Protons are blowing Rad Onc's boat out the CMS water

[scarbrtj]

The data are downloadable here.

There's an orgy of data in this spreadsheet. I will come back here from time to time to update, observe, etc. But first things first. This is the most recent data from 2018. Here are the "top 10" in radiation oncology for that year. Name, location, amount paid by Medicare (2 significant digits).

JW.... Provision Knoxville.... $8.5 million
TK.... Naples, FL.... $5.0 million
AM.... Provision Knoxville.... $5.1 million
TS.... TX Center for Proton Therapy.... $3.1 million
AL.... TX Center for Proton Therapy.... $2.9 million
DD.... Port Charlotte, FL.... $4.0 million
BC.... Princeton Radiology Associates.... $2.4 million
MS.... Urology San Antonio.... $2.3 million
HT.... Princeton Radiology Associates.... $2.3 million
AB.... Ft Myers, FL.... $3.4 million
EDIT1:
PROTON THERAPY CENTER HOUSTON LTD... Houston, TX... $8.3 million

Cursory glance I believe 7/11 are protons, 3/11 are (were) 21st Century Oncology, and 1/11 a "urorads."

Hey ASTRO. C'mon man.

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[scarbrtj]

Here's the distribution of CMS payment data by provider. Doesn't contain full range of data on x-axis.
One thing kind of sticks out: there are a substantial number of non-busy rad oncs in America.

If the "big leagues" is 1+ million, not great odds of reaching that as a rad onc.

 

[scarbrtj]

The top 1% of providers in radiation oncology account for 44% of all rad onc Medicare spending!

The "top performer" in the bottom 99% gets about $0.97 million a year.

In other words, you as a rad onc have a ~1% chance of making it into CMS's Million Dollar Club.

 

[medgator]

The top 1% of providers in radiation oncology account for 44% of all rad onc Medicare spending!

Any to look at total billed by provider easily? Not very adept at xl. Wsj only has through 2015

Medicare Unmasked: Behind the Numbers

Search Medicare billing records of over one million doctors and medical providers—a type of data long kept confidential. Then read our Pulitzer Prize-winning investigation into the motives and practices of America's health care providers.

graphics.wsj.com

 

[scarbrtj]

Any to look at total billed by provider easily? Not very adept at xl. Wsj only has through 2015

Medicare Unmasked: Behind the Numbers

Search Medicare billing records of over one million doctors and medical providers—a type of data long kept confidential. Then read our Pulitzer Prize-winning investigation into the motives and practices of America's health care providers.

graphics.wsj.com

Am I supposed to name names on the explicit ....... mods?

 

[Lamount]

The top 1% of providers in radiation oncology account for 44% of all rad onc Medicare spending!

I don’t know if these data are 100% accurate as an entire center’s procedures may sometimes be billed under a single provider.


One of my attendings during internship was listed as having erroneously racked up millions (news to him), when it was his entire service. I can’t say I understand the details.

 

[medgator]

I don’t know if these data are 100% accurate as an entire center’s procedures may sometimes be billed under a single provider.


One of my attendings during internship was listed as having erroneously racked up millions (news to him), when it was his entire service. I can’t say I understand the details.

It's accurate. High amounts basically show they are probably billing global in freestanding setting

 

[medgator]

Am I supposed to name names on the explicit ....... mods?

It's publicly available data...

 

[scarbrtj]

I can’t say I understand the details.

We need to.

 

[scarbrtj]

It's publicly available data...

Well this I'm sure very nice and highly intelligent young man ate rad onc's lunch in 2018. Charges of approximately $45 million under his name, payments of about $8.5 million. On the banks of the Tennessee River in the tiny burg of Knoxville Tennessee no less. Now let us imagine what private insurance paid the Provision center that year............... @thecarbonionangle did the top rad onc producer in 2018 come from a hellpit program?!

*Mod edit* - Removed link to a specific Radiation Oncologist who is not a public figure.

 

[scarbrtj]

Here's the distribution of CMS payment data by provider. Doesn't contain full range of data on x-axis.
One thing kind of sticks out: there are a substantial number of non-busy rad oncs in America.

If the "big leagues" is 1+ million, not great odds of reaching that as a rad onc.

btw if no one realized it this graph is yet one more objective data point that America needs half as many rad oncs. In the spirit of "it only takes one piece of falsifying evidence to invalidate a whole theory"... I stick by my original graph(s).

 

[scarbrtj]

About 1/3 to 1/4 of American rad oncs may be treating 10 Medicare patients or less per year. This is based on global billing though. But even if I'm a half order of magnitude off (and we allow for professional and global), we would still be talking ~10% of active practicing rad oncs treating VERY low numbers.

About half of all rad oncs are getting paid $200K or less by Medicare a year.

 

[Chartreuse Wombat]

Here's the distribution of CMS payment data by provider. Doesn't contain full range of data on x-axis.
One thing kind of sticks out: there are a substantial number of non-busy rad oncs in America.

If the "big leagues" is 1+ million, not great odds of reaching that as a rad onc.

Pareto distribution is ubiquitous

 

[elementaryschooleconomics]

About 1/3 to 1/4 of American rad oncs may be treating 10 Medicare patients or less per year. This is based on global billing though. But even if I'm a half order of magnitude off (and we allow for professional and global), we would still be talking ~10% of active practicing rad oncs treating VERY low numbers.

About half of all rad oncs are getting paid $200K or less by Medicare a year.

This takes the saying "20% of people at a company do 80% of the work" to an entirely new level...

 

[scarbrtj]

Pareto distribution is ubiquitous

true but I admit I wouldn't have predicted it to look so... Pareto.

 

[scarbrtj]

The data are downloadable here.

There's an orgy of data in this spreadsheet. I will come back here from time to time to update, observe, etc. But first things first. This is the most recent data from 2018. Here are the "top 10" in radiation oncology for that year. Name, location, amount paid by Medicare (2 significant digits).

JW.... Provision Knoxville.... $8.5 million
TK.... Naples, FL.... $5.0 million
AM.... Provision Knoxville.... $5.1 million
TS.... TX Center for Proton Therapy.... $3.1 million
AL.... TX Center for Proton Therapy.... $2.9 million
DD.... Port Charlotte, FL.... $4.0 million
BC.... Princeton Radiology Associates.... $2.4 million
MS.... Urology San Antonio.... $2.3 million
HT.... Princeton Radiology Associates.... $2.3 million
AB.... Ft Myers, FL.... $3.4 million

Cursory glance I believe 6/10 are protons, 3/10 are (were) 21st Century Oncology, and 1/10 a "urorads."

Hey ASTRO. C'mon man.

Getting some late stragglers coming in that didn't show up in first pass. I edited the original post.

PROTON THERAPY CENTER HOUSTON LTD... Houston, TX... $8.3 million

 

[scarbrtj]

Pareto distribution is ubiquitous

This takes the saying "20% of people at a company do 80% of the work" to an entirely new level...

For comparison and in honor of our friend @DoctwoB here is our old friend urology. Pareto but very different skewness and kurtosis than rad onc.

 

[RickyScott]

About 1/3 to 1/4 of American rad oncs may be treating 10 Medicare patients or less per year. This is based on global billing though. But even if I'm a half order of magnitude off (and we allow for professional and global), we would still be talking ~10% of active practicing rad oncs treating VERY low numbers.

About half of all rad oncs are getting paid $200K or less by Medicare a year.

Touching on key point. Bottom 25% of this specialty were still at the top of their medical school class. I doubt the bottom quartile is very vocal on social media. Ex: When someone boasts on twitter that they saw 35 ontreats, means someone else saw 5-10. Anyone of us could end up in a bad situation... In no other speciality is the bottom quartile so screwed.

 

[scarbrtj]

When someone boasts on twitter that they saw 35 ontreats, means someone else... and someone else.... and someone else... and someone else.... saw 5-10.

 

[Reaganite]

Don't tell any of the med oncs around me.... Still getting plenty of rectal/panc

The top 1% of providers in radiation oncology account for 44% of all rad onc Medicare spending!

The "top performer" in the bottom 99% gets about $0.97 million a year.

In other words, you as a rad onc have a ~1% chance of making it into CMS's Million Dollar Club.

Part of the problem with these numbers is the global vs prof only split difference between freestanding and hospital based. You're looking at potentially a 5:1 ratio in per patient reimbursement. A freestanding doc treating 3 new prostate patients a month will almost crack the million dollar threshold when u look at the medicare database even though take home may be only 20% of that figure.

 

[scarbrtj]

Part of the problem with these numbers is the global vs prof only split difference between freestanding and hospital based. You're looking at potentially a 5:1 ratio in per patient reimbursement. A freestanding doc treating 3 new prostate patients a month will almost crack the million dollar threshold when u look at the medicare database even though take home may be only 20% of that figure.

Very true and important to keep in mind. If on this list let's say $500K is attached to a name that you know bills freestanding and $500K is attached to someone's name you know works at a hospital, these are actually very different numbers and you could conservatively say $1.5M total for the person at the hospital. (And up to 5:1 as you say.) So context is needed.

 

[evilbooyaa]

Am I supposed to name names on the explicit ....... mods?

I advocate against directly calling out people based on a public search, especially those who are not considered 'public figures' (chairmen/women) or have done anything to put their own names into the public light (people writing research articles).

I have edited your post in question to remove the doctor who works at that facility. I am fine with calling out the facilities (and the fact that protons cause so much of the financial toxicity in this field), but I will draw the line at 'Do not call out individual physicians working for these facilities in a public space in the forums'.

 

[thecarbonionangle]

Well this I'm sure very nice and highly intelligent young man ate rad onc's lunch in 2018. Charges of approximately $45 million under his name, payments of about $8.5 million. On the banks of the Tennessee River in the tiny burg of Knoxville Tennessee no less. Now let us imagine what private insurance paid the Provision center that year............... @thecarbonionangle did the top rad onc producer in 2018 come from a hellpit program?!

*Mod edit* - Removed link to a specific Radiation Oncologist who is not a public figure.

I would imagine if anybody went to a hellpit place, they may leave residency jaded and may just want to make that cheese.

 

[Tigerstang]

Seeing as this info is in a public database, I don't think it matters if you call them out publicly. It's already in the public domain

 

[DireMoose]

About 1/3 to 1/4 of American rad oncs may be treating 10 Medicare patients or less per year. This is based on global billing though. But even if I'm a half order of magnitude off (and we allow for professional and global), we would still be talking ~10% of active practicing rad oncs treating VERY low numbers.

About half of all rad oncs are getting paid $200K or less by Medicare a year.

This was somewhat touched on by @Reaganite above, but I am not sure that the reimbursement numbers are a good indicator of the "busy-ness" of radoncs. For example, taking one of the heavy hitters from the top post - that person had 409 beneficiaries for $2.4M in Medicare payments. Just looking at a few academic radoncs known to be busy with prostate/breast: They had >650 beneficiaries and have listed payments of $192K and $102K.

I'm a total novice at this type of thing, but aside from the difference in the heavy hitters' global billing, what would be the best way to incorporate how much academic centers must be charging that is not showing up on this sheet?

I will have to come back to it, but I wonder what would the histogram would look like if binned by # of beneficiaries. Would it be that 1/3 are treating 10 patients or less per year?

 

[evilbooyaa]

Seeing as this info is in a public database, I don't think it matters if you call them out publicly. It's already in the public domain

Lots of things out there in public domain that SDN limits posting of. No call-outs of non-public figures, including individual docs who work for these facilities, similar to how we blocked call-outs of Evicore peer reviewers in the past.

 

[scarbrtj]

I am not sure that the reimbursement numbers are a good indicator of the "busy-ness" of radoncs.

Good point and worth discussing. I'm seeing ~1500 rad oncs nationwide, which would comprise >1/3 of all rad oncs in this cache of rad oncs from CMS, who are getting paid by CMS less than $100K a year. Even if billing professional only, you have to be 1) either not treating a lot of old people (which is somewhat unusual in rad onc), or 2) just generally not that busy overall. Unless I'm missing another possibility. If not, then I feel like the data is showing or at least hinting at rad onc MD under-utilization. And by under-utilization I mean a lot of rad oncs out there are not being used or worked anywhere near their full potential.

Which means: rad onc is over-supplied w/ rad onc MDs.

(EDIT: there are MD names on this list I know whose numbers are prof-only, and they are many multiples above >$100K/yr reimbursement... again showing the wide, wide variability in what I believe to be "busy-ness." And we should all have at least a possibility, or right, of being as busy as we want to be, But it does not look achievable for a pretty large proportion of rad oncs. Unless you work at a proton center! Get that proton fellowship kids... it's the 2020s' new rad onc residency?)

 

[deleted941485]

I have become an unabashed proton and MR linac shill. Because now my institution has at least one of them. In rad onc EBM, my choices are EBM my way out of a job or Just push the latest thing in the hopes it doesnt actually harm the patient. God when will the ABR let us get into something useful like IR.

 

[radiaterMike]

I would assume (maybe incorrectly) that regional Medicare advantage plans are missing from these data. That may account for some individual's low reimbursements.

Good point and worth discussing. I'm seeing ~1500 rad oncs nationwide, which would comprise >1/3 of all rad oncs in this cache of rad oncs from CMS, who are getting paid by CMS less than $100K a year. Even if billing professional only, you have to be 1) either not treating a lot of old people (which is somewhat unusual in rad onc), or 2) just generally not that busy overall. Unless I'm missing another possibility. If not, then I feel like the data is showing or at least hinting at rad onc MD under-utilization. And by under-utilization I mean a lot of rad oncs out there are not being used or worked anywhere near their full potential.

Which means: rad onc is over-supplied w/ rad onc MDs.

(EDIT: there are MD names on this list I know whose numbers are prof-only, and they are many multiples above >$100K/yr reimbursement... again showing the wide, wide variability in what I believe to be "busy-ness." And we should all have at least a possibility, or right, of being as busy as we want to be, But it does not look achievable for a pretty large proportion of rad oncs. Unless you work at a proton center! Get that proton fellowship kids... it's the 2020s' new rad onc residency?)

 

[scarbrtj]

Let's take money out of it. Let's just look at how often a code was billed.

Assuming O=outpatient hospitalfreestanding and F=freestandingfacility/hospital, then we have ~5400 providers billing ~136,000 IMRT (77301) plans. That's about 25 IMRT plans on average per provider. In other words, maybe only one IMRT plan every other week *****on average***** for US rad onc MDs for straight Medicare patients er "beneficiaries." Let's add IMRT and 3D.... for an average of about 5600 rad onc MDs... and all this would total ~50 IMRT/3D plans on average per US rad onc MD. Now Medicare wouldn't comprise all of an MD's business. I know that. But it can comprise a lot. If the average Medicare proportion per MD is 1/3 of all patients, then we might guess the ****average*** US rad onc MD is overseeing about 150 new XRT starts per year. The reimbursement data suggest the std dev on this would be kind of large; at least 50. Therefore WAG is at least ~12.5% of US rad onc MDs may be overseeing a total of one new starts per week or less. A crazy thought but I can see numbers that would support this "WAG."

Worth repeating, but there is data that the average number of new starts per year per MD in about 2005 was 350!

Potential counters: rad onc is comprised of *a lot* of academic MDs, and they are not that busy (sometimes, in terms of raw patient numbers) and Medicare doesn't have as much penetrance in academics as it does outside of academics perhaps.

 

[scarbrtj]

For every fraction of proton therapy given to Medicare beneficiaries in 2018, about 14 fractions of IMRT were delivered.

 

[scarbrtj]

The cost of IMRT treatments (the subject of so much unwarranted hate?) vs proton treatments...

Protons: $68 million
IMRT: $355 million

For protons and IMRT for CMS beneficiaries in a mix of freestanding/facility CY 2018 (EDIT: this may be freestanding only), protons comprised 6% of the treatments but 16% of the total cost betwixt the two.

 

[deleted941485]

The cost of IMRT treatments (the subject of so much unwarranted hate?) vs proton treatments...

Protons: $68 million
IMRT: $355 million

For protons and IMRT for CMS beneficiaries in a mix of freestanding/facility CY 2018 (EDIT: this may be freestanding only), protons comprised 6% of the treatments but 16% of the total cost betwixt the two.

Protons for all! yay protons!

It may be a but early but do that have any data on MR Linac treatment delivery?

 

[scarbrtj]

Protons for all! yay protons!

It may be a but early but do that have any data on MR Linac treatment delivery?

I wouldn't know how to track from just a list of CPT codes. The only tell-tale sign I know of re: MRI linacs is they bill many IMRT plans over a course of treatment. That wouldn't be individually trackable w/ the current lists CMS provides.

 

[deleted941485]

I wouldn't know how to track from just a list of CPT codes. The only tell-tale sign I know of re: MRI linacs is they bill many IMRT plans over a course of treatment. That wouldn't be individually trackable w/ the current lists CMS provides.

Good point. The replans would not show up. I wonder if there are any other technical charges unique to MR Linacs that are generated. It obviously would not give you the whole picture but I would just be interested.

 

[scarbrtj]

Good point. The replans would not show up. I wonder if there are any other technical charges unique to MR Linacs that are generated. It obviously would not give you the whole picture but I would just be interested.

One of these types things that flies under the CMS radar when they just look at the entirety of our specialty's data. It's probably ballooned 77301. I could look at that but I don't think the MR-linac'ing took off 'til recently and we only have data up to 2018.

 

[Lamount]

Alternative perspective:

When med oncs starting prescribing 6-figure courses of IO and targeted therapies, their colleagues didn’t throw stones... instead, they joined in

 

[medgator]

Alternative perspective:

When med oncs starting prescribing 6-figure courses of IO and targeted therapies, their colleagues didn’t throw stones... instead, they joined in

They had os to support its use

 

[RadOncDoc21]

Alternative perspective:

When med oncs starting prescribing 6-figure courses of IO and targeted therapies, their colleagues didn’t throw stones... instead, they joined in

I can’t afford a MRI Linac or a Mevion.

 

[scarbrtj]

Alternative perspective:

When med oncs starting prescribing 6-figure courses of IO and targeted therapies, their colleagues didn’t throw stones... instead, they joined in

I'm throwing stones at protons in hopes one or two sail past and hit ASTRO in the head near the part of the brain that governs the ability to think in terms of double standards.

 

[ramsesthenice]

I wouldn't know how to track from just a list of CPT codes. The only tell-tale sign I know of re: MRI linacs is they bill many IMRT plans over a course of treatment. That wouldn't be individually trackable w/ the current lists CMS provides.

Correction: we submit many IMRT plans which then prompt a peer to peer and more physician effort before they are denied.

But for tracking purposes it would probably be a good estimate of how much is out there.

 

[Lamount]

They had os to support its use

With a MASSIVE number of industry sponsored trials... like EVERY histology

med onc has benefited greatly from partnering with pharma

As a field, we would benefit from building similar partnerships with, for example, particle therapy manufacturers... and doing studies that find out exactly where protons are potentially better and where they aren’t. If there is some other new technology like FLASH, we should test that too!

It behooves everyone to thoroughly investigate technologies that potential add value to our field... which is why I don’t think it is helpful to throw stones

 

[Neuronix]

Pharma has to pay for studies to get their products FDA approved. Device manufacturers do not.

 

[RickyScott]

With a MASSIVE number of industry sponsored trials... like EVERY histology

med onc has benefited greatly from partnering with pharma

As a field, we would benefit from building similar partnerships with, for example, particle therapy manufacturers... and doing studies that find out exactly where protons are potentially better and where they aren’t. If there is some other new technology like FLASH, we should test that too!

It behooves everyone to thoroughly investigate technologies that potential add value to our field... which is why I don’t think it is helpful to throw stones

We had 20 + yrs to show a benefit for protons over IMRT. They are likely worse in common indications like prostate cancer as they can not be delivered without rectal balloons or spacers. Breast they are a total joke.

 

[scarbrtj]

As a field, we would benefit from building similar partnerships with, for example, particle therapy manufacturers... and doing studies that find out exactly where protons are potentially better and where they aren’t. If there is some other new technology like FLASH, we should test that too!

The four diagnoses of breast, prostate, lung, and bone mets comprise about 75% of all patients in radiation oncology, and the number one indication is breast. You want to do a study looking for proton benefits in early stage breast? That'd be the equivalent of trying to find gravitational waves in a rad onc clinic... without a LIGO. And what is "better" exactly; what kind of local control or grade 1/2 toxicity deltas cross over from "meh" to "better" at these cost scales. There are randomized trials where if I were to summarize the titles of the trials I'd (correctly) say "IMRT is better for breast cancer." And what'd that get from ASTRO? Stones. Big gnarly staghorn calculi. Or this guy. But protons... let's keep billing for 'em until we can show they're better.

 

[ramsesthenice]

Pharma has to pay for studies to get their products FDA approved. Device manufacturers do not.

Typically yes. Device manufacturers usually opt for the 510(K) equivalence pathway and typically get it. If they are truly first to market they may have to pay for studies to get coverage but that is the exceeding minority. Also, most devices are not approved by the FDA but rather cleared. Separate pathways with different bars. Can you tell who's wife is in regulatory? First pharma and now med device

 

[thecarbonionangle]

We have had 20 + yrs to show a benefit for protons over IMRT. They are likely worse in common indications like prostate cancer as they can not be delivers without rectal balloons or spacers.

Particle therapy of 20 yrs ago is not the same as it is now.

 

[RickyScott]

Particle therapy of 20 yrs ago is not the same as it is now.

Of course not, but everything else improves as well with time. What if we haven’t proven a benefit by 2030 when protons have been in use since the 1990s.
We all know prostate will be negative, and that in reality protons are inferior.

 

[thecarbonionangle]

Of course not, but everything else improves as well with time. What if we haven’t proven a benefit by 2030 when protons have been in use since the 1990s.
We all no prostate will be negative, and that in reality protons are inferior.

Prostate will likely be negative, i agree. Modern trials currently accruing. this may lead to pay parity where they are reimbursed same as IMRT.

i think theres interesting potential in other sites, however, just gotta let the data play out. Another one is the combination with immunotherapy and abscopal effect where the low dose bath may actually matter and lead to more immunosuppression. We got to let the science speak moving forward.

 

[ramsesthenice]

Another one is the combination with immunotherapy and abscopal effect where the low dose bath may actually matter and lead to more immunosuppression.

Happy to let the trials play out but the science behind that argument is very weak. Low dose bath has been accused of so many things over the years (like killing lung cancer patients) yet none of it has ever panned out. This is no different. Local immune suppression probably matters a lot more than subtle systemic immune effects yet hypofractionated RT appears to be better at stimulating immune responses than single high doses in most model systems...

Staying out of the protons debate this time around. All of the regulars know who is in the for and against camps. I can't recall anyone changing their position in a previous discussion so its not worth the effort.