Sean McBride’s, Vice Chair, Clinical Strategy, Operations, and Professional Practice at Memorial Sloan Kettering Cancer Center, shared on LinkedIn:
“Our commentary in IJROBP The Red Journal on virtual care in radiation oncology.
A few points to emphasize.
First, it is important to define the regulatory landscape and separate two concepts that are too often collapsed: supervised technical services versus the radiation oncologist’s personal performance of professional services.
Title: The Physician’s Presence: Focus on Quality Not Location
Authors: Sean M. McBride, Jordan Johnson, John J. Cuaron, Himanshu Nagar, Arpit M. Chhabra
- Radoncs supervise the services delivered by RTTs. When we talk about supervision, this is the type of activity that is being supervised.
- In contrast, evaluating, adjusting, and signing CBCTs prior to SBRT, on-treatment management, plan evaluations, etc are the professional services radoncs perform. An important threshold question: does federal law permit virtual supervision and virtual performance of professional activities?
- For hospital outpatient departments (HOPDs), we argue that federal statutes and CMS regulations permit both the virtual supervision of all incident-to radonc services and the virtual performance of all professional services in HOPDs. More controversially, we contend the same is true for freestanding facilities.
- Azar v Allina is a 2019 Supreme Court case that requires that any CMS policy that changes a substantive legal standard governing payment requires notice and comment. CMS guidance requiring direct, in person supervision in freestanding facilities was not subjected to notice and comment, and thus should not bind private practices. Allina is a case that all docs with an interest in operations and billing should know: Facts of the case
- Finally, we conclude that physician engagement, rather than location, matters most for patient safety. Safe virtual supervision and virtual care requires: real time availability clear escalation policies accountability diligent QA monitoring. Ultimately, local departments and practices are free to choose whether to adopt virtual supervision and care (bounded by state law). Professional societies and accrediting agencies should not mandate this choice for them.”
To which Jordan Johnson, Founder and Principal at Bridge Oncology and Legal Data Expert, added:
“What would we believe about on-treatment visits if a billing code werent involved?
Our new commentary in IJROBP The Red Journal looks at virtual supervision and virtual care in radiation oncology.
The starting point is a distinction that often gets lost.
Supervising the technical services RTTs deliver is one thing. A radiation oncologist personally performing professional services is another: reviewing CBCTs before SBRT, on-treatment management, and plan evaluations.
These are separate questions, and they have separate answers. Our argument:
- In HOPDs, federal statutes and CMS regulations allow virtual supervision of incident-to services and virtual performance of professional services.
- More controversially, the same holds for freestanding centers. Under Azar v. Allina (2019), CMS has to use notice-and-comment rulemaking before changing a substantive payment standard. The in-person supervision guidance for freestanding facilities never went through that process. Loper Bright and Kisor have narrowed agency deference further.
- The in-person expectation comes from CPT, not from clinical principle. 77427 and 77435 cover the same core work, yet SBRTs exam sits in the post-service period. Under per-patient payment like ASTROs own ROCR Act, the OTV stops being a billable event and becomes one tool among several, judged by outcomes.
- Enforcement history points the same way. Pensacola, the Florida IGRT case, and AnMed all involved physicians who were absent, not physicians who were virtually present. Logged, timestamped availability is easier to audit than a claim that someone was in the building.
- Economics matter too. With proposed 340B cuts landing on hospital budgets, requiring physical presence at every site wont put more physicians in front of patients. Its more likely to close satellite clinics and lengthen patients drives. Our conclusion: physician engagement matters more for safety than physician location. Safe virtual care requires real-time availability, written escalation pathways, clear criteria for holding treatment, accountability, and diligent QA.
Thats a higher bar than physical presence, and it can be audited.
Patients should still be seen in person when symptoms, exam needs, complexity, or their own preference call for it.
Departments should decide how to adopt virtual care within state law. Professional societies and accreditors shouldnt make that choice for them.
Patients judge our quality by outcomes, access, and whether we respond when they need us, not by where our chair is.
A longer article is coming soon. Id welcome your thoughts in the meantime.”
Other articles about radiation oncology on OncoDaily.