Can you comment on why dialysis and PAMPA are not good examples?
Sure -
PAMPA is the "talking point" if you ask ASTRO why they believe they have the political savvy/experience to pull something as wildly ambitious as ROCR off in the first place. "PAMPA" is the 2015 "Patient Access and Medicare Protection Act".
If you Google around, you'll find little blurbs in the healthcare news websites that say things such as "ASTRO successfully lobbied for passage of the Patient Access and Medicare Protection Act (PAMPA), which initiated CMMI’s work on an APM for radiation oncology".
Now, is it true that ASTRO was involved in lobbying in favor of PAMPA? Yes, of course.
But PAMPA was an absolutely massive cross-specialty, cross-organization effort. It was a serious piece of legislation that contained provisions for multiple aspects of American medicine.
From the AMA's blog post about it:
"Legislation adopted by Congress Friday will allow any physician who applies for a hardship exemption from the 2015 electronic health record (EHR) meaningful use program to be exempted from the penalties that would have been levied in 2017. This blanket exemption will alleviate burdensome administrative issues for both physicians and the agency...
The meaningful use provision in the new legislation, for which the AMA was instrumental in securing support, will grant CMS the authority to process requests for hardship exemptions to physicians through a streamlined process."
ROCR, by contrast, is a unilateral effort by just ASTRO, introduced as standalone legislation, that completely rewrites how Radiation Oncology exists in America in terms of Medicare reimbursement.
PAMPA, while important...all it did was freeze existing reimbursement levels. It didn't create anything new, let alone wildly and uniquely new, and it was not done as a solo vanity project.
Oh - and 21C/Liberty Partners were the key lobbyists for PAMPA, not ASTRO. Liberty Partners is currently who ACRO retains as a lobbying group, not ASTRO. Liberty Partners and ASTRO are not friends.
Unless, when we say "ASTRO", we really mean "Connie Mantz", in which case...we can say ASTRO was crucial for PAMPA lobbying, because Connie was the CMO of 21C during the PAMPA years.
I say that because this is all a matter of public record, after Andrew Woods, chair of Liberty Partners, sued 21C for $9 million dollars in backpay they owed him for, among other things, getting PAMPA passed.
Obviously, we can debate whether or not Woods deserves ALL the credit for PAMPA (I've read the court documents - 21C definitely owes him his money, and he's probably...at least 85% the reason PAMPA passed), but I don't think one guy can claim ALL of the credit.
The
dialysis (ESRD) thing...hoo boy.
So, again - that was not standalone legislation pursued unilaterally by a small professional society. The bill was "HR 6331 Medicare Improvements for Patients and Providers Act of 2008".
For starters, the way this thing became law is almost unheard of, and given the modern political atmosphere, will likely never happen again.
From an article written in 2008:
"July 15, 2008 -- The House and Senate voted Tuesday to override President Bush's veto of a bill blocking a big cut in Medicare payments to physicians.
The bill (HR 6331) now becomes law. Bush had vetoed it just before noon on Tuesday.
A few hours later, the House voted 383–41 to override the veto. The vote comfortably surpassed the two-thirds majority required, and the override produced almost 30 votes more than the 355–59 tally by which the House passed the bill June 24.
The Senate later voted 70–26 to override Bush. It had passed the bill by voice vote July 9 after voting 69–30 to overcome a procedural hurdle.
Tuesday's action represents the fourth veto override of Bush's presidency. Congress enacted a water resources bill (PL 110-114) over the president's wishes, and overrode him twice on the farm bill because of a procedural glitch (PL 110-246, PL 110-234)."
So a sitting president vetoed the bill, and then BOTH the House and the Senate overrode the presidential veto.
Obviously that's procedural/wonky and can be argued to be tangentially related to ROCR, but when ASTRO first whipped out this talking point about dialysis and I started reading about it...that was, uh, notable.
But what even is it? This is hard to easily find articles about, because it's now deeply tied up in a 2012 change that pegs payments to quality. But how it's talked about today:
"The Centers for Medicare & Medicaid Services (CMS) End-Stage Renal Disease (ESRD) Quality Incentive Program (QIP) is designed to encourage the delivery of high-quality services in dialysis facilities. The ESRD QIP is one of several pay-for-performance or “value-based purchasing” initiatives that CMS has undertaken to transform the healthcare payment system to one that considers the quality of services provided to beneficiaries, not just the quantity of services provided.
Each dialysis facility must post a Performance Score Certificate that documents the facility’s performance on the ESRD QIP including their Total Performance Score, scores on individual measures, and comparisons to the national average. Facilities must display their Performance Score Certificate within five business days of receiving notice from CMS that the certificate is available. The certificate must be posted for the entire year (January 1-December 31) in an area where it is easily visible to beneficiaries and their families or caregivers. These certificates must be updated and posted annually."
Here's an abstract from a review article also talking about the 2012 update to the legislation, which is relevant, because no one should believe ROCR, as it is written, is set in stone, even if it were to become law:
"The ESRD Quality Incentive Program (QIP) is the first mandatory federal pay for performance program launched on January 1, 2012. The QIP is tied to the ESRD prospective payment system and mandated by the Medicare Improvements for Patients and Providers Act of 2008, which directed the Centers for Medicare and Medicaid Services to expand the payment bundle for renal dialysis services and legislated that payment be tied to quality measures. The QIP links 2% of the payment that a dialysis facility receives for Medicare patients on dialysis to the facility's performance on quality of care measures. Quality measures are evaluated annually for inclusion on the basis of importance, validity, and performance gap. Other quality assessment programs overlap with the QIP; all have substantial effects on provision of care as clinicians, patients, regulators, and dialysis organizations scramble to keep up with the frequent release of wide-ranging regulations."
Now, at least compared to PAMPA, I think the ESRD talking point is indeed somewhat relevant to ROCR - other than it was just a part of an overall huge bill that took herculean efforts to pass.
It provides a case-based payment for dialysis from Medicare.
My biggest concern with holding ESRD up as the ROCR analogy is the fact that dialysis is only a single treatment/modality within the bigger specialty of Nephrology. Yes, dialysis DEFINITELY is the most lucrative aspect of Nephrology.
But ROCR proposes a mandatory reshaping of all of Radiation Oncology, everywhere, save for the notorious exemptions like protons.
Further, the ESRD program does not exist completely outside of Medicare/CMS, it is still inside the "regular" system.
ROCR creates a brand new, separate system for just Radiation Oncology - ALL of Radiation Oncology - so the similarities with ESRD begins and ends with "case-based payments".
Worst of all, these two things, PAMPA and ESRD, are the ONLY talking points around the concepts of "precedence" ASTRO has.
It's like me saying I'm going to enter and win the Daytona 500, because I've visited Florida, and I've driven a car.
