By Anne Hubbard, Director, Health Policy, and Bryan Hull, Assistant Director, Health Policy
Proposed Medicare payment policies set to start January 1, represent significant financial challenges for radiation oncology practices as they enter the new year, regardless of whether or not your practice is participating in the Radiation Oncology Alternative Payment Model (RO Model). Despite many practices experiencing revenue declines of 20-30% in 2020, the Centers for Medicare and Medicaid Services (CMS) is pushing ahead with massive cuts for radiation oncology and other specialties.
In August 2020, CMS issued the 2021 Medicare Physician Fee Schedule (MPFS) proposed rule effective January 1, 2021. The MPFS proposed rule includes significant cuts that will be implemented broadly across the field of medicine. Subsequently, on September 18, 2020, the Center for Medicare and Medicaid Innovation (CMMI) issued a final rule establishing a Radiation Oncology Alternative Payment Model (RO Model), effective January 1, 2021. The RO Model also includes significant payment cuts due to the payment methodology that involves discounts and withholds.
ASTRO is fighting hard to reverse these pending cuts, which are unwarranted and will potentially lead to serious access to care issues across the country. We have engaged ASTRO’s congressional champions and have contacted the highest levels of leadership within the Department of Health and Human Services to intervene. That said, ASTRO members must be aware of just how dire the consequences are for the field. Below is an overview of what practices can expect in 2021. Be forewarned, the outlook is grim.
Medicare Fee-for-Service Payments
Under fee-for-service payments, which will continue to apply to the professional component payments of those practices not participating in the RO Model, providers are paid according to patient care delivered based on the provisions of the MPFS. The Impact Table below (Table 90 of the 2021 MPFS proposed rule) shows the estimated impact on total allowed charges for radiation oncology based on the relative value unit (RVU) changes contained within the proposed rule.
The expected impact on radiation oncology is a combined reduction of 6% on payment rates for 2021. These reductions are specifically related to modifications of the Evaluation and Management (E/M) codes that create a shift in payments across all specialties resulting in a reduction to the Conversion Factor (CF) of more than 10% to comply with the statutorily mandated budget neutrality requirement.
Table 90: CY 2021 PFS Estimated Impact on Total Allowed Charges by Specialty
||Allowed Charges (mil)
||Impact of Work RVU Changes
||Impact of PE RVU Changes
||Impact of MP RVU Changes
|Radiation Oncology and Radiation Therapy Centers
Upon closer analysis, the budget neutrality adjustment results in even greater variation across radiation oncology services. For instance, CPT code 77014, Computed tomography guidance for placement of radiation therapy fields, is expected to see an 11% reduction in payment under fee-for-service billing in 2021. In addition, CPT code 77301, IMRT plan, including dose-volume histograms for target and critical structure partial tolerance specifications, is expected to see a 7% ($129.76) reimbursement cut for 2021. Of note, CMS proposed RVU increases for several key radiation oncology codes; however, the budget neutrality adjustment largely offset those increases. The table below demonstrates the impact of the CF reduction on key radiation oncology services.
||2020 National Rate
||2021 Estimated National Rate
||CT scan for therapy guide
||Radiation therapy dose plan
||Radiotherapy dose plan IMRT
||Radiation treatment aid(s)
||CT scan for therapy guide
||Radiation therapy planning
||Set radiation therapy field
||Radiation therapy dose plan
||Radiotherapy dose plan IMRT
||Radiation physics consult
||Design MLC device for IMRT
||Radiation tx management x5
||Stereoscopic x-ray guidance
||Radiation treatment delivery
||Radiation treatment delivery
||Radiation tx delivery IMRT
ASTRO is engaged in a comprehensive advocacy campaign to mitigate or postpone the expected cuts for 2021. In collaboration with a broad coalition of physician and non-physician health care provider organizations, ASTRO has urged Congress in a letter to waive the budget neutrality requirement for 2021 in any forthcoming health-related legislative package to provide relief from the reimbursement cuts associated with the MPFS updates. ASTRO’s congressional allies have also been contacted and are aware of the significant impact these cuts have on the profession. In addition to congressional action, ASTRO provided CMS with substantial comments in response to the 2021 MPFS proposed rule addressing how the budget neutrality adjustment poses a significant threat to the profession, which is already suffering significant losses as a result of the COVID-19 public health emergency (PHE). ASTRO urged CMS to use its authority under the PHE to waive the budget neutrality requirement for at least another year, allowing practices time to recuperate from significant losses already suffered in 2020.
RO Model Payment Rates for 2021
For those practices required to participate in the RO Model, it’s bad news as well. ASTRO has documented and is advocating for significant changes to the RO Model payment methodology, which layers a series of deep cuts on participants. But one aspect of the RO Model payment methodology, a “Trend Factor,” is influenced by the MPFS and Hospital Outpatient Prospective Payment System (HOPPS) and deserves greater scrutiny in light of the PFS cuts discussed above.
The Trend Factor serves as an annual update to the payment methodology by reflecting utilization and payment changes outside the Model, i.e., the MPFS and HOPPS. For 2021, the Trend Factor will use 2018 utilization data and 2021 MPFS and HOPPS data to establish an update to the RO Model payment methodology. Due to the anticipated reduction in the 2021 MPFS rates, the Trend Factor is likely to put additional undue financial strain on radiation oncology practices participating in the Model.
Practices participating in the RO Model are already subject to discount factors of 3.75% off the Professional component payment and 4.75% off the Technical component rates, as well as payment withholds for quality measures performance and incorrect payments. These reductions will be compounded by a low or potentially negative Trend Factor. This “double whammy” rate reduction is a disservice to practices that are compelled to participate in the Model, which is particularly disappointing given that the purpose of the RO Model was to establish rate stability over time. By establishing a Trend Factor that fluctuates based on the whims of the MFPS and HOPPS, CMS has effectively eroded the stability that practices thought they might be able to secure under the RO Model.
ASTRO has raised concerns regarding the RO Model’s aggressive implementation timeline and cuts with our congressional champions, as well as those at the highest levels of the Department of Health and Human Services (HHS). We are urgently seeking a delay in the RO Model’s implementation date of January 1, 2021, so that practices have more time to prepare for implementation. This will also allow for additional time to address the flaws in the payment methodology, which, as they currently stand, equate to a series of cuts on radiation oncology services.
As we enter the last quarter of 2020, a year that has been fraught with tragedy, we are bracing ourselves for further struggles in 2021, with serious potential for more financial instability. Whether your practice is in or out of the RO Model, Congress needs to hear your voice about the direct impact of these flawed policies. Go to https://www.astro.org/Advocacy/Become-an-Advocate and join the fight for the future of radiation oncology.
Posted: October 19, 2020
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by Gita Suneja, MD, MS, and Robert Miller, MD, MBA, FASTRO
We all aim to provide our patients with the best, most personalized care possible. Innovative research has identified a new frontier of cancer care: harnessing genomic and molecular data to develop treatment plans tailored to each unique patient with the potential to enhance treatment efficacy and limit toxicity. The use of biomarkers is growing within radiation oncology; however, more research is required to optimize biomarker use. To meet this need, the Radiation Oncology Institute (ROI) has selected “Biomarkers for Radiation Oncology” as the topic for its new request for proposals (RFP) to fund research grants aiming to improve patient outcomes in cancer treatment or improve the survivorship experience through the application of biomarkers.
The intent of the ROI’s new RFP is to solicit innovative ideas to leverage biomarkers for radiation oncology to enhance patient selection, to develop personalized treatment regimes, to quantify outcomes and manage toxicity. The grants, which will be announced next spring, will range from $50,000 up to $150,000 for projects with a larger scope. We invite all eligible applicants, including residents, to pursue this exciting new funding opportunity.
To apply, you must submit a Letter of Intent (LOI) through ProposalCentral by 5:00 p.m. Eastern time on November 16, 2020. The ROI Research Committee will review the LOIs and notify selected applicants to submit a full proposal in December. For examples of responsive projects, selection criteria and details on eligibility and how to apply, download the complete RFP.
As ASTRO’s research foundation, the ROI fills a special niche in funding for radiation oncology research, bringing together stakeholders from across the field to identify the highest priority topics for research that will heighten the critical role of radiation therapy in the treatment of cancer. The ROI is unique in that we develop a new RFP annually, allowing us to focus our funding resources on issues of immediate importance to the radiation oncology community. This year we were fortunate to have the added input from the ROI’s new Corporate Research Forum, a group of industry leaders that support the ROI; there was strong consensus among everyone involved in the RFP development process that biomarkers is a key area of research for radiation oncology right now.
We are eager to see all your creative research ideas to leverage biomarkers for radiation oncology with the potential to transform practice and improve outcomes for patients. Don’t miss your chance to apply for this year’s ROI funding opportunity by submitting your letter of intent by November 16.
Gita Suneja, MD, MS, is chair of the ROI Research Committee and vice-chair of CHEDI, and Robert Miller, MD, MBA, FASTRO, is vice-chair of the ROI Research Committee and editor-in-chief of Advances in Radiation Oncology.
Posted: October 6, 2020
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By Raymond Mailhot Vega, MD, MPH
In mid-December, a colleague emailed me a link to an ROhub discussion on the creation of a society for Hispanics in radiation oncology. This prospect excited me. Representation matters. As a Latino becoming a radiation oncologist, I did not see myself in the workforce. Becoming what I did not see presented unique challenges and, at times, a feeling of isolation since I struggled to find others who had shared my experiences. A silver lining is charting your own territory, but being on your own, it can be hard to know if you’re making progress heading towards your destination. How do you explain to an attending whose feedback post-consult is, “Wow, you speak Spanish so well” that while meant as a compliment, so do 15% of Americans and such an observation does not provide a meaningful critique of my patient knowledge or my memorization of the inclusion criteria of PORTEC-2. Now as an attending and full member of ASTRO, I am eager to extend a hand to the next generation as they navigate their careers.
Recently, ASTRO has been working to create different ROhub communities to provide virtual spaces for communities of radiation oncologists to gather, addressing an important need. A space for communities of radiation oncologists to gather is manifold in its benefits. Latinx physicians are drastically underrepresented in radiation oncology at only 2% of the rad-onc workforce overall,1 despite the fact that 15% of Americans identify as Hispanic. Established in education is the credo “you can’t be what you can’t see,” and medical training and employment is no different. A virtual affinity space allows for mentorship of trainees and junior faculty seeking career advice. A dedicated space also provides mental health support. Physician burnout continues to gain more visibility, and the extra stress and invisible labor that more commonly burden diverse faculty are well-documented.2 A defined space for Latinx doctors facilitates the creation of a community in which we can share our common experiences, interests, stories and struggles.
Some may feel that purposely creating communities around race or ethnicity could increase divisions between people. Divisions already exist, and the “I don’t see race” perspective from the 1990s blinds ourselves and hinders our ability to dismantle the extraordinary barriers developed over hundreds of years of systemic racism that affects both patients and doctors. A dedicated community can provide a safe space to generate ideas from lived experience and foster leaders to represent that community among the larger membership. The COVID-19 pandemic has thrust in the spotlight the disparities that communities of color have faced, and a forum representing those affected can create opportunities that successfully address such inequities in health care and oncology.
To address the need for connection among physicians, physicists and trainees, ASTRO is launching various ROhub communities. These forums will create a virtual space in which ASTRO’s underrepresented and diverse members can congregate and network along with all members who wish to participate. I am excited for ASTRO’s debut and kick-off of these ROhub communities — intentional spaces for radiation oncologists to unite and grow from shared experiences. Particularly as we face social changes with our Annual Meeting moving to a virtual experience, planned socializing and networking must adapt. The timing for this initiative could not be more appropriate. Opportunity is not a zero-sum game: we don’t have to lose power or influence when others gain it. Increased diversity will push our research forward, bring new ideas to the forefront and result in higher-quality care for all patients.
ASTRO’s initiative will provide a broader tent for all of us. I encourage you to speak out for increased equity in representation of your brown and Black radiation oncology colleagues, for bridging the health-care disparities that patients of color face, for making our system more accessible for the disabled, for improving gender parity among our workforce and for creating a safe space for those who identify as LGBT+. Our time is now.
Since the submission of this blog post, ASTRO is pleased to announce the launch of the Gender Equity Community on the ROhub, a space for members to discuss gender gaps, offer mentorship and seek or provide helpful resources. The community was created for those personally encountering gender-related concerns and for those who wish to support and promote gender equity within their workplace. Work is underway to launch additional communities in the coming months.
Raymond Mailhot Vega, MD, MPH, is a gay, Latino assistant professor at the University of Florida, where he directs the hematology radiotherapy program in addition to treating pediatric patients and patients with breast cancer. He is a recipient of a Global Oncology-Young Investigator Award to conduct educational interventions for pediatric radiotherapy treatment in Mexico to reduce disparate outcomes.
1. Fung CY, Chen E, Vapiwala N, et al. The American Society for Radiation Oncology 2017 Radiation Oncologist Workforce Study. Int J Radiat Oncol Biol Phys. 2019; 103: 547-56.
2. Matthew PA. What is Faculty Diversity Worth to a University? The Atlantic. 2016 November 23, 2016;Sect. https://www.theatlantic.com/education/archive/2016/11/what-is-faculty-diversity-worth-to-a-university/508334/. Accessed on May 11, 2020.
Posted: September 29, 2020
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Why the ASTRO Annual Meeting is more important, now, than ever
by Theodore DeWeese, MD, FASTRO, ASTRO Chair
ASTRO’s 2020 Annual Meeting theme, “Global Oncology: Radiation Therapy in a Changing World,” was chosen in mid-2019. Who could have imagined just how prescient the topic would be and how much the world would change since then?
This will be my 27th ASTRO Annual Meeting, and I am looking forward to it as much as I did, if not more, than my first year attending the meeting as a resident. I am especially enthusiastic about the immersive educational experiences the ASTRO staff and your professional colleagues have planned for you.
Last year in my Welcome Address article to our Chicago attendees, I wrote: “We all strive to transform science and improve care for patients on a daily basis, and the ability for our specialty to lead in these domains has never been greater. But, if we are to be highly successful, we cannot do these things in isolation.”
What a difference a year makes.
Who could have known that much of the world would be in isolation for a large portion of 2020? Yet, we have seen how reactive and responsive our field has been in this unprecedented time, which allowed us to quickly reengineer how we transform science and care for our patients. And our specialty’s ability to focus on patient health has truly never been greater, as we have seen through your unselfish and dedicated work caring for, and continuing treatment of, your patients during this public health emergency.
I went on to write that “working closely with our colleagues is important.” I would argue that this year it’s more important than ever. This year’s Annual Meeting will provide you with the opportunity to work closely, albeit virtually, with your colleagues from around the globe on the latest scientific advances. We already know that COVID-19 will have a long-term impact on cancer care for years to come, so the chance to learn from your peers in the global oncology community is especially important.
I also want to acknowledge and respond to all who have expressed your feelings about our pricing structure, both for members and residents. As Laura Thevenot shared in her blog post, the financial implications to a relatively small specialty association have been significant. Canceling the Miami meeting incurred tremendous costs. Our Annual Meeting is a primary revenue source for ASTRO and because we had to cancel the in-person meeting due to COVID-19 and the need to keep our communities safe, the organization absorbed the many monetary damages associated with canceling a city-wide annual meeting. The Board had to take extraordinary fiscal action inside ASTRO to keep our activities and member support services going. We know the Annual Meeting is the key educational activity of the year for many of our members and, thus, we as a Board decided to go “all in” on the best learning platform possible in order to keep our members engaged and educated and provide an experience that members would be willing to support. We also spoke with numerous department chairs and leaders about their support for their residents. Overwhelmingly, they noted that the savings from airfare, hotels and meals would allow them to support their resident’s attendance at our meeting. And to-date, we have seen strong registrations for our members-in-training. To ensure that as many as possible can attend, we are freezing the member-in-training and student rates at the early-bird level for the duration of the registration period. We also know that many people are still assessing their expenses for the year, so we are also extending our early-bird deadline for all attendees until September 8 to give you more time to secure your annual meeting attendance at the lowest rate.
Why register early?
- The meeting, customized for our specialty’s unique needs, includes all the educational and scientific programming you are accustomed to.
- In recognition of the financial impact our meeting cancellation will have on the Miami Beach area, ASTRO will donate a portion of all early-bird registration fees to two Florida cancer patient support organizations. We are happy to announce that the recipients are Caring Friends Cancer Support Group and Gilda's Club South Florida and we are pleased to show our support for their important work during this challenging time.
- All early-bird registrations will be recognized on our Patient Support Honor Roll, which will be unveiled during the Annual Meeting.
I am particularly excited about the internationally renowned Keynote speakers who will deliver remarks on timely topics including global health, COVID-19 and racial justice and equality. We are working on the final details of their presentations and will announce their names and the schedule soon. We also will have Storytelling, a new session that encourages you to share your experiences and interact with other attendees. The virtual poster hall offers a new feature ― author narration ― just one of this year’s virtual platform innovations designed to inspire and encourage you.
Not being able to meet in person is a disappointment, I concede. However, participating in this year’s ASTRO Annual Meeting offers you many opportunities that would not be possible in person, most notably that the content will be available to all registered attendees until November 30 to ensure access to all the presentations and materials. This year there are just as many ― if not more ― competing sessions, but you won’t have to miss any of them in this online format. There are more than 200 hours of CME credit opportunities — something that has never been possible before during a four-day meeting. We are also able to offer CAMPEP and ASRT credits. Additional new features include Master Classes on topics that include leadership, radiopharmaceuticals and the integration of medical marijuana into radiation oncology practice, and we are also bringing you more Cancer Breakthroughs sessions to showcase the top science from meetings that were postponed or held virtually, including ASCO, ESTRO and AAPM. The Cancer Breakthroughs session was added last year and was one of our highest evaluated sessions.
I truly am excited about the 2020 Annual Meeting and hope you are too. We know the importance that this meeting and the content presented provide in continuing your education and providing the latest science from the field. I invite you to check out the Meeting Highlights on the website and register now. We want you to take advantage of the best rates possible, so we’ve extended the early-bird registration through September 8 at 11:59 p.m. Eastern time. Your participation is important to creating a collaborative experience and I look forward to “seeing” you at the meeting.
Posted: August 18, 2020
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By Laura Thevenot, ASTRO CEO
In the wake of the COVID-19 pandemic, we know that each ASTRO member has been impacted as you continue to provide world-class cancer treatment to your patients (and manage a host of new responsibilities like homeschooling children). Likewise, ASTRO has been impacted in many ways as we continue our work to provide high quality services to our members. As we launch registration for our virtual Annual Meeting on July 9, I want to explain how this meeting is coming about and why your participation is so important.
The ASTRO Annual Meeting is the primary income source for ASTRO, which is a 501(c)6 nonprofit. Unfortunately, ASTRO is not eligible to apply for any of the financial support available to many small businesses as a result of the pandemic. While membership dues produce roughly 15% of the organization’s overall budget, the Annual Meeting and income generated by the sponsorships, exhibitors and attendees is the revenue engine for ASTRO’s overall operations. This allows ASTRO to provide members with education and training for their practice, reimbursement and health policy expertise, advocacy work on Capitol Hill, clinical practice guidelines, safety resources and so much more.
Last year in anticipation that more than 11,000 radiation oncologists, residents, physicists and other health care professionals would descend on Miami in support of the Annual Meeting, ASTRO secured contracts with numerous entities including the Miami Convention & Visitors Bureau, 54 hotel properties, transportation service providers, audio/visual firms, and much more. While the ASTRO Board acted quickly to change course to a virtual Annual Meeting due to COVID-19, there are still many contracts and significant damages that we are contractually obligated to pay. We do hold event cancellation insurance, which will offset some of these expenses, but we are in line behind more than 170 other medical meetings that canceled before us.
With the cancellation of the in-person event and other revenue generators, ASTRO proactively looked to streamline day-to-day operations and adjust budgets. Like many of you, we suspended all business travel, cut professional development and other costs and implemented pay and benefit cuts for all staff in an effort to curtail spending given the extraordinary disruption and an uncertain future. We instituted these budget cuts to avoid staff layoffs and maintain our commitment to provide you with the support and educational content you need. For ASTRO to continue to play its role in supporting members, we also need to keep the ASTRO organization healthy and fiscally sound.
In an effort to produce an immersive and interactive virtual meeting, ASTRO then invested in an online platform that is being customized for our community’s unique needs, including networking and interview opportunities and an expansive exhibit hall. I promise you this will not be a hyped up Zoom call! This virtual meeting will be immersive and unlike anything you have ever experienced before. This transition to a virtual platform required us to negotiate and secure new contracts with a range of vendors including an online platform provider, videographers and audio technicians, digital designers to create online materials, support to produce trainings and onboarding for all presenters and exhibitors, and so much more. Everything we have done to produce this Annual Meeting was done to create a world-class, unforgettable learning experience for you.
We recognize that every member of the ASTRO community has been impacted in so many ways by the pandemic, including financially. Based on our COVID-19 practice survey, we know that your patient volumes have been negatively impacted and therefore you expect revenue declines this year. At the same time, we have seen the resilience of radiation oncology during the pandemic, and we marvel with pride in your ability to provide cancer patients with needed treatments and services without disruption. We also know that cancer doesn’t wait for a COVID-19 vaccine, and the need to get the latest science out to the global oncology community is more pressing than ever.
Because we understand that both your time and financial resources are precious, we are making the content available to all registered attendees for 30 days to allow you time to view materials at a pace that works best for you. One of the top complaints we get about our meeting is that there are too many competing sessions, so key content is missed, but not this year! This format and the 30-day window allow us to provide over 200 hours of CME credits — something that has never been possible, nor ever offered before during a four-day meeting. We hope that the financial savings from airfare, hotel and meals will make it possible for more members than ever to participate and learn at our Annual Meeting. In recognition of the fiscal impact our meeting cancellation will have on the Miami Beach area, a portion of all early-bird registration fees will be donated to two local cancer patient support organizations in the greater Miami area.
While everything is different for the 2020 Annual Meeting, we hope that our community will continue to gather to learn from each other, network and show our resilience as we continue to make our way through this unprecedented time. Thank you for all that you do for ASTRO and for your care and support of cancer patients.
Posted: July 2, 2020
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