandemic isn't enough to convince admins that 3 days/week or whatever is okay, I'm not sure what will. (spoiler: it will be money. it will always be money.)

Because it’s (a rad onc showing up to clinic once a month) not practical. On multiple levels. You’d have broad patient dissatisfaction. There would be increased malpractice risks. If you’re treating more than 5 on beam, the logistics of the department would fall apart. Etc.

Egregious rad onc behaviors are happening, have happened, and will happen. Supervision doesn’t seem to affect it one way or the other.

 

[MidwestRadOnc]

I don’t think any reasonable person is advocating for once a month visits like oh this is the day of the month out IR guy comes.

A rad onc showing up 3 days a week is practical however. This is common in other fields where docs have to drive in to a rural site. You can be away from your family 2-3 nights a week. Not 4-5.

So it’s cool to give chemo infusions when med onc is there 2 days a week but a rad onc has to be there every single day including Saturdays to treat 1-2 patients?

What’s going to be the outcome of this?

 

[metallica81788]

So it’s cool to give chemo infusions when med onc is there 2 days a week but a rad onc has to be there every single day including Saturdays to treat 1-2 patients?

What’s going to be the outcome of this?

My hospital medoncs are all off on Fridays now with chemo infusing; purely to help in this hard to recruit area

While I'm sitting here with no clinic patients Friday afternoons stuck (I am "freestanding"). It's infuriating.

 

[Neuronix]

I'm still worried without supervision requirements that things will go radically downhill for employed rad oncs.

Oh, you only need to be on site 3 days? Have 60% salary.

Or even better for owners--five sites a week, one employed rad onc at each one day a week, for one low salary. This way you can consolidate the job of 2-3 rad oncs into one rad onc for the same cost.

What are you going to do about it? The job market will implode when the current oversupply meets that kind of crash in demand.

 

[MidwestRadOnc]

I'm still worried without supervision requirements that things will go radically downhill for employed rad oncs.

Oh, you only need to be on site 3 days? Have 60% salary.

Or even better for owners--five sites a week, one employed rad onc at each one day a week, for one low salary. This way you can consolidate the job of 2-3 rad oncs into one rad onc for the same cost.

What are you going to do about it? The job market will implode when the current oversupply meets that kind of crash in demand.

You're talking about supply and demand issues. The employed FTE farce is only an issue in competitive metro areas. You generate 10k wRVU but the hospital only pays you for 6k wRVU because you were only there 3 days a week and checked films and planned from home the other 2 days. Oh well then who generated the other 4? Oh, I did? And you're just going to keep them because I didn't come in close my door and watch youtube? Sorry, no.

Any reasonable rural hospital will consider 3-4 days on site without holding back rvus. Especially when the alternative is paying comphealth 4k/day to bring someone in for 5 days a week. Unfortunately there are many unreasonable admins who prefer the latter.

 

[RadOncDoc21]

I'm still worried without supervision requirements that things will go radically downhill for employed rad oncs.

Oh, you only need to be on site 3 days? Have 60% salary.

Or even better for owners--five sites a week, one employed rad onc at each one day a week, for one low salary. This way you can consolidate the job of 2-3 rad oncs into one rad onc for the same cost.

What are you going to do about it? The job market will implode when the current oversupply meets that kind of crash in demand.

It’s kinda like a chicken and egg thing. We lack innovation and efficiency because we can’t stop training people. In ten years, we’ll just have more rad oncs tied to a machine but this time we’re paid half because they have another you babysitting the machine together.