ROCR Town Hall/Webinar Discussion

[TheWallnerus]

ASTRO is, yet again, committing an obvious unforced error with ROCR.

ROCR Town Hall Live btw

Everyone introduces themselves, says their hospitals' names... Connie Mantz: "I practice in a large network of centers"... do tell, Connie!

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[RickyScott]

ROCR Town Hall Live btw

Everyone introduces themselves, says their hospitals' names... Connie Mantz: "I practice in a large network of centers"... do tell, Connie!

and he would really benefit from cheap labor due to destroying job market with ROCR
No employed doctors on this panel? Coincidence

 

[sirspamalot]

"This is all you're getting. 10 for protons/academia and 1..no wait... now improved to 2 with ROCR. You're gonna love it. Trust us. Its the best we can do. We are listening to you (screaming) and we came up with this solution that guarantees you will get screwed slower than before. Consider this a love making session from ASTRO. ROCR is the lube and just relax and it's going to be great m'kay? .... "


Nah. This is more nonsense, mystery meat...." gosh if we don't do it then cigna/evicore will be even worse for you. "

It's never..." bull**** sound off like you have a pair. ASTRO is here and wants to treat all radoncs fairly AND defend the specialty from enemies foreign and within. Our mission is for patients and that includes putting forth the best and most cost effective care that is proven value. No more will we shill for anyone or any group but rather focus on the practice itself. "


On that day when this gets said I will write a check for dues. Until then you can forget it. I'd rather buy lottery tickets as at LEAST I'D HAVE A CHANCE OF WINNING THE GAME

 

[RickyScott]

and he would really benefit from cheap labor due to destroying job market with ROCR
No employed doctors on this panel? Coincidence

kid from harvard just said rocr will offset consolidation? much of this needs to be fact checked

 

[communitydoc13]

kid from harvard just said rocr will offset consolidation? much of this needs to be fact checked

Yeah, does consolidation occur because someone is looking to buy or because someone needs to sell?

Curious as to what game theory models they employed to back up this statement.

 

[RickyScott]

Yeah, does consolidation occur because someone is looking to buy or because someone needs to sell?

Curious as to what game theory models they employed to back up this statement.

Consolidation happens because it makes sense for both parties. When you create a situation where neighboring centers are worth more to large healthcare systems with protons than present owners, you are driving consolidation.

 

[NotMattSpraker]

kid from harvard just said rocr will offset consolidation? much of this needs to be fact checked

Pretty bold to make the resident answer the proton question! I chuckled when I realized they picked him because he's a millennial.

I was very disappointed with that webinar, not a town hall. It is clear ASTRO has planted their flag, so to speak, with ROCR and their priorities.

I have a bad feeling the accreditation requirement will not be removed.

 

[evilbooyaa]

I was not aware that the only questions they'd answer were ones that they had already pre-screened/pre-vetted/pre-pared for. Suboptimal. Probably need to have another hour long session where they just answer questions from the chat.

Maybe I'm Naive, but I at least understand why protons can't join ROCR. Any proton center charging more than IMRT rates would immedatiately go bankrupt if they were included. It's not good to 'pick a winner' but that's the natural course of someone who builds a proton machine I guess. You get to charge more in an attempt to not go completely underwater. I also understand why PPS exemption is not going to be included - I appreciated the comments by Join Luh.

Overall, I at least appreciated the fact they had actual non-academic folks there, and although Casey Chollet has access to a proton machine, I'm not aware of the other 3 having one? Obviously Milligan had one in residency but doubt Maine has one? Does Genesis Care have any proton machines? Probably no protons in rural Ca?

If there's truly no MACRA/MIPS bull**** that'll help just with admin non-sense. Knowing how much Join Luh was against RO-APM, if he is on board with this, then maybe I can get on board.

I did like that some things were felt to be 'fluid' and not 'set in stone'.

Like the 90-day exemption could be shortened to 30 days? Sure it's not 0 days but much better than 90. Especially if the money doesn't change the way Mantz said. Although the discussion about bone mets with a brain lesion later getting included in bone met pricing is so ****ing stupid that I don't understand why no one understands.

The accreditation nonsense needs to be thrown out (similar to the 90-day rule). If CMS doesn't think accreditation is complete (as said by Join Luh) then why does ASTRO think it is?

Had to step out for a bit - was there any discussion regarding why CMS couldn't just cut the base or 'M' rate or whatever in the future?

 

[evilbooyaa]

As an aside - creating a separate thread solely for discussion of what was said at the just completed Town Hall. If someone could post a link for others to watch when it gets uploaded, that'd be great. Or PM it to me.

 

[RadOncDoc21]

Once you guys analyze it, make sure to send me the summary by Monday morning.

 

[evilbooyaa]

I expect lively SDN and twitter discussion over the weekend. I will not be participating. Have a good weekend!

 

[RickyScott]

I was not aware that the only questions they'd answer were ones that they had already pre-screened/pre-vetted/pre-pared for. Suboptimal. Probably need to have another hour long session where they just answer questions from the chat.

Maybe I'm Naive, but I at least understand why protons can't join ROCR. Any proton center charging more than IMRT rates would immedatiately go bankrupt if they were included. It's not good to 'pick a winner' but that's the natural course of someone who builds a proton machine I guess. You get to charge more in an attempt to not go completely underwater. I also understand why PPS exemption is not going to be included - I appreciated the comments by Join Luh.

Overall, I at least appreciated the fact they had actual non-academic folks there, and although Casey Chollet has access to a proton machine, I'm not aware of the other 3 having one? Obviously Milligan had one in residency but doubt Maine has one? Does Genesis Care have any proton machines? Probably no protons in rural Ca?

If there's truly no MACRA/MIPS bull**** that'll help just with admin non-sense. Knowing how much Join Luh was against RO-APM, if he is on board with this, then maybe I can get on board.

I did like that some things were felt to be 'fluid' and not 'set in stone'.

Like the 90-day exemption could be shortened to 30 days? Sure it's not 0 days but much better than 90. Especially if the money doesn't change the way Mantz said. Although the discussion about bone mets with a brain lesion later getting included in bone met pricing is so ****ing stupid that I don't understand why no one understands.

The accreditation nonsense needs to be thrown out (similar to the 90-day rule). If CMS doesn't think accreditation is complete (as said by Join Luh) then why does ASTRO think it is?

Had to step out for a bit - was there any discussion regarding why CMS couldn't just cut the base or 'M' rate or whatever in the future?

All 3 doc’s salaries are directly set by proffessional billings collections, so they benefit from ROCR. The vast majority of the rest of us are employed and our salaries are driven by supply and demand and almost totally disconnected from the drop in proffesional cms reimbursement rates over the past 20 yrs (during which hospitals fees are up several hundred percent over inflation)

In addition mantz’s company benefits from a bad job market. Salaries are probably their biggest expense.

 

[NotMattSpraker]

Maybe I'm Naive, but I at least understand why protons can't join ROCR. Any proton center charging more than IMRT rates would immedatiately go bankrupt if they were included. It's not good to 'pick a winner' but that's the natural course of someone who builds a proton machine I guess. You get to charge more in an attempt to not go completely underwater. I also understand why PPS exemption is not going to be included - I appreciated the comments by Join Luh.

Overall, I at least appreciated the fact they had actual non-academic folks there, and although Casey Chollet has access to a proton machine, I'm not aware of the other 3 having one? Obviously Milligan had one in residency but doubt Maine has one? Does Genesis Care have any proton machines? Probably no protons in rural Ca?

Reading between the lines on this presentation should be a clear message there will be no budging on protons or PPSE. Casey said it when she was discussing PPSE, "there will be outrage in some circles" (paraphrasing). This is our system. It is not easy to deal with it, but they had to say something. They've chosen a clear path forward either working with or avoiding the proton lobby, and that is their choice.

Their answer to the proton complaints was a decently crafted PR answer, but a PR answer nonetheless. I don't think this is about the personal beliefs of the panelists. It is just reflective of how ASTRO engages the membership on challenging issues that people often discuss online.

ASTRO made a choice to own their position on proton therapy by communicating through a resident. Not the president, not someone from government relations, not Dave or Anne, a resident. He implied why they chose him to present that part and it is ridiculous. It says a lot about the leadership and whoever is organizing ROCR communications.

Im happy I kept my money this year.

 

[elementaryschooleconomics]

That was peak ASTRO.

1) Friday at 4PM webinar. No advertising outside of Sameer taking the initiative to post on SDN. Managed to scrape together ~230 registrants, when I checked about halfway through: 183 in the meeting.

2) Four people were visible for the 30 minute introduction, which rehashed the talking points from the original webinar.

3) Of the four, one was the Chief Policy Officer for GenesisCare, currently in bankruptcy. Before that, he was Chief Policy Officer at 21st Century Oncology, which was subject to the highest profile whistleblower cases in American RadOnc history.

He introduced himself as "working for a large, freestanding network of centers".

4) Of the four, one was a resident. Well, to be fair, he just graduated. He hasn't started work yet. He'll start in the fall.

5) Anne Hubbard showed up at the 30 minute mark to moderate questions.

6) ...that weren't really questions. She read off a list of pre-screened/vetted "questions". Very high probability they were talking points dressed up in the style of questions.

Obviously...there's a lot more to talk about. But in case anyone missed it, I wanted to frame this event correctly in your minds.

 

[NotMattSpraker]

6) ...that weren't really questions. She read off a list of pre-screened/vetted "questions". Very high probability they were talking points dressed up in the style of questions.

Yes, that too. Totally. I actually laughed at one point at one of the questions.

I really wanted a "Why is ASTRO so awesome?" at the end. It would have at least left me smiling on a Friday afternoon.

 

[CaesarRO]

I'll repeat what I said before. I think we all make good points and have legitimate gripes about PPSE and Protons.

Photon reimbursement is also falling.

Do we want to avoid addressing the coming issues in the photon landscape because the other issues aren't being solved at the same time?

I appreciated Join's perspective on the PPSE as well. He mentioned they are in a totally different system, but it made me wonder for the first time if they are budgeted for outside of the governments general CMS budget too.

I also took away from Casey that they *do* want feedback. This wasn't presented as a fully formed concept, it was presented as an opening position and they want community input.

I *really* hope somebody directs them here and they read some of the feedback. I think some comments are more actionable than others, but if you want honest opinions no better place than SDN.

I see the problems too. I'm just in the "don't throw the baby out with the bathwater" camp.

Like the 90-day exemption could be shortened to 30 days? Sure it's not 0 days but much better than 90. Especially if the money doesn't change the way Mantz said. Although the discussion about bone mets with a brain lesion later getting included in bone met pricing is so ****ing stupid that I don't understand why no one understands.

My understanding of his comment was that if 20% of the time you have another treatment within the 90 days, that would be captured in the base rates. So if that same pattern holds up, 4/5 times you are paid more than you'd need for treating once in 90 days, but 1/5 times you'd have to bite the bullet and treat within 90 days and hope *on average* it balances out.

If we switch to 30 days, the rate would be set by looking at average payments within 30 days of treatment completion so the case rate would be *lower* than the 90 day case rate, but you'd recapture it when you did need to retreat. I took it more as a "the end result is a wash" comment instead of a "the case rate is unchanged" comment.

I do have some concerns about just averaging everything away.

I didn't hear payment neutrality discussed but if everyone is on the same payment schedule this *should* help freestanding and lower reimbursed hospitals and hurt higher reimbursed hospitals.

Just a different kind of tragedy of the commons, making us all average.

 

[NotMattSpraker]

My understanding is that this introduces site neutral payments and I think Connie said this at the top of the webinar too.

 

[CaesarRO]

Also, I did not catch (phone broke up) what Join explained on the administrative side and why he favored accreditation. If anyone can recap his explanation I'd appreciate it

 

[medgator]

How was PPS exemption justified?

 

[NotMattSpraker]

How was PPS exemption justified?

It’s a congressional program outside Medicare.

We discussed this on our podcast about the RO APM over a year ago and Connie and Join we’re both on the show. It was surprising to see it presented as a new revelation, but maybe I misunderstood what they were saying today.

 

[CaesarRO]

She basically made the baby and bathwater argument.

They are proposing a program to modify Medicare payments for our specialty alone.

Changing PPSE means modifying medicare and repealing separate legislation. If we try to do that, we're "declaring war" not just on Rad Onc in the PPSE but the whole PPSE system itself and we'd get squashed.

She explicitly said ASTRO isn't strong enough to take on that fight

 

[sirspamalot]

She basically made the baby and bathwater argument.

They are proposing a program to modify Medicare payments for our specialty alone.

Changing PPSE means modifying medicare and repealing separate legislation. If we try to do that, we're "declaring war" not just on Rad Onc in the PPSE but the whole PPSE system itself and we'd get squashed.

She explicitly said ASTRO isn't strong enough to take on that fight

OK fine. So we yield on PPSE because we can't muster the strength or courage to make it an issue. It may well be impossible. But if their reimbursement continues at insanely high rates and has zero impact on Medicare based reimbursement then wtf has ASTRO actually accomplished on behalf of pp in the last 20 years?

I find the attitude of ASTRO (leaders and admin) towards real world practitioners frankly just terrible.

I didn't even know about the webinar until it was already done.

I think it's time to have another org agnostic one with the goal to be to publish a set of mission objectives. Then we can see how far ASTRO will go.

Carefully controlled narratives and PR are not helping the cause.

 

[sirspamalot]

I just listened to this. How ANY SANE PERSON can support ROCR is NUTS.

Conflicts of Interest galore, overwhelming BS and acrobatic hedging is beyond the pale. Forced accreditation is the cherry on top F you to our peers.

Hey ASTRO: QUIT KILLING MY JOB.



What happened to our new shiny incoming President who said it was all going to be better, because this time it's different?

(chews sandwich, spits it out)

They want feedback so here is mine:

This will be the Hindenburg of our profession if it is put through.

Horrifying.

 

[Reaganite]

We've been part of case rate pilots, and they don't save you from cuts. You are still required to submit utilization by cpt, and health plans benchmark your utilization against traditional ffs expenditure. If your utilization suddenly drops in half, they will catch that and adjust the case rate. Imagine a world where rad onc utilization drops in half overnight...do we really think cms is going to reward us with increases in payment to match inflation?

 

[RickyScott]

We've been part of case rate pilots, and they don't save you from cuts. You are still required to submit utilization by cpt, and health plans benchmark your utilization against traditional ffs expenditure. If your utilization suddenly drops in half, they will catch that and adjust the case rate. Imagine a world where rad onc utilization drops in half overnight...do we really think cms is going to reward us with increases in payment to match inflation?

If the department stops treating patients at 1:00, no new hiring and many FTEs will be reduced, even if cms doesn’t adjust. Administrators and employers like Connie manz will happily keep the money. The game is over when departments close early.

 

[Rad Onc SK]

We've been part of case rate pilots, and they don't save you from cuts. You are still required to submit utilization by cpt, and health plans benchmark your utilization against traditional ffs expenditure. If your utilization suddenly drops in half, they will catch that and adjust the case rate. Imagine a world where rad onc utilization drops in half overnight...do we really think cms is going to reward us with increases in payment to match inflation?

Your post, in my opinion, is the rationale for ROCR (or something similar)

ROCR would take most of rad onc reimbursement out of CMS/HOPPS (and towards something similar to PPS exempt centers)

I personally do not favor PPS exemptions, but I also have to admire the work their administrators did 40 years ago to get that status. They have stood the test of time.

With ROCR, PC would be linked to MEI and TC to HIPPS.

 

[sirspamalot]

Your post, in my opinion, is the rationale for ROCR (or something similar)

ROCR would take most of rad onc reimbursement out of CMS/HOPPS (and towards something similar to PPS exempt centers)

I personally do not favor PPS exemptions, but I also have to admire the work their administrators did 40 years ago to get that status. They have stood the test of time.

With ROCR, PC would be linked to MEI and TC to HIPPS.

They will annihilate us by simply electing to chop 3% "bag of breast cancer xrt" payment.

ASTRO should earn it's members dues... Fight the long hard fight. Say no. Mobilize it's power to effectuate legislative change. Spend HALF THE BANKROLL on political activity if need be...and another quarter reaching out to every practitioner saying "this is where we draw the line. We die on this hill for you, for us. We are all equal in this together. United we stand." NO ROCR NO APM FIGHT FOR EVERY CPT CODE TO THE LAST BREATH.

NO more exemptions. NO more site of care vast payment differential. NO more tiptoeing around protons.

The situation is dire.

The time is now.

Fight the good fight or our specialty dies.

 

[deleted1111261]

It's dead. This "Town Hall" killed it. Own-goal. Give it 6-12 months and it will vanish from our collective consciousness. Thank goodness.

Curious how they think it went.

Such a dismal organization with regards to messaging and garnering support for anything, b/c they don't know how to do it without antagonizing half the membership.

Something good will come out of this.

Haha, just kidding. No it won't. Not unless the entire board changes the way it operates.

 

[sirspamalot]

It's dead. This "Town Hall" killed it. Own-goal. Give it 6-12 months and it will vanish from our collective consciousness. Thank goodness.

Curious how they think it went.

Such a dismal organization with regards to messaging and garnering support for anything, b/c they don't know how to do it without antagonizing half the membership.

Something good will come out of this.

Haha, just kidding. No it won't. Not unless the entire board changes the way it operates.

Based on the words spoken by incoming leadership right here on SDN....

Don't call me Nostradamus yet but...

Ain't nuthin gunna change bruh.

 

[elementaryschooleconomics]

Since the start, I've been thrown off by the genuine appeal for support.

Because...this is proposed national legislation. This is a big deal.

The language from the website is insane when juxtaposed with the Town Hall:

"Developed by internal ASTRO members, with the help of expert consultants, the ASTRO board approved ROCR after numerous versions were evaluated and analyzed"

"Expert consultants" = two dudes from Wakely
HP Council physician leaders = Connie, Catheryn...maybe Casey? That Harvard resident? Anne Hubbard and Dave Adler?
"Approved as legislative proposal" = it was repeated in the Town Hall this was NOT the final form

But...not only did this take the general RadOnc community by surprise, it took ACRO by surprise. It took the ACR by surprise.

If I was going to try something like this, I'd tag our oldest friends and comrades at the ACR from the start. They have much more experience and resources...and Congressional phone numbers.

What's the plan here? A printed brochure to hand out on the singular Advocacy Day?

 

[NotMattSpraker]

Your post, in my opinion, is the rationale for ROCR (or something similar)

ROCR would take most of rad onc reimbursement out of CMS/HOPPS (and towards something similar to PPS exempt centers)

I personally do not favor PPS exemptions, but I also have to admire the work their administrators did 40 years ago to get that status. They have stood the test of time.

With ROCR, PC would be linked to MEI and TC to HIPPS.

AMA is lobbying to link MPFS to MEI right now. This has been a focus of communications by AMA and was mentioned in the ROCR webinar too.

 

[BobbyHeenan]

I don't fully get this notion that ASTRO has to appease the proton lobby.
Now an argument can be made (which does have merit) that if proton centers go down the whole specialty is at risk. But the notion that there is a separate proton lobbying entity with divergent views/interests than ASTRO is questionable IMO.

 

[Fpg1245]

AMA is lobbying to link MPFS to MEI right now. This has been a focus of communications by AMA and was mentioned in the ROCR webinar too.

Probably more worthwhile to throw support behind than ROCR

 

[communitydoc13]

What's the plan here? A printed brochure to hand out on the singular Advocacy Day?

I know nothing. But it smells of opportunism.

Imagined telephone call....

"Hey Dave, this is (garbled....unclear name...husky voice) from the hill,...yeah... no...no... I'm doing great,... kids are great,....lacrosse game this weekend,... yep, yep,....oldest just got into Georgetown....very excited....yep...saw Kavanagh at Church....you might see him later this month at a BBQ?....nice!

Yeah, so Dave, I think we have a real window here to do something. As you know, Bernie heads the Senate Committee on Health, Education, Labor and Pensions...and you know Bernie....all about equity, primary care initiatives, this sort of thing....radical stuff....big stuff...yeah, not our cup of tea, but the libs in the lower chamber are cooking up something and I'm a bit worried, depending how the next election goes.....yeah...I think there is going to be a pretty radical push for global payment reform....we don't want to get caught up in this....yeah....no, we want to get ahead of this.

Thing is Dave,....everybody on the hill loves the radical (good radical not Bernie radical) stuff you're doing in your field....the proton stuff....yep...I mean we've got Patty Murray on the committee...yeah, she fronted to Seattle proton initiative, Romney is down with protons....really happy with the Huntsman facility....he's on the committee....and right now, we've got a republican house and three victories at the state level regarding forcing payment for protons....yep...of course...Tennessee, Illinois and Oregon...yep...protons are practically populist...

Koch is on board...he'll be trying to pick some winners, but he is all in on protons and of course the President is very grateful for the compassionate proton care that his family received...yep...might be some correlation there?... protons and compassion...yes, I agree.

So we've got an opportunity to pass something small and protect what you are doing before the proverbial s%#t hits the fan with global payment reform.

Just draw something up, do the routine cost analysis and get it into our hands ASAP. I think we can fold it into a larger initiative....just make it seem like you are saving us some money OK?... yeah, that's necessary in this environment....cut the routine stuff....great....look forward to seeing it."

 

[sirspamalot]

 

[OTN]

 

[Gfunk6]

This is ASTRO's third attempt to pass ROCR or its equivalent? I won't hold my breath.

I'm sure this is how the backdoor conversations between ASTRO leadership and congresional leaders went:

ASTRO: We don't like annual cuts to RO reimbursement, they are hurting our field.
Congress: OK . . .
ASTRO: How about instead of reducing RO reimbursement by 3% every year, you just cut it by 30% upfront and then freeze cuts for 10 years?
Congres: OK . . .
ASTRO: YAY!

 

[OTN]

There's one aspect about this that I haven't seen discussed, and it's one of my main concerns. I would like to start by saying that I blame all of Washington and both political parties for our current fiscal scenario, and I don't think it's going to be helpful to derail this into a political discussion, which it is not intended to be.

I'm worried that this would put us outside the rest of the field of medicine when it comes to reimbursement. I do understand the short-term pressures that led to the consideration of ROCR (hypofractionation, etc), but there are big-picture, longer-term issues which I don't think are properly being taken into consideration.

Mainly, while I'm less worried about the dollar losing its status as the worlds' reserve currency as I once was (BRICS has gone precisely nowhere, I think we're all, globally, seeing the benefit of having a global superpower with a powerful blue water navy, etc), even without that disaster scenario occurring the US will need to print an incredible amount of money to pay for the ~$140 trillion in unfunded obligations for which we are currently on the hook (Medicare and Social Security being the big two). The resulting inflation will require constant congressional/legislative fixes to the Medicare payment formula just to keep practices viable.

By disassociating from everyone else, we may be requiring an immense amount of work to be done by our advocacy organizations in the future, forcing them to continuously lobby to update whatever formula ROCR applies in an era of near-hyperinflation. Obviously, the details of the ROCR proposal will be important and will affect this risk. If, for example, the reimbursement formula is based on other areas in the house of medicine, then we could be somewhat protected.

Many in ASTRO's leadership likely will not be practicing at the time when these inflationary concerns will come to the fore. However, I'm fairly certain they will arise, as I cannot imagine a future where politicians dramatically cut services to their largest voting block- seniors. Only viable political option in our system is going to be to print the money needed to cover the bills. I really hope I'm wrong about the coming inflationary environment, but if I am not, I hope the proposal contains elements which help protect our future.

Edit: For example- https://x.com/TuurDemeester/status/1790721851141841157, but take it with a grain of salt, as the fella has a stake in bitcoin. Still, the concern is valid.

 

[fiji128]

View attachment 386792

“Supporting shorter treatments for certain cancers, allowing patients more time to work and spend time with loved ones.” Look I’d treat you in 15 fractions but ROCR didn’t pass so it’s going to be 30, sorry.

 

[thesauce]

I found a pretty good lobbyist that would be willing to fight against this. Would others be willing to chip in?

 

[elementaryschooleconomics]

I found a pretty good lobbyist that would be willing to fight against this. Would others be willing to chip in?

Yup.

 

[thesauce]

“Supporting shorter treatments for certain cancers, allowing patients more time to work and spend time with loved ones.” Look I’d treat you in 15 fractions but ROCR didn’t pass so it’s going to be 30, sorry.

Supporting shorter courses for ALL indications

 

[thesauce]

There's one aspect about this that I haven't seen discussed, and it's one of my main concerns. I would like to start by saying that I blame all of Washington and both political parties for our current fiscal scenario, and I don't think it's going to be helpful to derail this into a political discussion, which it is not intended to be.

I'm worried that this would put us outside the rest of the field of medicine when it comes to reimbursement. I do understand the short-term pressures that led to the consideration of ROCR (hypofractionation, etc), but there are big-picture, longer-term issues which I don't think are properly being taken into consideration.

Mainly, while I'm less worried about the dollar losing its status as the worlds' reserve currency as I once was (BRICS has gone precisely nowhere, I think we're all, globally, seeing the benefit of having a global superpower with a powerful blue water navy, etc), even without that disaster scenario occurring the US will need to print an incredible amount of money to pay for the ~$140 trillion in unfunded obligations for which we are currently on the hook (Medicare and Social Security being the big two). The resulting inflation will require constant congressional/legislative fixes to the Medicare payment formula just to keep practices viable.

By disassociating from everyone else, we may be requiring an immense amount of work to be done by our advocacy organizations in the future, forcing them to continuously lobby to update whatever formula ROCR applies in an era of near-hyperinflation. Obviously, the details of the ROCR proposal will be important and will affect this risk. If, for example, the reimbursement formula is based on other areas in the house of medicine, then we could be somewhat protected.

Many in ASTRO's leadership likely will not be practicing at the time when these inflationary concerns will come to the fore. However, I'm fairly certain they will arise, as I cannot imagine a future where politicians dramatically cut services to their largest voting block- seniors. Only viable political option in our system is going to be to print the money needed to cover the bills. I really hope I'm wrong about the coming inflationary environment, but if I am not, I hope the proposal contains elements which help protect our future.

Edit: For example- https://x.com/TuurDemeester/status/1790721851141841157, but take it with a grain of salt, as the fella has a stake in bitcoin. Still, the concern is valid.

You’re not wrong. What’s going to happen with this is that CMS will start to pay a flat 20-40k per fraction, because everything will be 1 or 2 fractions. That is not going to fly for long.

 

[NotMattSpraker]

I found a pretty good lobbyist that would be willing to fight against this. Would others be willing to chip in?

Yes, of course, but, I would like to hear:

ACRO is absent from the list of supporters and they employ a professional lobbyest. What are they doing?

ACR is on the list of supporters. So they support ROCR? I've never seen them say that until now. Do they support similar legislation for radiology? Do they not? The ACR has more clout than any of these people.

What does CMS say about this apparent end around with RO-APM kind of... undead?

Do we even know this isn't DOA?

Finally, how insane that ASTRO submitted this bill, announced it with a really embarrassing weird GIF, and I cant seem to find the text anywhere. I am a radiation oncologist, presumably I have great interest in the proposed bill's text! I have to get it from the government with the rest of the public, really?

I dont know how Dave and Anne stand in front of working physicians and ask for volunteer time with a straight face.

 

[thesauce]

Yes, of course, but, I would like to hear:

ACRO is absent from the list of supporters and they employ a professional lobbyest. What are they doing?

ACR is on the list of supporters. So they support ROCR? I've never seen them say that until now. Do they support similar legislation for radiology? Do they not? The ACR has more clout than any of these people.

What does CMS say about this apparent end around with RO-APM kind of... undead?

Do we even know this isn't DOA?

Finally, how insane that ASTRO submitted this bill, announced it with a really embarrassing weird GIF, and I cant seem to find the text anywhere. I am a radiation oncologist, presumably I have great interest in the proposed bill's text! I have to get it from the government with the rest of the public, really?

I dont know how Dave and Anne stand in front of working physicians and ask for volunteer time with a straight face.

I am interested in a lot of these answers as well, and a lobbyist can probably find some of this out, but in the end a lot of this is probably unknowable or out of our control. Getting someone to champion for us is not.

 

[Mandelin Rain]

CPI up 20% in past 3 years. A decade of constant cuts to our reimbursement. ASTRO lobbying Congress for another -3% to -8% cut over 5 years before settling on a -3% cut in perpetuity, rather than lobbying for a raise or stability. I understand trying to link to inflation, but so is the AMA for the entire house of medicine. Tough pill to swallow.

Also, I'm unclear on how this goes operationally. I mean, I've seen School House Rock and everything, but it feels like **** could go sideways. Say it passes the Senate and sent to House. Some fiscal hawk in the House axes the inflation adjustment, but it passes the House. Sent back to Senate, no one reads it, and sent to Biden. Biden is pro-cancer care so he signs it. Or, a somehow national abortion ban gets attached to it (and our profession is linked to that forever) or some other crazy legislative maneuver. Kind of out of our hands.

The fact that a very small number of people with massive COIs is pushing this down the collective throats of the entire profession is such a huge red flag, regardless of whatever the spreadsheet model that "they" gave you to play with says.

 

[OTN]

https://fitzpatrick.house.gov/_cache/files/9/f/9f0dfb6d-30eb-4d25-a31b-8a853eab2d6e/8DABD204A5AB9477B3D72796A941B578.fitzbr-105-xml.pdf

Have at it everyone

From my brief runthrough:
- accreditation necessary, via ASTRO, ACR, or ACRO
- payments neutralized across sites of service
- there is an inflationary adjustment added
- transportation payment for health equity
- I'm not finding a proton carveout but I haven't fine-tooth combed it

 

[BobbyHeenan]

https://fitzpatrick.house.gov/_cache/files/9/f/9f0dfb6d-30eb-4d25-a31b-8a853eab2d6e/8DABD204A5AB9477B3D72796A941B578.fitzbr-105-xml.pdf

Have at it everyone

From my brief runthrough:
- accreditation necessary, via ASTRO, ACR, or ACRO
- payments neutralized across sites of service
- there is an inflationary adjustment added
- transportation payment for health equity
- I'm not finding a proton carveout but I haven't fine-tooth combed it

this bolded above im not a fan of. If they are going to demand accreditation then they should allow for other entities to get involved to introduce more competition/variability/etc...otherwise those three can control prices and have power over things like supervision, staffing, etc.

 

[elementaryschooleconomics]

https://fitzpatrick.house.gov/_cache/files/9/f/9f0dfb6d-30eb-4d25-a31b-8a853eab2d6e/8DABD204A5AB9477B3D72796A941B578.fitzbr-105-xml.pdf

Have at it everyone

From my brief runthrough:
- accreditation necessary, via ASTRO, ACR, or ACRO
- payments neutralized across sites of service
- there is an inflationary adjustment added
- transportation payment for health equity
- I'm not finding a proton carveout but I haven't fine-tooth combed it

I'll read through this myself but:

In real life, when ASTRO met with my department, they were specifically asked "what changes have you made based on feedback". I did not ask the question.

The answer, from Adler, was something to the effect of "we removed the penalty for non-accreditation" (or something to that effect, I need to check my notes).

I'm reading this now, skimming, and this seems even worse...

It just flat out makes accreditation necessary but provides a nebulous exemption for "small radiation therapy provider" except...uh...ok I'll just screenshot it:

"A radiation therapy provider or radiation therapy supplier that is a small radiation therapy provider or small radiation therapy supplier may elect to satisfy the accreditation requirement..."

Is that English?

Am I going insane?

Does...I haven't slept much recently but that doesn't make sense as a sentence structure, does it?

 

[Ray D. Ayshun]

this bolded above im not a fan of. If they are going to demand accreditation then they should allow for other entities to get involved to introduce more competition/variability/etc...otherwise those three can control prices and have power over things like supervision, staffing, etc.

Did I misread, or is a single linac site, a "small radiation supplier," excluded from accreditation?

iii is something we already do.