Radiation Oncology Strategies for an Uncertain Future

From transitioning to value-based care to effectively onboarding new members of the care team, the ACCC Radiation Oncology Pre-Conference on March 5 covered current and near-term challenges facing the field of radiation oncology. The half-day multi-session program was held in conjunction with the ACCC 46^th Annual Meeting & Cancer Center Business Summit in Washington, D.C.

The pre-conference kicked off with in-depth look at current payment models in radiation oncology and discussion of anticipated changes to CMS’ proposed Radiation Oncology (RO) Model. CMS released the proposed RO Model released in July 2019, and the agency is expected to release the final rule this month. Vivek Kavadi, MD, of US Oncology, reminded attendees that the start date for the final model is slated for July 2020—a mere four months away.

Given this “extremely aggressive timeline,” Dr. Kavadi encouraged hospitals and practices to waste no time preparing for the transition. He recommended that radiation oncology programs adopt a “guideline-driven” approach to their implementation of the RO Model so that it is applicable to all cancer types and can be better used as a vehicle to improve quality of care.

Documentation
Presenter Amar Rewari, MD, MBA, a radiation oncologist at Adventist HealthCare, noted that CMS is looking to improve its prior authorization process, which will impact not only radiation oncology, but also medical oncology and pharmacy. Prior authorizations can be the biggest challenge for radiation oncology providers in both non-academic and academic settings, he said. This aligns with ACCC’s 2019 Trending Now in Cancer Care survey findings where 49% of respondents reported payer reimbursement requirements as leading the top five threats to cancer program growth and 48% ranked transition to value-based payment in second place. Many patients experience treatment delays due to unanticipated authorization issues, Dr. Rewari noted; automating the prior authorization process can help to streamline the workflow.

“With the transition to value-based care, documentation will be a key component,” he said. To prepare, he suggested programs take an in-depth look at how the RO Model will potentially impact their practices or programs. Dr. Rewari stressed that automated documentation can enable a smoother auditing process, be used to help better determine payment rates, and be the ultimate justification for rate reviews.

Risk Reduction
Speaker Ed Kline, MS, CNMP, RT(N)ARRT, founder of RadPhysics Services LLC, addressed the importance of effective incident reporting systems in radiation oncology programs. Safety issues, he noted, are more prevalent in radiotherapy than in other specialties. Being able to promptly and efficiently register patient safety events gives programs the ability to respond swiftly when time is of the essence, said Kline. But the perfect should not be the enemy of the good: “Developing a culture that focuses on reducing risk rather than overemphasizing ‘zero’ harm goals will improve risk-related outcomes.”

Looking to the future Kline said artificial intelligence and machine learning will be important in risk reduction. “Automation has the potential to predict high-risk error situations and can be built into already-established workflows, ultimately closing the gap in radiotherapy-related errors and injuries.” One of the current significant barriers to error-reporting, added Kline, is fear of reprimand. Technologies like automation can take that issue out of the equation.

Expansion, Mergers, & Acquisitions
Presenting on how health system expansions, mergers, and acquisitions can affect the radiation oncology service line, Bryan Schmalhofer, MBA, RT(R)(T), identified the onboarding process as an area ripe for potential mismanagement if not handled well. “Onboarding already-established cancer centers into a new [health] system’s organizational culture, mission, and vision can be challenging and sometimes dysfunctional,” he cautioned. The key to managing this type of change, he said, is identifying physician champions who will encourage staff engagement and buy-in, particularly from providers.

When joining with or becoming part of another organization, breaking down the silos within and across the health system and promoting an openness to clinical differences is essential, said Schmalhofer. Organizational leadership that is willing to evaluate and take into account center-specific workflows, barriers, and staffing, are likely to experience a smoother expansion or merger process. Recognizing and respecting each cancer center’s unique culture and workflow will help leadership better integrate new organizations into existing management structures. “The ‘mothership’ should not drive clinical workflows,” said Schmalhofer. “The ultimate goal is treating the patient, which takes a unique approach in each location.”

The Multidisciplinary Cancer Care Team
Continuing the discussion with a focus on patient-centered care, Toby Bressler, PhD, RN, OCN, shared the story of her program’s integration of an advance nurse practitioner (ANP) role into the care team. “Radiation oncology nurse practitioners are the newest advance practice nurses in oncology practice,” said Dr. Bressler, Director of Nursing for Oncology and Clinical Quality and Assistant Professor of Medical Oncology at the Icahn School of Medicine at Mount Sinai. With customized education and well-planned integration into the team—often overseen by a radiation oncologist or medical oncology nurse already with the practice—Dr. Bressler said ANPs can play a key role in coordinating care and promoting positive patient outcomes.

Dr. Bressler has implemented a program at Mount Sinai to onboard and educate nurse practitioners who have little to no prior clinical oncology experience. She emphasized that creating an individualized professional development plan for each nurse helps identify ongoing learning needs and sets individual expectations. At her program each nurse practitioner is given the goal of obtaining AOCNP certification. Today, said Dr. Bressler, the majority of the nurse practitioners in her program have successfully obtained certification on their first try.

Technology
Concluding the pre-conference, John Lefkus, president of RAD Technology Systems, focused on the challenges around keeping current with improvements in radiation oncology technology. As with the other pillars of cancer treatment, radiation oncology technology continue to evolve and improve. Keeping pace with advances can be costly, said Lefkus, and cancer centers can find themselves paying off a new linear accelerator long after the technology begins to age. However, there are alternatives to capital acquisition. Rather than making high-price tag investments in new tech, cancer centers can consider short-term solutions such as leasing options. “A temporary solution can have its advantages,” he said. “Using an operation lease instead of a capital purchase can be a better choice.”

According to Lefkus, RAD Technology’s minimal and removable foundation system is an example of a type of temporary solution that can help cancer centers maintain patient capacity, mitigate staff loss, and create an easier conversion for future technologies. “Innovation in care does not require permanent concrete add-ons,” said Lefkus. “Temporary options can be just as beneficial.”  

With the first RO Model around the corner and uncertainty clouding the reimbursement outlook, radiation oncology programs may want to investigate and expand on available options to support quality care delivery.
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Stay tuned for more takeaways from the ACCC 46th Annual Meeting & Cancer Center Business Summit, held March 4-6, in Washington, D.C.