April 2019

Transportation help for patients: Where the rubber meets the road

By Dave Adler, ASTRO Vice President of Advocacy

Radiation oncologists looking to provide their patients with local transportation services to access their clinics should closely examine a new road map for health care providers.

For rural radiation oncology patients, travelling long distances on a daily basis for weeks can often be a significant road block in completing radiation treatment regimens. Time away from work and the costs of travel quickly add up for these patients, many of whom are lower income. As part of the new ASTRO Rural Radiation Oncology Initiative, some members have asked whether providing transportation services to shuttle patients to their daily treatments constitutes a beneficiary inducement under the Anti-Kickback Statute (AKS).

As background, beneficiary inducement rules prevent providers from offering patients remuneration that they know is likely to influence the selection of a provider. While designed to protect patients and the Medicare program from abusive practices, some policymakers and providers, particularly in rural and underserved areas, expressed concern that the rules lacked street smarts and restricted access where there was a low risk of abuse.

On January 6, 2017, the Department of Health and Human Services Office of Inspector General  issued new rules that codified new safe harbors and exceptions to the beneficiary inducement provisions. Thanks to the changes, a local transportation program may provide free transportation to and from health care provider appointments for established patients of a provider. According to Crowell Moring LLP, ASTRO’s outside legal counsel firm, to be protected under the safe harbor, transportation services must follow these rules of the road:

  • Free or discounted transportation services may be provided to patients to travel to and from appointments with health care providers or suppliers.
  • The availability of free or discounted local transportation services cannot be determined in a manner related to the past or anticipated volume or value of federal health care program business to or from an individual or entity.
  • The transportation services made available cannot consist of air, luxury or ambulance transportation.
  • A transportation program or the availability of transportation services cannot be publicly marketed.
    • Marketing includes posting signage in public areas, including waiting rooms or lobbies of provider locations, posting online or otherwise communicating en masse the existence a transportation program or available transportation services.
    • To ensure no public marketing, the availability of free or discounted transportation services should be discussed with a patient only based on a reasonable belief that the individual patient both: (1) is currently a patient of the affiliated provider, and (2) needs free or discounted transportation services to be able to keep his appointments.
  • Transportation services may be made available only to established patients of the health care provider location to which they require transportation. A patient is considered “established” after he or she selects and initiates contact with a provider to schedule an appointment.
  • The entity making arrangements for the transportation must also be the entity bearing the costs of the services. The cost burden cannot be shifted to a federal health care program.
  • Services must be offered to patients only for the purpose of obtaining medically necessary items and services.
  • A slightly less extensive set of requirements apply to a “shuttle service” that runs along a pre-established route.
  • Transportation services can only be available for distances up to 25 miles in urban areas and 50 miles in rural areas.


While the rules could put some radiation oncology clinics on easy street to provide transportation services to patients, there is concern that the 50-mile restriction for rural areas will stop traffic. We’re interested in hearing from members on these issues, including:

  • Are these rules right up your alley and allow your practice to provide enhanced transportation services?
  • Is the 50-mile restriction a dead end for reaching patients in rural areas?
  • Have you identified any innovative approaches that are the ticket to ride for providing transportation services to patients in rural areas?


Enter your response in the comment section below, we look forward to your feedback.

Before putting the pedal to the metal to offer local transportation, ASTRO members should avoid blind alleys by consulting their practice’s legal counsel to ensure compliance with the new rules and other relevant regulations.

Posted: April 16, 2019 | 0 comments

How two radiation oncology facilities increased practice efficiency, patient safety and company culture

An interview with Yoichi Watanabe, PhD, and David Hong, MD
By Randi Kudner, Senior Quality Improvement Manager

Yoichi Watanabe, PhD, has been involved in various aspects of radiation oncology accreditation in his many years at the University of Minnesota in Minneapolis. David Hong, MD, became interested in practice accreditation during his residency days at New York-Presbyterian Brooklyn Methodist Hospital and now works with Southeast Radiation Oncology Group in Charlotte, North Carolina. Both sat down with ASTRO’s Senior Quality Improvement Manager, Randi Kudner, to discuss the importance of accreditation and the practical improvements it can provide.

How did you become interested in practice accreditation?

DH: My department was due for re-accreditation towards the end of my second year in residency. It was the first I’d ever heard of the topic and I was surprised to learn that there were so many items material to the operation of radiation oncology practices that I’d never heard of or thought about. Figuring it would be better to learn about these sorts of things during residency than later as an attending, I approached our department chair Hani Ashamalla, MD, and asked to help. A year later, Dr. Ashamalla forwarded me an ASTROgram soliciting committee volunteers and encouraged me to apply. I was accepted by the Accreditation Committee and have since gained an appreciation that despite institutional variation, we all follow the same fundamental process of care and share similar day-to-day concerns.

YW: The University of Minnesota started the accreditation process in December 2015. At that time, accreditation was not popular among radiation oncology facilities in the Midwest, particularly in Minnesota. However, we saw an increasing concern for the safety of treatment in both the radiation oncology community and the potential patient population and felt the need to reexamine our current practice from a more objective point of view. Given the increased focus on safety and quality improvement in the field, we chose ASTRO’s Accreditation Program for Excellence (APEx®) since the program was built upon Safety is No Accident: A Framework for Quality Radiation Oncology Care. Because APEx was new and no other institution in our area had such an accreditation, we envisioned an opportunity to prove the excellence of our practice. We expected at least two benefits with the application process. First, it would help to improve the quality of our clinical practice. Second, it could serve as an advertisement for our facility because of the strict accreditation requirement focused on the safety of radiation therapy. The fact that determinations in APEx are established through a committee review of a blinded facility report made it even more appealing for us as an objective program.

What is the value of accreditation in a radiation oncology practice?

YW: Accreditation is an external validation of quality, demonstrating the practice’s compliance with standards and best practices. The process allows for an objective, outside perspective that helps a practice identify strengths and weaknesses. It also shows patients that they can trust an organization and demonstrates to a community that the practice wants to provide the highest quality care possible. They respect that a practice has voluntarily undergone the process of meeting rigorous standards.

DH: It’s all about the effort put in. Done well, undergoing accreditation allows a radiation oncology practice to critically analyze, codify and improve policies and procedures, reduce variation through standardization of processes, and help establish a framework and culture of safety that can guide future practice improvement efforts. This does require a significant commitment of time and resources, but it’s a worthy investment. Providing this sort of structure was crucial to making our department a better place to work.

Both of you have gone through accreditation and been involved with APEx. What areas have you seen improve the most within your practice?

DH: The biggest change I witnessed was reduced friction and overall stress levels due to improved intradepartmental communication. Team members had a clearer understanding of what needed to be done and when. Patient wait times were reduced and our machines ran on schedule more often with less overtime and missed family time. Dosimetrists were able to deliver better plans faster after developing patient-specific planning directives. We were able to review our compliance and billing mechanisms and significantly improve our revenue cycle, primarily by improving documentation, pre-authorization, activity capture and auditing processes. We did not routinely use an incident learning system, but if we had, I believe that our rate of near-miss events would have been reduced dramatically. I could keep going, but in the end, I felt that going through an accreditation process served as a catalyst for improving most aspects of our practice’s operations over time.

YW: The review of procedure documents also significantly improved our practice. Our facility had most of the required documents already written, however, the policies and procedures were difficult to locate because of the lack of proper document management. Some had not been updated and others were never approved by management, so those were not officially used. The document preparation process was one of the most rewarding tasks because it required our team members to work together and understand our clinical process better while identifying our shortcomings and weaknesses. Through this exercise, our culture of teamwork was further improved for higher quality care.

Although we were proud of the quality care we provided to the patients, APEx made us identify and correct many deficiencies in our practice. We made changes and improvements in our daily practice, including:

  • Adding radiation therapists to increase the number of staff available for treatment and simulation.
  • Rewriting many existing, and developing many new, policy and procedure documents to clarify the procedures and meet the APEx requirements.
  • Introducing a daily morning huddle to discuss the clinic schedule on that day.
  • Forming a departmental safety committee; we meet quarterly to discuss the incidents reported to our incident reporting system and identify ways to improve the process.
  • Adding an additional weekly chart round meeting to spend more time in reviewing treatment plans and the contours drawn by physicians for peer review of treatment planners and physicians.

Now we are more confident in our ability to provide the best care and service to our patients among many institutions in our local region and beyond.

Thank you both for sharing your insight into practice accreditation. There are many aspects for a practice to consider, and hopefully your experience will help other practices. Other than what you have already shared, what are your final comments?

YW: The most important requirement for successful completion of the accreditation process is the availability of a leader who drives the entire practice to work toward the goal. This encouragement and leadership will result in a willingness of departmental staff to participate in the process with the goal of success.

DH: Aside from the practice benefits, which are many, patients and referring providers expect safe, high quality services when entrusting us with their care. A convincing way of demonstrating this is through accreditation with a rigorous program.

Join the 110 facilities who chose to strengthen their practice and demonstrate that they provide the highest quality radiation oncology care by becoming an APEx accredited facility or network.

Posted: April 2, 2019 | 0 comments

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