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Supervision Town Hall Recording and FAQs

Attended by more than 200 participants, ASTRO’s Supervision Town Hall covered Centers for Medicare and Medicaid Services (CMS’) supervision policy and provided attendees with an opportunity to share insights regarding the impact supervision has on their practice. A recording of the Town Hall is available below, as well as answers to questions raised during the Town Hall.

During the Town Hall, ASTRO leadership shared insights on CMS supervision policy, specifically how it differs between hospital and freestanding settings. Additionally, the Town Hall featured interactive surveys, live chat, and a Q&A session that allowed for broad participant interaction.

A supervision work group has been established to inform ASTRO’s position in response to changes to CMS' supervision policy. The work group consists of ASTRO members who represent a variety of different practice types and settings. Participants will be charged with formulating recommendations that will be shared with ASTRO’s Board of Directors at its June meeting. The Board approved recommendations will then be used to form ASTRO’s response to the 2025 Medicare Physician Fee Schedule which is expected to include the proposed supervision policy revisions. View is a list of participants.

ASTRO members are encouraged to continue sharing their opinions on supervision via ROhub or send an email to the health policy team.


Supervision Town Hall FAQs

Can ASTRO clarify its position regarding supervision policy in the hospital setting?
ASTRO supports direct supervision policies in both the hospital and freestanding settings. Lack of proper oversight could lead to errors that could potentially harm patients. As we noted in our letter to CMS, there should be practical flexibilities for radiation oncologists to participate in tumor boards and other clinic responsibilities for the good of patient care, as well as some latitude to ensure that patients in rural areas have access to treatments that otherwise may not be available due to coverage constraints.

Is ASTRO the only medical society calling for a return to direct supervision?
For the record, ASTRO is NOT against telehealth. There are circumstances in radiation oncology practices where remote virtual care offers advantages to patients and their health care providers. A virtual initial consultation or follow-up care can be helpful for patients that travel long distances or have transportation challenges. However, in the daily practice of radiation oncology with patients actively receiving therapy, the availability of the physician to attend to clinical matters is very important.

Advances in technology enable the delivery of higher doses of radiation per daily treatment, shortening the overall course of therapy. While shorter treatment courses reduce the number of visits and length of time a patient is under treatment, they increase the complexity of the treatment due to the higher dose per daily fraction. Lack of proper oversight could lead to errors that could potentially harm patients. Another medical society that supports direct supervision in their practices is the American Society of Anesthesiology. The risks to patients while receiving care can be mitigated with the immediate availability of appropriately trained physicians.

Are residents allowed to supervise patient care?
Under CMS rules, while providing care in the course of their medical training, residents are not permitted to act as the direct supervising physician of patients receiving radiation treatments. Ultimately, the attending physician is responsible for the care of the patient.

CMS’ Role

Can ASTRO explain why supervision is dictated at the Federal level rather than via society guidance or at the hospital/facility level?
As a condition of Medicare payment, the Centers for Medicare and Medicaid Services (CMS) sets Medicare physician supervision requirements that apply to services, including radiation therapy, furnished in hospital outpatient and physician office settings. These requirements differ according to the type of service and the practice setting where the service is rendered, as defined by the various benefit categories under Title XVIII of the Social Security Act. Specific guidance regarding physician supervision is published in the Code of Federal Regulations and the Medicare Benefit Policy Manual.

Why would CMS treat radiation oncology differently?
CMS supervision policy has evolved over the last several decades and continues to change as technology advances impact where patients receive care and how that care is delivered. CMS seeks input from specialty stakeholder groups, like ASTRO, to provide it with guidance on appropriate supervision policy.

In 2020, at the onset of the PHE, ASTRO initially requested and received special consideration for 77427 to be included on the telehealth list enabling practices to perform the OTV portion of patient management virtually. In 2021, the Agency agreed with ASTRO to remove 77427 from the temporary telehealth list at the end of the PHE. The Federal PHE, declared under Section 319 of the Public Health Service Act, expired May 11, 2023. However, CMS has extended the use of the temporary telehealth list through the end of 2024. ASTRO issued its letter to CMS in February to express support for removing 77427 from the temporary telehealth list at the end of the year. Similar to efforts related to 77427, ASTRO anticipates that CMS may propose changes to its broader supervision policy for radiation oncology services as part of its annual rule making process.

ASTRO Process for Regulatory Review

Can ASTRO explain the process for submitting letters to CMS?
ASTRO regularly monitors CMS regulatory proposals so that it can advocate on behalf of the specialty when policy changes are under consideration that impact radiation oncology, directly or indirectly. Once a proposed rule is issued, ASTRO staff issue a summary of key points impacting radiation oncology to the Health Policy Council and the broader membership via ASTROgram.

The next step is the development of a comment letter. ASTRO staff drafts a comment letter that is circulated within the Health Policy Committee. The committee provides suggestions and assists staff with refining responses to key issues impacting the specialty.

Next, the Health Policy Council leaders review the letter, which is also reviewed by the Government Relations Council leaders to ensure consistency with legislative initiatives. Next, the letter is finalized by the Chair of ASTRO’s Board of Directors and signed. Finally, the letter is submitted to CMS in response to the Notice of Proposed Rulemaking (NPRM), posted on ASTRO’s website and highlighted in ASTROgram and our other communications channels. In many cases, ASTRO arranges a meeting with CMS to discuss the issues in more detail.

CMS’ public comment process allows anyone, including individual radiation oncologists and other stakeholders, to submit comments on CMS regulatory proposals.

Rural/Small Clinics

Can you share more on the implied flexibilities that ASTRO is seeking to establish for solo-physician, small, and rural cancer centers?

When ASTRO met with CMS, we brought up the need for flexibilities for solo-physician, small, and rural cancer centers. CMS officials said it would consider policies where regulatory precedent could be applied to radiation oncology services at these centers.

ASTRO is forming a work group, which will include representation from small, rural and solo practices as well as health policy, clinical affairs and quality, and government relations committee leaders, to further consider various existing policies and how they could be applied to enable greater supervision flexibilities. Policies under consideration include the New Jersey 90% direct supervision rule, as well as using Rural-Urban Continuum Codes to define rural health care areas that may benefit from the application of a more flexible supervision policy.


Is ASTRO considering workforce implications as part of its supervision policy?
The supervision policy advocated by the Health Policy Committee was focused on patient safety. However, should there be a proliferation of tele-radiation oncology due to relaxed supervision standards and expansion of virtual supervision, then we anticipate that there could be a negative impact on the future radiation oncology workforce.

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