Controlling cost while maintaining or improving quality and patient safety will require this transformation of the medical physicist’s (and radiation oncologist’s) role. In direct collaboration with the radiation oncologist, the physicist will be a central part of team‐based care in a value‐based care model that is responsible for optimizing key business aspects of a well‐functioning practice (patient census, clinical workflow, and development of quality improvement and patient safety initiatives). Ultimately, the RO‐APM will be a great benefit to the medical physics profession.

Patient‐specific decisions made by the medical physicist will include: patient immobilization and PTV delineation, patient imaging for setup and inter‐ and intra‐fraction monitoring, type and approach of radiation delivery, the necessary steps to ensure quality and safety of the treatment plan, and treatment delivery. The physicist will liaise with other physicians (e.g., medical, surgical, referring physicians) and their support staff as necessary to facilitate a patient’s care. Technological innovations will be alive and well in this new paradigm because the physicist will determine how and when to implement them. Innovation of new hardware and software technologies will occur via the traditional pathway of securing extramural funding from vendors, private foundations, or the government to support that development; just as the radiation oncologist basic science researchers do.

What does the transformation look like? The new medical physicist role will have primary responsibility for all technical decisions related to patient care in radiation oncology including the management of the patient’s care path through radiation treatment. After the decision has been made by the radiation oncologist to use radiotherapy, the physicist will then lead the radiation treatment team, collaborating with the radiation oncologist, to determine and deliver the best radiation treatment. The radiation oncologist will make the decision of whether or not radiation should be used to treat the patient’s disease, CTV delineation, managing short‐ and long‐term complications, as well as seeing any patient with a suspected cancer diagnosis to coordinate that patient’s care – even for those who do not require radiation therapy. Shared decisions by the radiation oncologist and physicist will be related to secondary imaging and GTV delineation, total dose, and fractionation.

With these two axioms in mind, I can confidently say that the RO‐APM would be much more of a benefit to the medical physics profession than it is a detriment – provided that physicists are willing to transform their current clinical role. This transformation will be easier if the physicist’s work is not defined by specific billing codes needed for reimbursement. The RO‐APM would remove this barrier and allow flexibility in the physicist’s job functions.

How can I argue for the proposition? To answer that question, we need to go back a ways. I started working in radiation oncology back in 1992 – before MLCs, IMRT, IGRT, SGRT, AI/ML, and all the rest of the novel or once novel technologies that we have now. Fast forward about 10 years when I started doing clinical research in quality and safety, moved to UC San Diego to build and lead a team of physicists and by necessity, stepped back from routine clinical work. From these perspectives, two ideas crystalized for me: 1) the only way to create a large improvement in quality and safety is to change the system of care – new technologies or process tweaks will not reach that goal, and 2) the level of education, training, and clinical acumen of medical physicists entering the field today is so consistently high, compared to when I started, that the current clinical role of the medical physicist drastically undervalues their potential impact on patient care.

A change to the RO‐APM is likely to result in a further emphasis on efficiency and cost reductions to maintain radiation oncology profit margins. This focus could lead to a reduction in staffing levels (including medical physicists) and have serious deleterious effects on treatment quality and patient safety. Physicists could easily be replaced with less qualified (and less expensive) staff that would be tasked with the majority of technical/routine work, leaving only a very few qualified physicists in the department for key physics‐only work such as output calibrations. Achieving further operational efficiency might be realized by an increased use of hypo‐fractionated treatments, which are more complex and risky than conventionally fractionated treatments. Paradoxically, when a physicist’s expertise needed most, the medical physics profession might be contracting. In addition to all this, the RO‐APM could stifle innovation in radiation oncology because of the technical expertise will not exist in the department to develop and implement it; not to mention that hospital administration will not have the financial incentive to do so. It is a bleak outlook when you stop to think about it.

The RO‐APM led by the CMMS aims to improve quality and control cost of healthcare by shifting from a fee‐for‐service to an episode‐of‐care reimbursement model. While the final configuration of the RO‐APM is not finalized, it is very clear that the U.S. health care system must move in this direction to control costs or risk a lowering GDP, lowering employment, and increasing inflation.

2.2 Eric Ford, PhD

The potential effects of the RO‐APM are difficult to judge given its complexity and the fact that this will be the first mandatory APM for any medical specialty. One stated goal of the CMMS is to cut costs. Therefore, one might predict that one effect of this new model is lower overall support paid out, at first for Medicare patient but eventually also for private payers (insurance companies). The overall result is a pressure to reduce costs. Of this there is little doubt. This might lead to reduced staffing of medical physicists, increased reliance on technical staff who are not qualified medical physicists, or reduced support for medical physics activities in other ways. Thus, medical physicists have a well‐founded anxiety about the potential impacts of the RO‐APM system.

The effects of the RO‐APM may be compounded by other factors as well. One likely outcome of the RO‐APM is an increased reliance on hypo‐fractionated regimens (as in single‐payer systems like Canada and Europe). Deploying such services safely, however, typically requires more physics support, not less. The RO‐APM also comes at a time where automation is being increasingly used. This may impact medical physicists. The commissioning of a linac, typically, is thought to require 8–12 weeks of intensive physics time, but now at least one vendor is advertising a system with a commissioning time of two days. This unit also includes automated system for quality assurance. Automation may mean that more routine parts of the medical physicist’s job are quickly taken over. There will likely be other cost pressures on the healthcare system as well. Some models have suggested that the RO‐APM will require that more support staff be hired to manage the administration of this complex system. These higher costs may drain resources away from medical physics.

Given these pressures, it is difficult to see how the RO‐APM might improve the lot of medical physics profession. Perhaps an enlightened administrator or other decision maker when confronted with the new model might take a new look at established safety recommendations such as the Safety is No Accident report from ASTRO.3 This might move them to retain or even increase support to medical physics. Or perhaps this decision maker might consider new roles for medical physicists beyond routine tasks (e.g. a medical physicist hired to be an in‐house expert on automated treatment planning). While this may well happen in a handful of centers (as indeed is already happening), the reality is that for many administrators it will be far simpler to reduce costs by simply cutting physics support.

Consider also the signals that administrators and decision makers are receiving. An example is the separation of reimbursements into professional fees and technical fees (in radiation oncology typically 20% of the reimbursements are billed by clinicians as professional fees while the rest are technical). This split system has existed for many years and will continue to exist under the RO‐APM. It has resulted in a symbiotic interdependency between clinical providers and administrators. Because the revenue from professional fees was never enough to support the salaries of clinicians the two parts became intimately dependent. This sends a signal of sorts. If this signal could be decoded it might read something like this: “[Memo from CMMS to Hospital X]: Do not back off on your support for physicians. Remember we are paying for this support.” No such signal exists for the medical physicist. There is nothing baked into the system that specifically recognizes their value.

In the end we are all a team and these divisions may not matter much (or should not matter). However, this is predicated on the fact that a functional and effective team is in place at each center. Will the new system reward and support such teamwork? In some ways it certainly will. If, for example, your team can achieve a lower rate of re‐hospitalization you will be rewarded. If your team participates in a quality improvement program under a Patient Safety Organization like RO‐ILS: Radiation Oncology Incident Learning System, you will be rewarded. And so on. In other ways, however, it does not. If the business entities were to undertake extreme cost‐cutting measures, the system would have little to say about it until the quality metrics fell below some level. That might be acceptable. After all, quality of care is what we are after. However, quality metrics are notoriously difficult to measure, especially in oncology. The result is that a wide drift in quality may be allowed in the new system and there may not be enough backstops to the cost pressures to prevent this.

There are many things that are unclear about the new RO‐APM system, but the danger for medical physicists is that it makes them into the equivalent of the Greatest American Hero (1981‐1983). In this show, Ralph Hinkley, an LA public school teacher, is visited by aliens while on a school field trip. The aliens give him a superhero suit which allows him to fly and do amazing feats, but they leave him little else in the way of support. (He has an instruction book for the suit, but he loses it). Without this support he is “flying away wing and a prayer.” Is it me?