ROCR: ASTRO's New Payment Direction

Just when I wonder what I will write about, an avalanche of business related items land: ROCR, CMS Payment / Supervision info and their effects on the Workplace Analysis.

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Quick Take: Hypofractionation creates a clearly detrimental impact on the US financial radiation oncology landscape. And ASTRO understands it is real.

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August 16th is National Medical Dosimetrist’s Day - Celebrate their efforts!!

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Welcome to another Business Wednesday Edition:
Radiation Oncology Case Rate Program (ROCR)

If you haven’t heard, ASTRO is rolling out a new initiate (ASTRO LINK). It is a legislative approach looking to move 90% of US radiation oncology billing into a bundled payment plan.

In some ways, this announcement was quite shocking to me. If you back up to just a few years ago, ASTRO proposed a voluntary shift to a structure like this - the initial RO-APM proposal. CMS then moved it to 1 in 3 mandatory participation via a selection of zip codes removing the voluntary aspect. And today, just a few years later ASTRO is trying to get to a bundled payment model for 90% of our field.

Quite a leap - at least from my seat. Perhaps I’ve been out of the loop and I didn’t appreciate the urgency of intent with RO-APM, but this early vision seems to be more focused and more on target - less problematic - at least in ways. Or maybe the first proposed ASTRO version of the RO-APM was similar and via negotiations with CMS it changed? Or maybe RO-APM just lowered my expectations to the point that this now seems improved? Regardless, I think it is, in general, a good direction.

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My Clinic’s Experience:
~420 patients in 2021 growing to ~625 per year now, with FLAT revenue.

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Wow. In the prior decades one would be rolling on any financial spreadsheet with nearly 50% growth in less than 2 years - we are, after all, a high fixed cost business model so the incremental volume should all flow off the balance sheet. But today? Flat revenue requiring a TON more work.

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From rolling in the dough to running faster on the hamster wheel.

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While it can be contributed the several factors, this is dominated by hypofractionation or outright omission. And we ain’t done - look at any journal any week - it is arguably the PRIMARY publication topic of this decade. (Past few weeks ultrahypofractionation for prostate, 2 fraction prostate, single fraction lung, SBRT for lung, short course for liver, and I haven’t listed the omission trials - list goes on and on).

The financial impact of less fractions has been dramatic and by market standards - quick. Paired with longer national trends towards a general attempt at cost control and it has real impact. It hurts physician payment, but maybe to a greater extent, it crushes technical revenue needed to support capital investment in our specialty.

To me, that is the context. Leadership is clearly acknowledging the issue and have then proposed a legislative approach to attempt to address the issue. Is it enough? Is it fast enough? How did we get here? I think all valid questions, but today we’ll choose to look forward.

Today, I’ll broadly give my perspective that I have from 20+ years in private practice / business world of our field. I’ll focus more on perspectives than details. At least that is the goal. But it isn’t just ROCR, it is CMS payment rules, CMS remote supervision expansion until January of 2025, and even how these changes affect the ASTRO Workforce assessment.

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I honestly didn’t follow ASTRO that closely for many years in private practice. Wasn’t a member for some 10 years. Re-joined with move into proton world ~5 years ago.

I do have prior significant contract experience, 10 yr practice leadership, single specialty and multi-specialty board experience. Helped developed PET/CT center and invested early in founding a medical malpractice insurance company and arms length help in Federal bankruptcy purchase of multi-room proton center, But no US political experience and no real legislative work. Take the opinion within that context.

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ROCR Model:

Here is how I interpret this effort - it is an effort along the lines of PPS exempt cancer hospital billing path - a legislative approach. To review, below is a listing of those institutions and importantly for today, the caption lists the associated legislative pieces. Like the ROCR proposal, these are the bills that alter CMS’s ability to impact these centers.

A similar legislative path appears to be ASTRO’s approach: Present a new model asking to have a bill enacted that contains language to move remove radiation oncology from a fee for service model and move it to a case rate approach - a bundled payment approach, per patient, per episode - removing 90% of our specialty from a Fee For Service CMS reach. In ways, similar to RO-APM which was also a case rate program but in ways different. RO-APM was a CMS / ASTRO approach to transition towards a case rate model. This would be a legislative “Congressional” / ASTRO approach via a piece of passed legislation - partnering with congress rather than CMS (wow, government is big and complex).

It would likely be listed here under a Medicare Innovation Model. If you look at that Medicare page, you will see ROAPM and the Vermont and Maryland exclusions as just a few examples.

What is interesting is to consider the history of RO-APM alongside this new version of a plan forward. I really think this older podcast on the RO-APM model is great at giving insight as to changes that happened from concept to implementation.

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Accelerator’s Podcast on initial RO-APM rollout
Warning: Not short (1:47), but lots of great insight and many players within ASTRO working on the current project.
https://accelerators.buzzsprout.com/1839275/9457893-a-very-special-episode-ro-apm

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So here with ROCR, the concept again seems on point - you have to do something today to stop what I see regarding the global reimbursement trends in radiation oncology - one can’t just look at the professional side - it must consider both the technical and professional components. And I think the goal is to attempt - my words from their webinar - to “side step” CMS and work on a legislative solution. They appear to consider the final RO-APM to have too many compromises from the initial version. This time, the goal therefore is to take a legislative path.

Honestly, I think the proposed model is a reasonable structure within a complex landscape. To bundle any payments when costs of delivery can differ by large amounts is difficult. Pair that with differences in settings (hospital / non-hospital, academic / private practice, employee / ownership models) and one price tag is a nearly impossible task for all circumstances. You’re simply trying to find a reasonable compromise for the vast majority of situations.

But I think it demonstrates leadership is trying to move in the correct direction. I wrote something earlier that was far LESS reaching - my proposal was simply to address a single code towards this approach (ASTRO Workforce Analysis: Pressures Unique to Our Field). ROCR is far more reaching, which I find quite surprising.

That’s my take - pretty concise, but I think this is the correct direction. And to me, that is step one - the forest view - thumbs up or down on the concept and this would be a marked improvement for the specialty. To me, it has potential to stop the downward market forces and then later (once we aren’t bailing so much water) allow us to more idealistically approach hypofractionation / efficiency questions. Maybe not the ideal answer many would like, but 20 years in, with lots of business dealings and I think often compromise is the correct path in bridging past actions to future goals.

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It Better be Better

This should be a good path after all. These are people - all from within our specialty trying to present something they think is reasonable yet supportive of our field for long-term stability. This has NOT been through the legislative process and absolutely will be altered / changed significantly away from this “ideal” scenario - again this is “us” proposing this.

Is it too little too late? Was the role out of information ideal? Are the compromises made the best / correct ones? Are the rationales presented for the compromises airtight? And what about protons!! And PPS!!

I get it. Their are a number of questions that one could look back upon that might be reasonable to consider. But rather than focusing there, today, I think it is best to get across the line and decide good or bad. And here I land on good.

Remember: Look at the practice revenue implications up top and it is clear that hypofractionation is the single dominant factor in our specialty. I know of several facilities in my region either closing or closed. I know of machines not in use and machines sitting idle in garages. And next to those idles machines are ones being used for salvage parts rather than treating patients. Literally. And then look at ViewRay not being sustainable.

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Or look at the collapse of GenesisCare. At one point, radiation oncology was lucrative and might have avoided one or both of these outcomes. Today the landscape is different. Cuts to our field and the real pressure of hypofractionation have had a real impact and something large would be the ideal answer.

In the days following the roll-out of the RO-APM, I remember arguing that hypofractionation, not the bundled payment model carried the most risk. And I was working in a proton center - and this was in that short period where protons were in the model. Perhaps that statement was incorrect, but my thinking was: RO-APM carried a chance of dramatic change and therefore was not guaranteed while hypofractionation was guaranteed. At the moment, I was deemed wrong and I think viewed as crazy - but just a few years later…

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A Grab Bag of Things to Consider:

So now we’ll go into the grab bag of items - because it isn’t just ROCR but also news from CMS as well as how these changes impact on the ASTRO Workforce analysis.

CMS Payment Model:

Simply stated, CMS has an agenda - move everyone into just a few big hospitals. At least that is what one has to perceive from their actions.

The general push towards being an employee of a hospital - a big one - continues. 3% physician cut compared to >1% for hospital outpatient prospective payments (LINK). In conjunction, this allows for better and better relative contracts via employee structures. This has been a goal for seemingly 15-20 years at a minimum but worth stating that they pushed this lever ~5% in a single year.

CMS Supervision Model:

At the same time, CMS extends virtual supervision requirements. This one is rather complex with lots of different perspectives, but it has a neutral (other’s argue) to very negative (my view) impact on the ASTRO Workforce project that was just completed.

Really that is the problem with forecasting. Watch CNBC and look at end of year market projects. Run a financial plan and get some crazy answer from an “expert” about where your net worth will be in 5 years. Look at these terrible Covid modeling attempts just 2 weeks apart (too soon??).

In two weeks, the Oklahoma prediction that put us into lockdown went from 4763 beds required to 882 beds required - not arguing covid wasn’t terrible - it was. But so is our ability to model the future. And therein lies the problem with the ASTRO Workforce project. It didn’t comment on any level about the possibility to continue remote supervision of services that I could find. Yet 3 months later, that happened - at least through 2024.

I’ve seen people argue for “neutral” effect on workplace analysis. I disagree - quite strongly. On the hospital side, maybe. They do not have a current supervision requirement and they already utilize many tiers of low cost MDs - consider the many “salary levels” that create a pyramidal structure within academic programs or look at the rapid expansion of “fellowships” - ie underpaid fully trained physicians which now comprise >5% of the total workforce (United States Radiation Oncology Fellowship Growth From 2010 to 2020). But this lack of supervision requirement will have an impact on the workforce. Trust me.

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Four examples:

Story 1: I was President of an ~8 person radiation oncology practice for 10 years. We covered at most 6 facilities. We were NOT aggressive - it was a very casual 1980’s type retro-practice - literally when I arrived two partners had no idea (within 100-200k) of how much they were making - they had plenty (via just professional fees) - they were fine.

But over the years, there were times when we had to make calls on whether or not to hire someone. Proud to say every single hired MD made full partner within 3 years. And we were flat - shared equal dollars once partner regardless of RVU - 1 tier. Sign on or full partner - heck I ran the practice for 10 years and saw basically no extra pay (one time 0.2% bonus of new 5 yr contract agreement). Regardless, we had to cover 6 facilities and we liked our vacation. We literally hired an extra person to cover emergency issues. Say 98% of the time, this hire would just added to existing coverage but IF someone had an emergency - car wreck, fall, heart attack - we had a back up for that day. It was required - supervision was required. So we hired. Every time.

This negates that need. No doubt. Even the most altruistic practices will shave a bit of coverage. Is it a massive shift? No. Academics eat up over half the market so lets say 35% is outpatient settings - that outpatient will see a 10% downward shift so to me, it is easily a 3%-5% downward shift on the required workforce needs.

Story 2: Current scenario - about 60 people main center and new site about 30 min that will have 10-20 under beam. We have 2.5 physicians (I’m the 0.5). For anyone to have a week of vacation, we were going to have to hire - now we don’t. Flex 1 person 1 day per week. What just required an MD for January of 2024, now doesn’t. At least until January of 2025.

Story 3: Genesis Care bankruptcy - today, people are literally bidding on these facilities - I’ve talked to two of them. Short term deals at “super bargain low rates”. For many the first basic proforma is a 2-3 year outlook - can I turn a profit in a 2-3 year window. Beyond that, they know the effects of hypofractionation will dominate, but IF can they make money 2-3 years, then maybe. Now >12 months of that window can be serviced with very little MD coverage. That helps the proforma while diminishing the need for physicians - again, less jobs in fewer places to fill.

Argument against: The only viable argument against this push towards less staff is an RVU argument - at some point, we will be so very busy that we opt for more people - the 14k workforce number often referenced. But, in general our field is a low end user of APNs and that lever is easier to pull if you remove the supervision requirements. And so in the future, I firmly believe this will lead to an expansion of APNs if not addressed. Which brings me to story 4.

Story 4: Look at this model: https://bridgeoncology.com/providers/
For an old guy, this is quite scary - remote pretty much everything with NPs and PAs in the clinic. It is the lack of supervision requirement by an MD that makes this feasible. Sure - I get it, it potentially improves access but to me, it comes with quite a bit of real cost.

And so just 3 months later, just like the Covid curves, the time spent on the analysis looks far less valuable and I believe that in 2 years it has potential to be as comical as the financial planner who gave me some plan that looked like I won the lottery. Predicting the future is hard - really hard - and models are just that - models. Ask anyone on Wall Street. But loosening supervision is a negative on the job market workforce analysis - I have no doubt.

Summary:

Back in 2005 - 2008, the physicians were clearly in control of the market - if you knew how to pull the strings. The radiation machine was a money maker - even using shorter treatment courses and limiting resources. I used to openly discuss “the vault within the vault”.

(This is the IMRT payment issue that some will refer to - likely, in part, a reason for why the market today behaves like it does, but if you were around, it spelled opportunity).

And to open the vault, administrators needed radiation oncologists to open the lock and let the money flow out to their organizations. That simple premise let me renegotiate salaries up nearly 50% from our prior base in one year. Within three separate negotiations - all governed by 3rd party consultants in a non-profit organization - our pay basically doubled. Three times, my initial offer on paper was LESS than after we finished the negotiations. It went like this: here is my quick look and $$$ request. Ok, ok… board meetings, bring in outside consultants, more time for me to do all the work really needed, crunch the numbers, think about tactics and three times - the final contract, supported by data and consultants, raised my initial offer.

Today, I fear is quite the opposite. The vault often has no money and you don’t even require a full time radiation oncologist. You need part of part of one if these supervision requirements stick. Really the main supporting factor for salaries will be momentum, salary surveys, and the fact that most are now employees. Each of which will assist in having pay decreases track years behind actual declining reimbursement. Hiding within big systems, these items can take years to unwind.

And that assumes the machines don’t just loose money - even the relatively inexpensive ones due to declining volumes. If they loose money, eventually that will be the next lever to apply pressure to salaries as more centers “close” or “consolidate” creating more competition for the surviving jobs. Aggressive further decreases in fractionation have real potential to significantly amplify what already will be a tough road.

(As a final example: this week I was discussing options for trying to save a GenesisCare facility - low volume, now down to 8-10 under beam per day with shorter courses but the only radiation facility within a ~60 mile radius. And the only way it is viable is via a remote supervision model with part of the professional fees being used to support the entity. Read that again, it requires professional income support to the technical side. So exactly the opposite of the vault analogy. What a turn in 10 years).

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In simple terms we are seeing the beginning features of commoditization within our field. When is good enough tech, good enough. When is shorter about as good. Even “we” think: “Sure, it might help a little for me to be on the ground in the clinic, but I can do most of it pretty well from administrative styled dashboard with a NP on the ground - I mean I even contour at meetings or in the airport reasonably well” (if you’ve read the site, hopefully you appreciate the sarcasm in this last sentence).

It is happening across all of medicine - just ask primary care physicians what they think about CVS entering the landscape. We’re still on the edges, but I think, as a field, many are bright enough and involved enough to see the trends and to be concerned.

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If you listen, there is a small minority that is quite on point and educated in my assessment. They have voiced concerns about the job market for a while. Its been a few years since I really backed up and looked at the national landscape (I was focused on clinic / proton info), but looking around, it is clearly different than 15 years ago. From my perspective, pay for our field is still excellent and we have options to move forward successfully, but we need to address the rate of change. It affects income, but more importantly right now it is beginning to affect access to care and influences to a significant degree the quality of our workforce which then impacts our future on multiple levels. I think this plan is a viable path towards that end.

I do wonder if it is fast enough but at least I believe I see a pivot and the current initial presentation seems more clear in its priority to acknowledge the issues that we created? or haven’t been able to address. That said, I want to be clear - these are elite world problems. We are each blessed to do what we do and have compensation near what it is with an ability to impact the lives of so many patients in such a powerful manner - in a value oriented area of oncology - opinion of one.

But what of the problems? The inequity and the general unfairness of protons being excluded and those pesky PPS exempt institutions. Well, a lot of that was in here, but to give those very real issues the amount of time to unpack, I need to come back next week with a part two.

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PART TWO IS RELEASED:

So until then, keep posting great insight and creating great content on this issue so as a specialty we can make progress towards better. I believe we’ll can get there and I’m planning to put forward my thoughts on direction and solutions beyond just the payment model in the future - maybe I just have faith in the silver lining. As we move forward, there will be some real changes required - yesterday’s article was a huge reminder of just how far some have strayed. But looking ahead, I believe we have opportunity to come out the other side stronger if we have good, reasonable, and sometimes difficult discussions.

And thank you again for the support in this first 50.

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HAND PICKED RELATED PRIOR PROTON101 ARTICLES RELEVANT TO OUR DISCUSSION:

• Protons 101: That Cost Money Thing

• ASTRO Workforce Analysis: Pressures Unique to Our Field

• A Glimpse Behind the Curtain: ViewRay

And if you want to monitor the market,
here are two to follow:

They consistently discuss current topics regarding our workforce:

Author: Todd Scarbrough
https://twitter.com/toddscarbrough/status/1688325330962939904

Specifically, follow post 2 of 18 - it leads to a second 29 entry thread - combined, they are excellent global context.

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Author: Jason Beckta
https://twitter.com/drbeckta/status/1690051126236717057

Between Todd and Jason, they are deep in the weeds trying to find answers seemingly everyday. Great resources to monitor where the market likely lies.