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

[Mandelin Rain]

I love that ASTRO is so scummy that they have re-defined the term town hall in their own image.

The irony is it’s a virtual direct town hall.

---

Members don't see this ad.

 

[communitydoc13]

I guess I'd just say there are important parallels in our field, and a lot of academic radiation oncologists reach out to tell me they feel over worked/under paid/not on mission.

Academic radoncs really should be doing academic stuff. There has always been a relatively small minority of academic docs who were essentially clinical only...and liked it, but this was not the bill of goods we were sold when applying 10-20 years ago. In my limited experience at a couple institutions, the clinical docs were clearly not perceived as equivalent to the docs doing research.

In a field without much funding and without many translational initiatives that couldn't easily fall under medical oncology or radiology, the question is: How many academic radoncs should there really be?

The answer, obviously is not that many. But in an era where large systems have almost uniformly accumulated community practices, a way to prop up this number is by mandating direct supervision...and calling community doctors employed at academic institutions academics.

 

[Neuronix]

ROhub is getting interesting!

Wow that thread on ROhub "Supervision policy discussion". Twenty replies to the ASTRO president. I'm waiting for it to get nuked. What now @Rad Onc SK , are you going to ban all the posters in that thread from ROHub?

Each quote below is a different post, most from unique users. #RescindOrResign

Highlights:


"Why even bother with a town hall forum at this point? You inconsiderate arrogant academic jerks already submitted the written request to CMS, completely screwing those of us in rural community practice. This behavior has unfortunately become common place among so called leadership at ASTRO (alternate payment model, etc.) that you've successfully managed to alienate a fair swath of your membership."


"I am in a rural area that is very hard to attract a doctor.
I have tried for 3 years to get a doctor to cover another clinic.
No luck whatsoever.
I even offered higher pay than what was being brought in from the center in terms of revenue.
Still no luck.
Then comes general supervision.
It became possible, and many practices in a similar situations evolved to utilize general supervision.

There has been no data supporting dangers of general supervision. You bring up anecdotal accounts in your letter to CMS. Whatever happened to data driven mindsets?

It is highly offensive that you send a letter to CMS without querying your constituents, then realize you were offensive, AFTER sending the letter, and NOW ask for comments.

Many of us in the real world cannot get doctors to rural areas.

We fall outside of the CAH definition. Likewise, under old rules we cannot complete general supervision.

ASTRO is all about providing care where needed in the community.

Your stance regarding direct supervision is obtuse.

I ask that you rescind your offensive letter to CMS."


"ASTRO Members,

Until today I was not paying attention to this matter but now I am very upset. We have been doing just fine without direct supervision which is an unnecessary expense and a waste of money in most cases. When direct supervision used to be required, we had to hire an expensive locum physician for every vacation for coverage and all he or she did mostly all the time was sit around doing very little with almost no patient interaction at all. The time was spent searching the Internet, drinking coffee, and eating lunch and snacks. That unnecessary expense adds to the cost of providing our services and does virtually nothing for the benefit of our patients. We have two centers that are 4 miles apart and having one physician on site and offering virtual coverage at the other works just fine, except of course for stereotactic procedures, HDR, etc.
I cannot understand how our leadership could possibly write this letter to CMS. It is really a shame that action like this would be taken without more input from the membership with very different practice situations. Very disturbing. Thanks a lot!"


"ASTRO:

I have always believed that you are a force for good for our patients… our profession. I believe that you help us serve a diverse population in urban centers, academic centers, community centers, and rural centers. You represent the underserved, those in minority, and those who are neglected.

A few months ago I was asked to salvage one of our rural oncology centers that had lost all of its oncologists. I met Mr. S in this context. He is a gentleman who is in his 60s and a member of an underserved population group. He suffers from alcoholism, nicotine addiction, lung cancer, and head and neck cancer. He has historically very poor adherence to treatments because he lives 120 miles from our rural center. I met him in the context of him requiring a 5 fraction treatment course. As part of our staffing plan for this rural center, I told him we could offer this but not at our rural center and he would have to travel 240 miles to our main facility to receive this care. He told me “Doc if you don’t do this here, I will simply go back home and die.”

Suffice it to say, I have transferred my practice to focus on the success of this rural center. Your supervision policy recommendations will prevent us from adequately caring for our patients.

I work within one of the largest rural healthcare providers in the country. 2 of our radiotherapy sites will no longer have adequate coverage based off of your policy recommendations and may be forced to discontinue offering radiotherapy services. These two centers serve a rural, underserved population and a large Native American population. Patients are often driving 2+ hours to simply get care here. If these centers would close, the next closest facilities for some patients may be 240 miles away.

Thank you for your help. I come to work every day ready to take care of patients with advanced neglected cancers in an underserved population. Please help me. At the very least, please do not hurt our patients and show us the respect to include us in discussions before submitting recommendations that will harm patient care."


"I believe you have hit upon the reasons for "direct" supervision. When you said, " 2 of our radiotherapy sites will no longer have adequate coverage based off of your policy recommendations and may be forced to discontinue offering radiotherapy services." Closing smaller centers would be the point of "direct" supervision. These patient would the be force to go to larger academic centers where most of the people associated with ASTRO work."


"Anyone who has practiced radiation oncology for any period of time recognizes the improvement in safety has come 100% via computerization and vast improvement in linear accelerator technology. Having a Radiation Oncologist virtual or "direct" makes no difference whatsoever. Sad truth that old timers just don't what to accept."


"I think I could articulate arguments on both sides of this issue.

That said, the minimum we should expect from a society that represents our specialty is that they would seek opinions from all strata of doctors in the society before making blanket recommendations to CMS. That's showing respect to your members rather than treating them like residents. It's a level of professionalism that should not have been too much to ask from our 'leadership'. Hopefully you learn from this and make more thoughtful and representative decisions in the future before acting."


"Here is an idea. Why do you first start by rescinding the letter sent by ASTRO to CMS? Then you can meaningfully engage with the providers you supposedly represent to discuss ideas and concerns. Without that, any discussion and town hall you are proposing are worthless."


"I would agree with those calling to rescind the letter until further discussion.

Jeff, is this something you are willing to do?

Like other technology, virtual supervision or even indirect supervision, should be viewed as tools used by qualified radiation oncologists to enhance care.

In my experience, radiation oncologists are some of the most available and responsive physicians in the community.

The proposal in the letter has little impact on an academic chairs with residents and other resources.

In fact, the contents of the letter are weak at best and would actually call for stopping offline review as a practice.

If the real concern here is decreased reimbursement, we have already lost that battle yet again. The only way to reverse the trend in payment cuts is to organize our whole specialty and put real pressure on Congress.

Please retract the letter and start a bigger conversation. We have much bigger issues to tackle."


"I agree with the previous comments that virtual supervision is a safe and effective management strategy for our patients. It has allowed me to deliver advanced care that would not be otherwise available to patients outside of our metro area; and also improved patient satisfaction with more timely and convenient care. "


"Your argument is inaccurate and unscientific. It is inaccurate in that you assume that the department is abandoned if the physician is not present. There will be (or should be) other medical personnel present, such as an APP or a nurse. The first two scenarios you present, mucositis and dermatitis, are easily handled by trained non-physician personnel in contact with the physician. An APP or nurse can look in the patient's mouth or at their breast, contact the physician and have the proper treatment initiated. The third scenario, treatment of the wrong area, is a systems failure that needs to be addressed by a systems correction rather than by the potential notation by the physician. Further, the reaction will be slow in developing, assuming it is dermatitis, and will be picked up at the OTV. Whether 20 or 22 treatments are given is not the issue once the wrong site is treated.

Your argument is unscientific in that no cost-benefit analysis would be positive based on your argument. A trivial similar example is that one can get PET scans on everyone and find a few early, curable cancers, but the cost for this is unacceptable. The same argument holds here. You have no data that having a Radiation Oncologist present increases patient safety in any measurable way. Rather, as CMS points out, there is no evidence of decreased patient safety during the several years of virtual supervision.

Finally, as CMS stated when direct supervision was lifted from hospital-based practices, all CMS is saying is that direct supervision is not required. If your practice wants to continue it, so be it. But that is not a reason to require it for all practices. "


"I appreciate the open forum though I would expect leadership to actually ask for input prior to a letter to CMS. I've already sent an email to ASTRO objecting to such language and lack of rationale for this decision. I would encourage ASTRO to rescind this letter and update guidelines for modern day patient care. "


"ASTRO has rightly been shamed for their preposterous February 26th letter to CMS. Their attempts at mea culpa will fail unless they admit they were wrong and actively support rational, reasonable supervision requirements. #NoBabysitting"


"As an addendum to my earlier comment, I will go so far as to say that you should either rescind the letter ASAP or resign from your position., You have little regard for the feelings of many of your members and took this action with very minimal input. I do not feel that you represent my interests or those of many other members at all. Sorry to be so expressive, but I do feel that this is an abuse of power."


"#RescindOrResign"


"I also strongly disagree with ASTRO's recent recommendations regarding supervision. The examples of incidents that supposedly occurred due to lack of supervision do NOT happen with proper policies and procedures in place and with well-trained and experienced staff.

Is there data showing that the virtual supervision during the pandemic resulted in greater incidents as compared to pre-pandemic? In my opinion, requiring direct supervision for routine treatments (non-SBRT, non-SRS, non-HDR) is not necessary as we and many others have demonstrated with virtual supervision during the pandemic.


This feels like another example of ASTRO leadership being out of step with its membership. And to send such a recommendation without first seeking feedback from membership is quite absurd.

This letter should be rescinded immediately."

 

[MidwestRadOnc]

"ASTRO has rightly been shamed for their preposterous February 26th letter to CMS. Their attempts at mea culpa will fail unless they admit they were wrong and actively support rational, reasonable supervision requirements. #NoBabysitting"

A candid apology is really needed, not just a retraction. And a commitment to include the interest of small community rad oncs in their mission. Otherwise, this may be the nail in the coffin for ASTRO's membership outside of academic centers.

Nobody at a community center, especially rural center, should be using any CME funds for ASTRO membership or conferences at this point. There are alternative ways to use those funds rather than giving it to people who hate you.

Is there data showing that the virtual supervision during the pandemic resulted in greater incidents as compared to pre-pandemic? In my opinion, requiring direct supervision for routine treatments (non-SBRT, non-SRS, non-HDR) is not necessary as we and many others have demonstrated with virtual supervision during the pandemic.

There is no good data from basically anything involving the pandemic. Just emotions, politics, and pearl clutching. This is no different.

It's hilarious that everyone saw immediately that this was an attack on general supervision using covid-direct as a strawman -- i.e., they want to bring back babysitting.

 

[metallica81788]

Is this what it took for our specialty to grow some balls?
Either way I'm here for it and appreciate
Wonder if my ASTRO membership has lapsed already or if I can go on ROhub for a few more days...

 

[Reaganite]

I can't tell if our leaders are just that stupid or that arrogant? In light of all CMS has written about supervision the last couple of years it just boggles my mind these idiots would write a lettter advocated for essentially the nuclear option of direct supervision at all sites. The change to general in hospitals was like 4 or 5 years ago and every single time CMS has commented on supervision they have hinted they are going to relax the requirements because they have not seen any safety issues. Now these boneheads write a letter stressing we must have direct supervision because of breast skin reactions? These guys truly are the dumbest guys in the room.

 

[medgator]

The only advice I can offer ASTRO at this time is best delivered by Ice Cube.

love the rest of that line..... probably what will happen to ASTRO finances after membership reacts to all of this

 

[drowsy12]

who has a link to ROHUB and can I read it even though im not a member?

 

[Gfunk6]

who has a link to ROHUB and can I read it even though im not a member?

LOL, good luck with that. Even if you have an ASTRO membership you would probably have an easier time finding the CIA intranet than that abomination of a message board.

 

[Gfunk6]

Is this what it took for our specialty to grow some balls?
Either way I'm here for it and appreciate
Wonder if my ASTRO membership has lapsed already or if I can go on ROhub for a few more days...

My ASTRO membership JUST expired. So sad, just in time for me to miss out on all the fireworks

 

[NotMattSpraker]

And a commitment to include the interest of small community rad oncs in their mission.

Ive heard this from multiple people. It sounded like Sameer was walking around recruiting "small community" rad oncs to be on committees and so forth and get them more involved in ASTRO. I thought he said this to me as well on his campaign call but I cant remember.

Not true?

 

[elementaryschooleconomics]

I can't tell if our leaders are just that stupid or that arrogant?

 

[drowsy12]

I think Michalski is toast. Guy will go down like William Henry Harrison. Like a fool in the cold.

 

[thecarbonionangle]

There is no path forward for JM. Resignation in shame and going away is the only solution. People will take their rightful anger out on him for his stupid letter but also for all the blood bath washu stuff. i agree dude is more toasted than the grill at waffle house. This is a deeply unserious person.

Grab your popcorn and pitchfork.i call for a vote of no confidence!

 

[NotMattSpraker]

There is no path forward for JM. Resignation in shame and going away is the only solution. People will take their rightful anger out on him for his stupid letter but also for all the blood bath washu stuff. i agree dude is more toasted than the grill at waffle house. This is a deeply unserious person.

Grab your popcorn and pitchfork.i call for a vote of no confidence!

Wait so, how would this happen. He would resign and Sandler takes over and then... they retract the letter?

I guess anything is possible, but presumably the policy staff participated in this letter and believe in the message.

Everyone will resign then?

Honestly, I just could never see that guy resigning anything, but I really love surprises.

 

[radoncftw]

I think Michalski is toast. Guy will go down like William Henry Harrison. Like a fool in the cold.

wish sir spam was here to see this

 

[elementaryschooleconomics]

wish sir spam was here to see this

Some say that each year, if you go outside near midnight on the winter solstice to look up at the stars, if you're really lucky and happen to be standing in some ultra-rural location, 200 miles from the nearest Walmart, you can hear the faint echo of what sounds like a scream...

"750 or GTFO"

 

[TheWallnerus]

Some say that each year, if you go outside near midnight on the winter solstice to look up at the stars, if you're really lucky and happen to be standing in some ultra-rural location, 200 miles from the nearest Walmart, you can hear the faint echo of what sounds like a scream...

"750 or GTFO"

Rumor is sir spam, KHE, and scarb went in partners and started a life insurance company in Stevens Point, Wisconsin

 

[Ray D. Ayshun]

Some say that each year, if you go outside near midnight on the winter solstice to look up at the stars, if you're really lucky and happen to be standing in some ultra-rural location, 200 miles from the nearest Walmart, you can hear the faint echo of what sounds like a scream...

"750 or GTFO"

Every time someone speaks ill of jm, a single seat prop plane gets its wings.

 

[thecarbonionangle]

What happened to spam?

 

[Mandelin Rain]

I actually don’t know, but the gif was enjoyable.

 

[RadOncDoc21]

What happened to spam?

He went a little off the rails in the sociopolitical part of SDN.

 

[radoncftw]

Every time someone speaks ill of jm, a single seat prop plane gets its wings.

i have heard some stories from residents that trained there
seems like not matt spraker can corroborate.

 

[drmg5000]

LOL, good luck with that. Even if you have an ASTRO membership you would probably have an easier time finding the CIA intranet than that abomination of a message board.

Supervision Policy Discussion is still up and active on ROHUB, now with 30 responses.

 

[radoncle]

Supervision Policy Discussion is still up and active on ROHUB, now with 30 responses.

Is anyone commenting in favor of what Astro did? Is Astro trying to defend themselves at all? Is this just another fake gesture by Astro?

 

[elementaryschooleconomics]

Supervision Policy Discussion is still up and active on ROHUB, now with 30 responses.

I wouldn't be shocked if it's because the staffer that knew the admin account login information rage quit last year and ASTRO just realized they never had anyone write it down.

Dave Adler is probably going to call his nephew in high school who's "really into computers" to ask him to help delete these vile attacks against ASTRO on their own message board...

 

[GapCalc]

I'm not an ASTRO shill but blanket virtual supervision (seemingly advocated by many on this thread) would spell disaster for our specialty.

Now ASTRO bungled the letter and the response (to absolutely no one's surprise) but I believe allowing virtual supervision across the board for all practice settings would have an extremely detrimental impact to employment opportunities and income.

The biggest employers of RO in the modern era are hospitals either offering direct employment (community or academic) or a PSA-type arrangements. Let's say CMS decides virtual supervision is good enough... do you think your hospital will continue to offer a $60/RVU production deal on your PSA when you can be there 3 days a week instead of 5?

The argument that we should 'trust rad oncs' to decide how to manage their practice pattern is well intentioned, and I think most docs would not take advantage of this rule change. But that assumes the docs are in charge -- and we aren't. Hospital c-suites (either community or academic) would look for opportunities to 'increase efficiencies' and 'decrease overhead'...

I don't know much about Bridge Oncology <website here> but it seems their model is an APP on-site for most stuff, and the RO comes in weekly/twice monthly. Consults, follow ups, and OTVs could all be virtual. All this in exchange for a cut of the global (again, I'm not clear on the details). I've heard there is private equity money behind this guy (Jordan Johnson) and this seems like every community hospital's dream. Outsource everything, keep most of the money, worry about fewer details. The only catch is, that one doctor could be covering 2 or 3 or 4 hospitals. Great for him/her, not great for whoever is working that job now. (Also, I think it's not great for patients to mostly see APPs but that's just my own opinion and I know people who are big believers in virtual everything... just not me.)

There is a place for virtual supervision but we need to be very careful about how it's implemented...

 

[thecarbonionangle]

I believe I saw on linked in one of the attendings of NY proton as “co-founder” of Bridge

 

[GapCalc]

I believe I saw on linked in one of the attendings of NY proton as “co-founder” of Bridge

This feels right (and gross…)

 

[drowsy12]

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.

 

[thecarbonionangle]

This feels right (and gross…)

Just looked again i was correct, Dr. AC. I picture a future where they win that virtual suppervision lawsuit then can funnel tons of patients to get protons in the surrounding areas. This is the way.

 

[MidwestRadOnc]

Of course this is the way it’s going to play out. Very reasonable allowances via general supervision for rural hospitals to have a single rad onc on site 3-4 days a week are going to be blown up by vultures like Jordan johnson trying to get a cut as a middleman having a rad onc there twice a month.

Ridiculous

The answer here is no virtual OTVs, consults, sbrt supervision, or sims. This allows full time docs to not be chained to the linac 5 days a week while its on but doesn’t allow JJ to exploit the rules and dump uninvested rad oncs (the kind of people who work for evicore on the side) on rural patients.

 

[Reaganite]

I can understand the concerns regarding the job market, but it's not the job of cms to protect that. As long as far more acutely toxic treatments such as chemo, dialysis. Etc do not require direct supervision and as long as serious medical illnesses continue to be managed via virtual care across the country, how can ASTRO make a legitimate clinical argument for onsite supervision of igrt or for excluding radiation management services from telehealth? Not to mention direct supervision doesn't even exist in other xrt centers across the world. Again, I understand people's concern regarding the job market, but as someone who worked in the heyday of draconian supervision rules and opportunistic therapists reporting you for going to tumor boards, I'll let JJ have his rural centers all day, every day.

We need to cut residency spots and people need to stop applying to the field. Medical students who continue to apply to this dumpster fire are, sorry, stupid. Like you people realize you're never getting a job on the coasts or any desirable market, right? You will be stuck treating patients in middle America in perpetuity....or maybe u won't have a job at all once Jordan's side wins.

 

[thecarbonionangle]

Of course this is the way it’s going to play out. Very reasonable allowances via general supervision for rural hospitals to have a single rad onc on site 3-4 days a week are going to be blown up by vultures like Jordan johnson trying to get a cut as a middleman having a rad onc there twice a month.

Ridiculous

 

[TheWallnerus]

I'm not an ASTRO shill but blanket virtual supervision (seemingly advocated by many on this thread) would spell disaster for our specialty.

Now ASTRO bungled the letter and the response (to absolutely no one's surprise) but I believe allowing virtual supervision across the board for all practice settings would have an extremely detrimental impact to employment opportunities and income.

The biggest employers of RO in the modern era are hospitals either offering direct employment (community or academic) or a PSA-type arrangements. Let's say CMS decides virtual supervision is good enough... do you think your hospital will continue to offer a $60/RVU production deal on your PSA when you can be there 3 days a week instead of 5?

The argument that we should 'trust rad oncs' to decide how to manage their practice pattern is well intentioned, and I think most docs would not take advantage of this rule change. But that assumes the docs are in charge -- and we aren't. Hospital c-suites (either community or academic) would look for opportunities to 'increase efficiencies' and 'decrease overhead'...

I don't know much about Bridge Oncology <website here> but it seems their model is an APP on-site for most stuff, and the RO comes in weekly/twice monthly. Consults, follow ups, and OTVs could all be virtual. All this in exchange for a cut of the global (again, I'm not clear on the details). I've heard there is private equity money behind this guy (Jordan Johnson) and this seems like every community hospital's dream. Outsource everything, keep most of the money, worry about fewer details. The only catch is, that one doctor could be covering 2 or 3 or 4 hospitals. Great for him/her, not great for whoever is working that job now. (Also, I think it's not great for patients to mostly see APPs but that's just my own opinion and I know people who are big believers in virtual everything... just not me.)

There is a place for virtual supervision but we need to be very careful about how it's implemented...

Very reasonable allowances via general supervision for rural hospitals to have a single rad onc

I hate to keep bringing up facts, but much of the above glosses over some important facts.

Most importantly, general supervision of radiation therapy (including SBRT and all the other buzz words) is permanent for hospital outpatient. This happened in 2020 and had zero to do with COVID. IGRT, which happens to be a diagnostic test, was made permanent by CMS to be (directly) supervisable by APPs in hospital outpatient departments in 2021 (and also had zero to do with COVID). Again, these two things are permanent rules. Virtual supervision is on the same tier as direct supervision, so virtual supervision would be a higher supervision than general.

We know ASTRO said "direct supervision for all sites of service." But this is a fantasy. CMS will not roll back its permanent rules because of one tiny society's protestations. CMS has never and will not ever apply direct supervision to rural hospitals.

At best, CMS might make virtual direct go away...
but this will only affect freestanding centers.

 

[drowsy12]

I can understand the concerns regarding the job market, but it's not the job of cms to protect that. As long as far more acutely toxic treatments such as chemo, dialysis. Etc do not require direct supervision and as long as serious medical illnesses continue to be managed via virtual care across the country, how can ASTRO make a legitimate clinical argument for onsite supervision of igrt or for excluding radiation management services from telehealth? Not to mention direct supervision doesn't even exist in other xrt centers across the world. Again, I understand people's concern regarding the job market, but as someone who worked in the heyday of draconian supervision rules and opportunistic therapists reporting you for going to tumor boards, I'll let JJ have his rural centers all day, every day.

We need to cut residency spots and people need to stop applying to the field. Medical students who continue to apply to this dumpster fire are, sorry, stupid. Like you people realize you're never getting a job on the coasts or any desirable market, right? You will be stuck treating patients in middle America in perpetuity....or maybe u won't have a job at all once Jordan's side wins.

Astro is not seriously making a safety concern argument; even if that’s what they say or couch it in, thats not their real concern.

 

[Reaganite]

I hate to keep bringing up facts, but much of the above glosses over some important facts.

Most importantly, general supervision of radiation therapy (including SBRT and all the other buzz words) is permanent for hospital outpatient. This happened in 2020 and had zero to do with COVID. IGRT, which happens to be a diagnostic test, was made permanent by CMS to be (directly) supervisable by APPs in hospital outpatient departments in 2021 (and also had zero to do with COVID). Again, these two things are permanent rules. Virtual supervision is on the same tier as direct supervision, so virtual supervision would be a higher supervision than general.

We know ASTRO said "direct supervision for all sites of service." But this is a fantasy. CMS will not roll back its permanent rules because of one tiny society's protestations. CMS has never and will not ever apply direct supervision to rural hospitals.

At best, CMS might make virtual direct go away...
but this will only affect freestanding centers.

There was an astro document that may still be in circulation stating general supervision in hospitals actually does not apply to igrt. 😆

 

[elementaryschooleconomics]

I can understand the concerns regarding the job market, but it's not the job of CMS to protect that.

This is the most important point.

Obviously, this is about the job market masked as a safety issue.

As has been pointed out, even if you took away Virtual Direct supervision, General Supervision in hospital outpatient settings was a pre-COVID decision.

What's on the table is the concept of "Virtual Direct Supervision" being permanent for all of medicine.

If ASTRO wants to bring back Direct Supervision, the 2019 version of it, that would require CMS to not only make the specialty of Radiation Oncology unique in all of medicine, it would require them to undo a decision they made many years ago.

It's just not feasible.

But even if they succeeded, as has also been pointed out, APPs on-site count as "Direct Supervision", providing a glaringly obvious loophole if you want to use this regulatory mechanism as a way to "protect" the RadOnc physician job market.

None of this makes any sense, and it's not CMS' job.

 

[elementaryschooleconomics]

There was an astro document that may still be in circulation stating general supervision in hospitals actually does not apply to igrt. 😆

Yeah this was from 2019, there's a reason that argument was abandoned (notice it doesn't show up in Jeff's letter).

IGRT is not a diagnostic test. Just because something emits x-rays doesn't automatically make it a diagnostic test. That was the whole argument for IGRT.

Also, to those that have heard this argument from Ron - no, you do not have to be physically on site to approve IGRT either.

If that were true, the entire industry of telerads would disappear literally overnight.

 

[RickyScott]

Yeah this was from 2019, there's a reason that argument was abandoned (notice it doesn't show up in Jeff's letter).

IGRT is not a diagnostic test. Just because something emits x-rays doesn't automatically make it a diagnostic test. That was the whole argument for IGRT.

Also, to those that have heard this argument from Ron - no, you do not have to be physically on site to approve IGRT either.

If that were true, the entire industry of telerads would disappear literally overnight.

Not to mention diagnostic devices need fda clearance as such. If a radiologist billed cms for a diagnostic report based on cbct, they would go after him for fraud.

 

[MidwestRadOnc]

I hate to keep bringing up facts, but much of the above glosses over some important facts.

Most importantly, general supervision of radiation therapy (including SBRT and all the other buzz words) is permanent for hospital outpatient. This happened in 2020 and had zero to do with COVID. IGRT, which happens to be a diagnostic test, was made permanent by CMS to be (directly) supervisable by APPs in hospital outpatient departments in 2021 (and also had zero to do with COVID). Again, these two things are permanent rules. Virtual supervision is on the same tier as direct supervision, so virtual supervision would be a higher supervision than general.

We know ASTRO said "direct supervision for all sites of service." But this is a fantasy. CMS will not roll back its permanent rules because of one tiny society's protestations. CMS has never and will not ever apply direct supervision to rural hospitals.

At best, CMS might make virtual direct go away...
but this will only affect freestanding centers.

Please explain. If CMS rolls backs rules to 2020 precovid, how is igrt and sbrt general in a hospital so that you don’t have to be there?

If igrt is and always was direct then how is it ok for us to work from home and check images at the end of the day? Don’t you have to be immediately available while images are acquired?

 

[Reaganite]

Yeah this was from 2019, there's a reason that argument was abandoned (notice it doesn't show up in Jeff's letter).

IGRT is not a diagnostic test. Just because something emits x-rays doesn't automatically make it a diagnostic test. That was the whole argument for IGRT.

Also, to those that have heard this argument from Ron - no, you do not have to be physically on site to approve IGRT either.

If that were true, the entire industry of telerads would disappear literally overnight.

During Covid, Ron's group was telling people they still had to be on site to check films, even though they didn't have to be there to actually supervise the IGRT portion. (They wouldn't even admit to the latter actually, but when pressed they said "probably" ok). Imagine that--you don't have to be there to oversee the procedure, but you have to be on site to check a film after the fact. The crazy thing is one could actually interpret billing rules to support that stance. Technically, if you are doing telerads you are supposed to register your home address as a site of service if you do it more than "occasionally." That's how crazy supervision had gotten prior to COVID. I can just imagine these meetings with CMS. Well-intentioned folks trying to improve access to care during a worldwide pandemic, releasing clear rules regarding supervision only to have ASTRO and Ron telling them their own rules don't actually mean what they think they mean.

 

[TheWallnerus]

There was an astro document that may still be in circulation stating general supervision in hospitals actually does not apply to igrt. 😆

True. (I won't debate... for now... if IGRT is actually a diagnostic test; let's just assume it is for sake of argument.)

Which is why I had said (link added for proof's sake):

IGRT, which happens to be a diagnostic test, was made permanent by CMS to be (directly) supervisable by APPs in hospital outpatient departments in 2021 (and also had zero to do with COVID).

 

[TheWallnerus]

Please explain. If CMS rolls backs rules to 2020 precovid, ?

If igrt is and always was direct then how is it ok for us to work from home and check images at the end of the day? Don’t you have to be immediately available while images are acquired?

Here is my best answer on this. It is a tad convoluted, but here goes.

1) Checking images is a physician professional service (-26 modifier), while the taking of images is a technical service (-TC modifier).
2) Look in the physician fee schedule to determine the supervision level of each and every CPT code: Search the Physician Fee Schedule | CMS
3) Here is what you'll find for 77014:

4) Then cross-reference this with the supervision levels from Medicare: https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2018downloads/R251BP.pdf

5) You may ask what if you bill the 77014 globally, i.e. with no modifier in a freestanding setting? Freestanding has its own supervision level specifically for X-ray therapy (and diagnostic tests!) as a carve out in the Social Security Act, and it's always direct. Freestanding centers would have more gray zone issues with remote image checking, but knowing that (freestanding imaging center) radiologists do this, it is probably OK to perform the professional service... professionally/personally (don't conflate "personally" with level 3 personal supervision here... you can't personally supervise yourself!)... at any place you want. Although, again, it's a gray zone (if billing globally in freestanding).
6) HOSPITAL (probably freestanding too): So you have to be present for IGRT (level 2 supv)... or an APP may be present for IGRT (level 2 supv)... but you can check images from home (level 9 supv).

how is igrt and sbrt general in a hospital so that you don’t have to be there?

I answered IGRT above. For SBRT, CPT 77373, the supervision level is "9" and it is a radiation therapy and it is known and a rule that radiation therapies are general supervision in a hospital. Presence may not even be necessary in a freestanding center:

Second, the Court rejected the relators' reliance on the LCDs for the IMRT and SBRT therapies, because they "fail[ed] to direct the Court to any requirement in the LCDs that a radiation oncologist be present at the time of treatment." Although relators had cited a separate LCD provision that did expressly require a radiation oncologist's direct supervision of a fifth type of therapy not at issue in the case, Image Guided Radiation Therapy (IGRT), the Court declined to extend this requirement to other therapies.

 

[Exokie67]

I believe the letter to CMS may be a follow-up to the January letter sent to CMS requesting the discontinuation of telehealth as an option for 77427-weekly treatment management. Perhaps ASTRO is hedging their bets in case CMS rules against them on this issue. They may see 77427 as the one code that still requires physician presence in the clinic and should be protected at all costs - as a defeat could in theory lead to a department which is largely remotely administered by a radonc any distance away.

Alternatively - and ironically -the letter’s request to reinstate direct supervision may be part of the ROCR initiative. ROCR’s case rate plan eliminates the need to bill for 77427 - weekly treatment management and the required in-person evaluation by the radiation oncologist (and only the radiation oncologist). Direct supervision fills this hole in ROCR. Ultimately, all of this is meant to “fix” the manpower issue by increasing demand for linac babysitters while reducing salaries and maintaining the current output of new graduates. It’s ludicrous solution which ignores the real issue and a ridiculous overreach by a society that has always ignored the impact of their previous dictates on small/solo practices.

 

[elementaryschooleconomics]

I believe the letter to CMS may be a follow-up to the January letter sent to CMS requesting the discontinuation of telehealth as an option for 77427-weekly treatment management. Perhaps ASTRO is hedging their bets in case CMS rules against them on this issue. They may see 77427 as the one code that still requires physician presence in the clinic and should be protected at all costs - as a defeat could in theory lead to a department which is largely remotely administered by a radonc any distance away.

Alternatively - and ironically -the letter’s request to reinstate direct supervision may be part of the ROCR initiative. ROCR’s case rate plan eliminates the need to bill for 77427 - weekly treatment management and the required in-person evaluation by the radiation oncologist (and only the radiation oncologist). Direct supervision fills this hole in ROCR. Ultimately, all of this is meant to “fix” the manpower issue by increasing demand for linac babysitters while reducing salaries and maintaining the current output of new graduates. It’s ludicrous solution which ignores the real issue and a ridiculous overreach by a society that has always ignored the impact of their previous dictates on small/solo practices.

Too bad a couple of insiders wrote ROCR in secret.

These "holes" in ROCR could have been prevented if there had been like...a comment period or...something...before it was unleashed on everyone...

 

[MidwestRadOnc]

Here is my best answer on this. It is a tad convoluted, but here goes.

1) Checking images is a physician professional service (-26 modifier), while the taking of images is a technical service (-TC modifier).
2) Look in the physician fee schedule to determine the supervision level of each and every CPT code: Search the Physician Fee Schedule | CMS
3) Here is what you'll find for 77014:
View attachment 384156
4) Then cross-reference this with the supervision levels from Medicare: https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2018downloads/R251BP.pdf
View attachment 384157
5) You may ask what if you bill the 77014 globally, i.e. with no modifier in a freestanding setting? Freestanding has its own supervision level specifically for X-ray therapy (and diagnostic tests!) as a carve out in the Social Security Act, and it's always direct. Freestanding centers would have more gray zone issues with remote image checking, but knowing that (freestanding imaging center) radiologists do this, it is probably OK to perform the professional service... professionally/personally (don't conflate "personally" with level 3 personal supervision here... you can't personally supervise yourself!)... at any place you want. Although, again, it's a gray zone (if billing globally in freestanding).
6) HOSPITAL (probably freestanding too): So you have to be present for IGRT (level 2 supv)... or an APP may be present for IGRT (level 2 supv)... but you can check images from home (level 9 supv).



I answered IGRT above. For SBRT, CPT 77373, the supervision level is "9" and it is a radiation therapy and it is known and a rule that radiation therapies are general supervision in a hospital. Presence may not even be necessary in a freestanding center:

Second, the Court rejected the relators' reliance on the LCDs for the IMRT and SBRT therapies, because they "fail[ed] to direct the Court to any requirement in the LCDs that a radiation oncologist be present at the time of treatment." Although relators had cited a separate LCD provision that did expressly require a radiation oncologist's direct supervision of a fifth type of therapy not at issue in the case, Image Guided Radiation Therapy (IGRT), the Court declined to extend this requirement to other therapies.

What if the hospital employees the rad onc and bills globally? Then no issue to acquire images and the physician checks them from home because he is not there that day at all and providing general supervision from off site?

 

[Reaganite]

What if the hospital employees the rad onc and bills globally? Then no issue to acquire images and the physician checks them from home because he is not there that day at all and providing general supervision from off site?

Prof services are submitted on a cms 1500 form, tech services are on something called a "UB". At least in my state the employed physician prof claims are still submitted separately from the tech claims. If checking films is akin to telehealth radiology (is it?), you should technically submit the professional claims under the address of the site where u made the read. I doubt cms ever thought of making this a fraud issue esp for rad onc, though. The issue was more reimbursement-related on the teleradiology side. If someone is reading out of state, their professional services may fall under a different mac jurisdiction. This really isn't happening in rad onc. People are just looking to check images from their home a few miles from the center. Also, cms allows for some radiology reads to be done off site while not requiring you to register the location (i.e. your home) as a site of service if it's not routine. But I could never find a strict definition of "not routine." Finally, for global billing there is no way to submit separate claims but per acr policy it seems to be ok to submit from the location where the imaging was performed even if read offsite as long as both services were provided in the same general geography (i.e. same MAC).

 

[TheWallnerus]

What if the hospital employees the rad onc and bills globally? Then no issue to acquire images and the physician checks them from home because he is not there that day at all and providing general supervision from off site?

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.)

 

[Mandelin Rain]

Just cut residency spots. Duh.

Pissing in the wind with CMS will be much less fruitful than just controlling the things our specialty can control.