

Letter Writing Campaign

The American Medical Association's Board of Trustees has been referred to an issue central
to the practice of radiation oncology and will make policy decisions in that regard in the next
couple weeks. We need your help to raise a strong voice for our specialty.
A resolution was introduced at the AMA Interim meeting in November that asked the AMA
to oppose any designation of radiation therapy services as ancillary. Because there are
complicated issues surrounding the term "ancillary" as used in self-referral limitation law, the
issue was not acted on immediately by the House of Delegates but was referred to the Board
for a final decision. They need to be educated about this issue, and writing a letter to them
as a physician can make a difference. Here are some talking points to consider discussing:
Talking points

The training and practice of Radiation Oncology involves four post-graduate years,
with a focus on clinical Radiation Oncology, radiation treatment planning and
dosimetry, radiation physics, radiation safety, radionuclide therapy, and the
integration of all of these elements into the practice of clinical oncology. No other
specialty in medicine has this rigorous training or examination related to
radiation.

Radiation Oncologists have the training and credentials to utilize radiation sources
regulated by the US Nuclear Regulatory Commission and the individual States.

Prior to World War II, the practice of administration of radiation for cancer therapy
was somewhat haphazard, essentially empirical and unscientific, and delivered in a
variety of settings by physicians in multiple specialties, often with sincere interest
but little training. Subsequent to World War II the training of Therapeutic
Radiologists (now called Radiation Oncologists) became formalized and the
American Board of Radiology developed a board certification process. Initially, the
process involved examination in General Radiology but the specialties became
more complex and disparate. In 1976, the training and certification process were
split completely, and the specialty of Radiation Oncology took its place as a
unique and separate entity in the House of Medicine.

Several years ago, the Medicare program elected to allow physicians to utilize basic
laboratory and x-ray equipment in their offices under the doctrine of “in-office
ancillary exemption,” since these services were considered to be a routine element
of office practice. Due to the historic relationship to General Radiology, the
“ancillary” designation has inappropriately been extended to Radiation Oncology.
Compared with actual ancillary services, radiation oncologists are distinct in
participating in hands-on patient management, decision making, follow-up, and
long-term monitoring of treatment outcomes.
"Ancillary" suggests that radiation therapy services are subordinate or auxiliary.
Radiation is a unique treatment modality and is used in the treatment of 60% of
cancer patients. While in-office lab tests or x-rays may be ancillary in the sense
that they are used by a physician who may not directly specialize in their
interpretation, therapeutic radiation is in no way similar.
Radiation therapy services occupy a distinct service level on the cancer treatment
continuum. The provision of these services result from the “referral” from one
physician to another physician – not to an “ancillary service.”
While the issues surrounding the specific statutory language of the Stark laws need to be
handled in a way that is fair to all parties, we do not want that concern to define this issue of
radiation oncology being considered ancillary. For that reason, your letters would be better
by not including certain arguments as well. For example:



Do not suggest or accept the argument that this issue is a "turf war" or motivated
solely by scope of practice issues. That physicians of various specialties have a
monetary stake in the designation of radiation oncology as ancillary is a concerning
side issue, but irrelevant to the factual arguments of the appropriateness of the
designation.
Avoid discussing the complexity of certain business arrangements that may or may
not need to change if radiation oncology was no longer "ancillary".
While there may be a connection between this issue and over-utilization of IMRT,
referral patterns, and patient care, discuss these very relevant issues in terms of
science or your direct experience rather than conjecture that can't be
substantiated.
Send letters NOW to:
Board of Trustees
American Medical Association
515 N. State Street
Chicago, IL 60654
FAX 312-464-5849