Jordan Johnson, Founder and Principal at Bridge Oncology and Legal Data Expert, shared on LinkedIn:
”The first-week response to Not About Access: The Economics of Radiation Oncology has reinforced something I strongly believed when I wrote it: this conversation is bigger than one specialty.
Radiation oncology is showing us what happens when clinical innovation moves faster than the economic model supporting it.
We are treating patients in fewer fractions, using better technology, and improving outcomes. At the same time, labor, software, cybersecurity, prior authorization, compliance, capital replacement, and administrative costs continue to rise.
That is why the 2027 proposed rules matter.
The debate cannot stop at whether individual codes increase or decrease. We need to ask whether payment policy reflects the true cost of maintaining the infrastructure required to deliver modern cancer care.
The central idea of Book One is simple: access is the outcome. Sustainability is the foundation.
If we want to preserve access tomorrow, we have to build the economics correctly today.”
Book One Was Never Just About Radiation Oncology. The 2027 Proposed Rules Prove Why.
Last week, Not About Access:
The Economics of Radiation Oncology was released as Book One of the Oncology Finance Trilogy. The response in the first week has been stronger than I anticipated, and the early sales numbers make one thing clear: this topic matters. Physicians, administrators, health system leaders, policymakers, consultants, investors, and industry partners are all wrestling with the same fundamental question.
How do we preserve high-quality cancer care in an environment where the economics of delivering that care are becoming increasingly difficult?
I am grateful for everyone who has purchased the book, shared it, challenged the ideas in it, or started a conversation because of it. More importantly, the response tells me that there is a real appetite for a different framework for understanding what is happening in radiation oncology and, increasingly, across healthcare.
For years, we have discussed declining access, reimbursement pressure, workforce shortages, consolidation, technology costs, prior authorization, rural healthcare instability, and capital constraints as if they are separate problems. They are not. They are interconnected parts of the same economic system.
That is the central argument behind Book One, and it is especially relevant as we prepare our responses to the 2027 Medicare Physician Fee Schedule and Hospital Outpatient Prospective Payment System proposed rules.
The title of the book, Not About Access, is intentionally provocative. Access obviously matters. It matters enormously. Patients should be able to receive timely, affordable, high-quality cancer care regardless of where they live. The problem is that access is often the outcome we can see, rather than the underlying condition that caused that outcome.
One of the lines from the book that captures this distinction is simple:
‘Geography determines where care could be delivered. Economics determines whether care will continue to be delivered.’
That distinction changes the policy conversation. If we define the problem as a shortage of radiation oncology locations, then the logical response is to build another center, subsidize another facility, provide another grant, create another demonstration project, or increase reimbursement. Those interventions may help in the short term, but they do not answer the more important question: why did the market become unsustainable in the first place?
Radiation oncology is particularly useful for understanding this problem because almost every economic pressure is visible at once. The specialty has extraordinary fixed costs, expensive technology, highly specialized labor, significant capital replacement requirements, increasing administrative burden, and persistent reimbursement pressure. At the same time, clinical innovation has reduced treatment fractions and made care more efficient for patients.
The book describes the financial sequence clearly. Population influences patient volume. Payer mix influences reimbursement. Reimbursement affects margin. Margin creates capital. Capital allows organizations to replace equipment, recruit physicians and staff, modernize technology, and maintain competitiveness. When that cycle weakens, the reverse occurs. Capital investment slows, equipment ages, recruitment becomes more difficult, referral patterns shift, volumes decline, and margins compress further.
Eventually, access disappears.
Access is therefore the end of the equation, not the beginning.
This is why the 2027 proposed rules deserve a deeper conversation than simply asking whether an individual CPT code went up or down. CMS is once again confronting how physician work, practice expense, technical resources, site of service, and overall payment methodology should reflect modern healthcare delivery. In radiation oncology, those questions are especially important because the economics of the specialty have changed far more quickly than the basic structure of reimbursement.
As Bridge Oncology prepares comments to CMS, one of the most important themes will be consistent with the argument in Book One: payment matters, but payment cannot be separated from cost structure.
The experience of 2026 is a perfect example.
The radiation oncology treatment delivery coding changes created substantial operational disruption across the country. Changes involving 77407 and 77412 were not simply changes to numbers on a fee schedule. They affected coding interpretation, payer mapping, authorization workflows, denial management, documentation, claim edits, compliance review, and appeals.
Practices had to assign staff to investigate denials. Authorization teams had to reconcile payer policies with CPT definitions. Billing departments had to build new edits and workflows. Physicians were pulled into peer-to-peer reviews. Compliance teams had to evaluate documentation standards. Revenue cycle teams spent countless hours determining why claims that were clinically appropriate were not being adjudicated correctly.
Every one of those activities has a cost.
This is precisely what I describe in the book as part of the hidden economics of radiation oncology. Administrative complexity has become one of the fastest-growing components of the cost of care. Prior authorization, appeals management, coding changes, payer edits, cybersecurity, software licensing, compliance requirements, and fragmented workflows all consume financial and human resources that do
not directly deliver radiation therapy but are nevertheless required to operate the program.
The paradox is that radiation oncology has become clinically more efficient while the infrastructure surrounding the episode of care has often become more expensive. We hypofractionate. We reduce patient visits. We improve precision. We automate portions of treatment planning. We use better imaging and smarter technology. From a clinical perspective, these are enormous advances.
However, the underlying cost structure has not declined proportionately. Linear accelerators still require maintenance and replacement. Physicists and therapists are still required. Software costs continue to increase. Cybersecurity obligations expand. Administrative requirements grow.
Workforce costs increase. Vendor contracts remain expensive. The economics of the delivery system have not evolved at the same pace as the clinical model. This is why one of the most important arguments in Book One is that payment reform alone cannot solve a cost problem.
Appropriate reimbursement is essential, and CMS should absolutely ensure that payment reflects the resources necessary to deliver high-quality care. However, simply increasing reimbursement without addressing the underlying cost structure only provides temporary relief. If technology, labor, administrative burden, vendor pricing, compliance requirements, and software costs continue increasing, those additional dollars will eventually be consumed by the same delivery model.
That is why the conversation around the 2027 proposed rules should be broader than individual payment rates. We need to talk about the total cost of delivering radiation oncology. CMS should ask what infrastructure is truly required to maintain cancer-care capacity.
Providers should identify workflows that add cost without adding clinical value. Payers should recognize that every new authorization requirement, documentation request, and appeal process creates administrative expense.
Manufacturers should understand that technology pricing cannot remain permanently disconnected from the changing economics of treatment. Health systems should evaluate oncology as part of a larger cancer-care ecosystem rather than judging every department solely on short-term margin.
This also applies to the ongoing site-neutrality discussion. The question should not simply be whether the same service should receive the same payment regardless of location. The more important question is whether the economic environments in which those services are delivered are truly comparable. A low-volume community hospital, a large metropolitan academic center, and an independent physician practice may deliver the same clinical service, but they may operate under substantially different workforce, capital, overhead, payer mix, and infrastructure realities.
Policy becomes dangerous when it assumes that identical codes automatically represent identical economics.
Book One begins the trilogy because economics has to come first. Before we can redesign oncology organizations, payment models, technology strategies, workforce structures, or accountability systems, we have to understand the economic foundation underneath them.
If we continue defining every closure as an access problem, every reimbursement reduction as the problem, every staffing vacancy as a workforce problem, and every denial as a revenue-cycle problem, we will continue solving individual symptoms while the underlying system deteriorates.
The conclusion of the book is intentionally simple:
‘If we build sustainable economics, we will preserve sustainable access.’
The first-week response to Not About Access tells me that many people across healthcare are ready to have that conversation.
The 2027 proposed rules give us an opportunity to have it where it matters most.
Our comments to CMS should absolutely address reimbursement, coding, practice expense, site neutrality, and payment methodology. But they should also ask a much larger question.
Are we designing payment policy to preserve today’s procedures, or are we designing an economic system capable of preserving tomorrow’s cancer-care infrastructure?
Those are not the same thing.
If we want patients to have meaningful access to radiation oncology five, ten, and twenty years from now, then the policy conversation has to move beyond what we pay today and begin addressing what it actually takes to sustain care for the future.
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