By Michael J. Katin, MD
On July 6, 1928, the town of Potter, Nebraska, was struck by a 1.5 pound, 7 inch in diameter hailstone, which held the record for largest hailstone until 1970 and still ranks third all-time. On July 6, 1946, the course of world history was altered irreversibly by the births of George W. Bush and Sylvester Stallone. And on July 6, 2012, the fabric of the universe was shredded when the Centers for Medicare and Medicaid Services ( CMS ) announced the proposed Medicare Physician Fee Schedule ( MPFS ) for 2013 and the specialty of Radiation Oncology was immediately referred for Hospice care.
This is not the first time there has been panic over reimbursement issues, but it is the first time that the proposed changes could wipe out scores of radiation oncology facilities throughout the United States. The comment period extends until the beginning of November, at which, after all input is received and opinions reviewed, the proposed fee schedule will be codified and outpatient radiation oncology will cease to exist . Unfortunately, it appears that CMS has concentrated on the increased efficiency of getting a patient to receive the actual treatment without regard to the extra preparation involved, equipment cost, and staffing cost that allows this, not to mention the expense of regulatory compliance .
Can we approach this with the expectation there are no setbacks without opportunities? That when one door is closed , another one opens? I suppose there's a bright side to having an infection with flesh-eating bacteria, but I'd just as soon not be in the position to be able to find out. In the case of the vanishing IMRT allowance, some of our colleagues have expressed that there can be some solace in knowing that competitors may be wiped out as well. That's similar to the rationale of the nuclear deterrence strategy of the 1950's.
This time there may be no escape. If the fee schedule is not adjusted, it will be financially impossible for a small- to medium-sized rural or suburban freestanding radiation oncology center to continue to operate. The intention to improve access to optimal cancer treatment techniques will have been thwarted, and patients will need to travel long distances to a reduced number of centers to be treated, if they are, in fact, in a position to do this at all.
It's true that we can't always get what we want, and maybe it won't be possible to reverse this decision. In that case, where shall we go? What shall we do ? Does anybody else care? We need to have a back-up plan, and I think there may be only one alternative: abandon the system.
Having said that, we should remind CMS that a 40% cut in IMRT reimbursement (19% overall) may still allow some freestanding units to survive within the system. An IMRT cut of 80% would definitely wipe them all out. This would go along with efforts of other government agencies to do in the whooping crane and snail darter while claiming to want to protect them. When we are liberated of the burdens imposed by Medicare as well as other insurance programs, we can go on our own way. It has already been shown that people are willing to pay cash for medical expenses, as long as cosmetic procedures and pet care are involved. It is hoped this attitude may be transferred to radiation therapy as well. Charges for paying customers may be able to be substantially reduced. There may be substantial equipment discounts available on E-bay on units that have to be dumped by centers that don't have the same survival mentality. We can follow the leads of many other businesses by incorporating offshore to make it difficult for creditors and litigants to take action when treatments are given that may not be quite up to par due to using (and older older equipment and fewer) staff (an all-encompassing consent form might also be a good idea, although recognizing that the attorney who would draw it up would not work based on a fee schedule) . This could help to eliminate costly and wasteful defensive measures and, eventually, quality control procedures. When income from work has diminished and employees (and physicians) are no longer able to keep their homes, there would be acceptance of a communal attitude, in which everyone can live at the center to reduce expenses. There will be space available when specially designated rooms, such as for HDR, are converted to apartments ( LDR brachytherapy will still be able to be offered due to the long shelf-life, and Radium-226 sources will again be brought into use). brought in by patients (subtly solicited by the staff Food ) will be able to be shared . Paying for day care will not be necessary since everyone will be living in the same building. . Additional income can be generated in several ways. Patients who are appreciative of not having to drive 60 miles each way to be treated at an impersonal academic center will be generous in filling tip jars. Treatment-related paraphernalia and souvenirs can be sold in the front lobby, including snow globes with models of linear accelerators within them, T-shirts (I Rode the Cyberknife), and photographs taken of the patient on the treatment unit Advertising can be sold, with premiums on spaces within the treatment vault and the waiting areas. Additional revenue can be generated by instituting mandatory valet parking. There could be a slight charge for desirable treatment times and perhaps even for specific lockers in the changing rooms , and for call-ahead treating Concessions can be sold in the waiting room, and this might even be subcontracted to save on personnel costs. Changing gowns may be sold in various colors and designer styles. If these generate enough revenue, things could work out all right. The ultimate goal would be able to offer the actual treatments for FREE , generating even more patient good will and driving up demand.
The classic question is therefore answered. How will we make money when we give treatments for free?
(thanks to Michael Boellner and Milton Larrea for comments that contributed to this month's column)