I’ll buy you a drink sometime and you can decide if I am a good clinician 😀Nobody has ever assuaged my proton concerns and I have never met a good clinician who wasn't willing to abandon protons personally for all adult malignancies.
I’ll buy you a drink sometime and you can decide if I am a good clinician 😀Nobody has ever assuaged my proton concerns and I have never met a good clinician who wasn't willing to abandon protons personally for all adult malignancies.
The rest of us employed docs are going to be hugely impacted by an even tighter job market as patient load is cut in half. No wonder ASTRO didnt feature an employed doc on the panel, despite them making up a supermajority of the workforce.
None of them are hurt by the ROCR.I think you are right about all your comments, but I don’t think it was intentional to feature community PP over community employed.
I suspect the intention was that they were not academic, these were “community physicians” who do not (on a superficial level) benefit from the ROCR exclusions.
None of them are hurt by the ROCR.
He seems to be a good guy, but I bet if he was employed and thought about, he would be opposed.Well Join was 1% down but was optimistic about the future 😃
I don’t know, obviously I was not involved haha. I just the sense many at ASTRO still view things a “academic or private practice” so I’m not sure there is an intention to not include employed non-academic.
He seems to be a good guy, but I bet if he was employed and thought about, he would be opposed.
I'm sure you're a great doc.I’ll buy you a drink sometime and you can decide if I am a good clinician 😀
What if I told you.. There is no ROCR spoon...I'm sure you're a great doc.
But, If I offered you a major grant to do fundamental proton work, really really fundamental dosimetry, phantom, cell culture, variation in populations regarding RBE ratio type stuff. Let you keep your same salary for the next 10 years and told you you had to use photons to treat all your lungs and livers during that time frame (I'd let you use the present proton machine for 24Gy CSI on kids).
```would you feel bad about it, or would you be like "F yeah!"
What if I told you.. There is no ROCR spoon...
There is no guarantee of stability in life, except maybe death and taxes, right?Please send these comments to that ASTRO “feedback” email. No idea what will happen to them but at least they were sent then. They are great comments.
I too am wondering why this guarantees stability?
As one of the growing group of employed rad oncs, I’m worried what decreased technical will do to my life as a cog haha.
I'm sure you're a great doc.
But, If I offered you a major grant to do fundamental proton work, really really fundamental dosimetry, phantom, cell culture, variation in populations regarding RBE ratio type stuff. Let you keep your same salary for the next 10 years and told you you had to use photons to treat all your lungs and livers during that time frame (I'd let you use the present proton machine for 24Gy CSI on kids).
```would you feel bad about it, or would you be like "F yeah!"
Yeah, I got you.It would be fun, no doubt. For the time being, I wouldn’t mind availing myself of protons for the thymic carcinoma, or IIIC NSCLC where VMAT gets me a V20 of 42%.
Some jobs call for a screwdriver, others call for a drill. No need to forsake one for the other when both are available.
I’m W2. I’m leaving after last patient done. 1ish.
1-2/3 for most of us, but Simul may have hit that perfect trifectaYou might have the best job in rad onc
Negative Ghost Rider... The bank account is full (3.5 day work week)..You might have the best job in rad onc
Yeah, I got you.
I just want our government to act rationally and our professional organizations to advocate for rational payment reform.
ASTRO doesn't want me to be incentivized to use IMRT over 3D or complex planning. Or to be incentivized for longer fractionation schedules. I understand.
But they do want to incentivize choices towards protons, perhaps even proton center growth. Or at least, they are not worried about this.
This, in the setting of the data that we have (or don't) and the peculiarities of proton toxicity.
Farcical.
The feds should also know that the standard of a "better plan" on a treatment planning platform is a terrible standard for choosing protons in general (not to say you aren't thinking deeper than this).
Perhaps ASTRO could just factor in the presumably judicious present use of protons and adaptive RT into what the case based reimbursement should be? Pay everything the same, but let protons and adaptive raise all ships? Then trust the docs to use the more expensive strategy only when they see clinical benefit.
Wonder what the cost analysis of that would be.
That would be rational.
Sweet sentiment, but I can't see this working in any regard. I hope the feds don't believe that they are doing this when they assign value.Not unreasonable suggestions. In my opinion, the ideal payment approach would be to compensate the physician proportional to the effort necessary. Cases that need protons likely need more effort (implying correlation, not causation). The question is... how can the need for effort be quantified to payers honestly and efficiently?
I mean, it is certainly possible… but it requires a competent coding system created by disinterested experts and approved by well-intentioned bureaucrats. It’s about as likely as all of the air spontaneously assembling on the other side of the room… but there is a nonzero chance.Sweet sentiment, but I can't see this working in any regard. I hope the feds don't believe that they are doing this when they assign value.
2 OTVs is more effort than 1.
2 isocenters more effort than 1.
C-section more effort than not (maybe?)
Surgery is likely more concerted effort than anything else always.
AC is more effort than TC.
Sim more effort than clinical set-up for skin.
We do have codes for extraordinary cases and special physics work. (Re-irradiation, etc).
Payors should be concerned with outcomes. Medicare lets you bill for time regarding patient encounters, which is fair, as time spent with patient has value IMO (surprisingly human take by CMS).
From a technical standpoint, outside of duration of treatment (more treatments and smaller fractions), more effort seems strongly correlated with more risk.
We don't want to promote more risk (although sometimes it is necessary).
Don't see how one could ever have both case based payment and effort based payment. (I'm in favor of case based payment BTW).
It’s actually one of the reasons I joined sdn. It quickly became apparent that all is not well with this field. Yes, there is an occasional bad apple trying for a mammosite boost after imrt for dcis, but far more prevalent are academic centers in the “choosing wisely grey zone” . First case, was a top 3 center requesting 28 fractions of protons for a small asymptomatic sagital sinus meningioma (stereo would probably give you better plan). Plenty of protons for Gleason 6 prostate cancer and whole breast protons for small postmenopausal UOQ left breast cancers.I strongly advise anyone in practice for a few years to do a small amount of pa work. Pay sucks, but you learn so much. Key is to do it for just a handful of hours per week for several months.
Astro and many of these centers fraction and modality shame desipite being the worst abusers)
And no reason to almost ever treat the spine ap/pa. Also Academic centers selectively deploy hypofract for patients they know will have transportation issues.I watched it week 1 of residency. Taking pride in delivering 8 Gy x 1 with an AP-PA field to a spine met because the greedy PP would use IMRT in 10 fractions. Now they have protons. Hah. What's best for the patient was probably 10 fractions IMRT all along.
8 in1? My god man think of the lost Proton billing opportunity.. You will not get promoted with this poor billing attitude!And no reason to almost ever treat the spine ap/pa. Also Academic centers selectively deploy hypofract for patients they know will have transportation issues.
The issue is that when you add up the number of patients on beam divided by number of docs at these centers, the average per doc sucks. Yes, there are academics who have a lot of rvus or grant funding, but they are a Pareto 20%. Huge number seeing 3-4 new pts/wk so when they see a pt, there is a strong pressure to meet rvu targets. Even the absolute laziest docs, or those that believe they deserve a vastly reduced load because they wrote 40 seer papers, when they are forced to see an actual pt are going to “make it count” rvu wise.8 in1? My god man think of the lost Proton billing opportunity.. You will not get promoted with this poor billing attitude!
Maybe some of the academic docs on here can speak to the pressures they feel regarding maximizing reimbursement?The experience brings home that academic centers are operating in a full court press for profit mode.
Igrt prevents mis administration and (theoretically 2ndry malignancies, by confining radiation to treated area, not spreading it around due to setup uncertainties)Oh, I always do IGRT for pretty much every thing. Getting paid for it or not doesn't matter.
The great Todd Scarborough explained rationale a few years ago, Sushil stated the same rationale recently.
IGRT is one of the best things about modern RO.
Igrt prevents mis administration and (theoretically 2ndry malignancies, by confining radiation to treated area, not spreading it around due to setup uncertainties)
Oh, I always do IGRT for pretty much every thing. Getting paid for it or not doesn't matter.
surface guidance is an option, but the main benefit with igrt is catching some type of set up mid administration that occurs 1/1000+ . If 2nd malignancy is a concern, you don’t want that 300cgy /per fraction randomly being floated around a 1 cm cross section of body around the target due to setup variability. A cone beam is less than 1cgy with almost all that dose being absorbed on the surface.Hmm, I don't know here. I also IGRT almost everything, because keeping treatment volumes down, even in the palliative setting, matters some for acute toxicity or heme toxicity in the pelvis, abdomen, thorax and head and neck regions.
But RA for an extremity bone met? Come on. More integrated dose, more low dose bath (including from imaging). Never ever seen meaningful fibrosis from palliative doses in these areas. They are not sparing bone like in sarcoma.
Maybe just me.
SDN crew is diverse.
This is basically why I am a rad onc now, the expansinon of training spots during that time gave me a window into a very competitive field. It's like chars went to a seminar in 2008 or so and all came out with the exact same three step plan to success:but had become remarkable financially conscious by the early 2010s. This correlated with massive expansion (both of clinical departments and residency programs).
The cynic in me believes that there was a generation of radonc chairs that benefited from this, some of whom have been able to graduate from our field and become corporate academic leaders. (Big academia is very corporate at this point).
May not be intentional but something like natural selection where these are the best steps to achieve maximum profit, which is their real mission despite “nonprofit” status.This is basically why I am a rad onc now, the expansinon of training spots during that time gave me a window into a very competitive field. It's like chars went to a seminar in 2008 or so and all came out with the exact same three step plan to success:
1. Acquire local PPs and turn into satellites
2. Expand residency program
3. Cut salaries
Then you're on your way to the next big thing!
It's always about the moneyMay not be intentional but something like natural selection where these are the best steps to achieve maximum profit, which is their real mission despite “nonprofit” status.
Not arguing about the IGRT. I'll IGRT almost anything to reduce treatment volume.surface guidance is an option, but the main benefit with igrt is catching some type of set up mid administration that occurs 1/1000+ . If 2nd malignancy is a concern, you don’t want that 300cgy /per fraction randomly being floated around a 1 cm cross section of body around the target due to setup variability. A cone beam is less than 1cgy with almost all that dose being absorbed on the surface.
In 2007, when we 1st started using kv/cbct, caught 2 potential misadministrations within first 3 months.
RA?Not arguing about the IGRT. I'll IGRT almost anything to reduce treatment volume.
It's the RA in this setting that I don't get. Particularly if it costs more.
If it's not an SBRT or reirradiation case, my palliative extremity cases are getting AP/PA typically.
To each their own. Apparently MAYO will also choose RA (at least in 2/2 cases that I got to see).
As an aside, 2nd malignancies are weird and I don't believe there is a monotonic correlation between dose and risk.
Definitely diverse view points - it took me a while to get to where I am now on IGRT. I started at Banner in 2018 and they did it on every bone met, drove me nuts.Hmm, I don't know here. I also IGRT almost everything, because keeping treatment volumes down, even in the palliative setting, matters some for acute toxicity or heme toxicity in the pelvis, abdomen, thorax and head and neck regions.
But RA for an extremity bone met? Come on. More integrated dose, more low dose bath (including from imaging). Never ever seen meaningful fibrosis from palliative doses in these areas. They are not sparing bone like in sarcoma.
Maybe just me.
SDN crew is diverse.
What would happen to your patients on beam?If it was the same reimbursement / cost to system, what would you do for a mid femur met, non-surgical, but has widespread disease, so we are not treating for cure, just pain relief.
I would do VMAT and probably 16/1, per Anderson paper.
WellWhat would happen to your patients on beam?
Well
Though we track wRVUs, the global revenue is what my superiors care about. I explained to death when I got here about SRS/SBRT, HypoFx, technical fees, etc. I said don't even look at on beam number. Just look at what we produce. That being said, I always like more rather than less
Yeah, they share all financial with me. Tech and prof.Do they share the actual collection numbers with you?
Is it legal for a hospital to compensate an employed doc in actual collections (the way a PP usually does) instead of RVUs with a conversion factor?
Good reference. I looked up the paper. Still a little nervous giving 16 Gy x1 to mid femur (this is like 60Gy in 30 and is close to fracture inducing dose). Paper had a minority of extremity lesions and may have had very few extremity lesions getting 16Gy. 1 fracture in the 16 Gy group, don't know story on it.I would do VMAT and probably 16/1, per Anderson paper.
It sounds like you have a more progressive administration, but I get the sense that most hospitals are more like my own: technical collections are never shared and admins would jump at the chance to cut physician FTE if we were leaving routinely at 1:00 or supervision was relaxed. Staff hours would be flexed and we would lose them to larger systems.Yeah, they share all financial with me. Tech and prof.
I wish we were busier, b/c other than that, this is the best group of people I've worked with - admin and such.
I don't know the answer to that. I can ask my CEO. He knows all the technicalities.
Yes, it's legal. Was the way of my old PSA. They charged 5% for collections. I make more with rvu based pay.Do they share the actual collection numbers with you?
Is it legal for a hospital to compensate an employed doc in actual collections (the way a PP usually does) instead of RVUs with a conversion factor? Or if the hospital does the billing is that not permitted?