Rad Onc NP’s/PA’s in Non-Academic Settings

[Aphiah]

How do NP’s/PA’s benefit private practice and hospital employed Rad Oncs?

More specifically in terms of: PATIENT CARE (how do patients benefit from seeing an NP instead of the Rad Onc, is it simply “well it’s either NP or no one so at least patient gets to see someone?”), TIME (do they really improve efficiency?), FINANCES (does hiring an NP for ~$80,000 or more end up benefiting the Rad Onc in terms of productivity and ultimately his/her salary to the extent that the $80,000 or so leads to productivity greater than the salary/value of the NP?)

Lastly what makes an NP/PA qualified to see Rad Onc patients? Is it simply on the job training?

For these questions let’s assume every NP/PA is “good.”

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[Gfunk6]

NPs or PAs are only beneficial if you have capacity problems. Like if are generating 15,000 RVUs and you cannot manage it alone. NP/PAs can be trained to:

1. See simple consults (think prostate and breast)
2. See OTVs
3. Perform preliminary contouring
4. Have their own survivorship clinic for patients you've definitely treated and need to be followed

It is unlikely that an NP/PA will ever generate enough revenue via billing for them to be even close to "cost neutral." It is more of a quality of life enhancement for the supervising Rad Onc. The best NP/PAs are trained well by their supervising Rad Oncs - there is no specific certification or training that is required.

 

[Reaganite]

There are some pretty darn amazing NPs basically running high volume med onc clinics, family practice offices, and even some derm clinics. There's no reason they couldn't help out in a rad onc clinic where patients aren't generally as sick and complex as a med onc clinic. I agree with all the indications mentioned by Gfunk. You could probably train a rock star rad onc NP to shoulder a significant burden of scut work, otvs, and preliminary contouring. It's only our national body and vague billing/supervision rules that keep people from using them more.

 

[Aphiah]

There are some pretty darn amazing NPs basically running high volume med onc clinics, family practice offices, and even some derm clinics. There's no reason they couldn't help out in a rad onc clinic where patients aren't generally as sick and complex as a med onc clinic. I agree with all the indications mentioned by Gfunk. You could probably train a rock star rad onc NP to shoulder a significant burden of scut work, otvs, and preliminary contouring. It's only our national body and vague billing/supervision rules that keep people from using them more.

I've definitely worked with some extremely kind and capable NP's/PA's but comments like yours inadvertently call into question the value of medical education and residency training. If my dream was to "basically run a high volume Med Onc clinic" because I've always dreamed of being a Med Onc (and I didn't care about income or handling super complex cases), why choose medicine? Maybe you're on to something, or exaggerating, or maybe a little of both.

 

[Sheldor]

NPs or PAs are only beneficial if you have capacity problems. Like if are generating 15,000 RVUs and you cannot manage it alone. NP/PAs can be trained to:

1. See simple consults (think prostate and breast)
2. See OTVs
3. Perform preliminary contouring
4. Have their own survivorship clinic for patients you've definitely treated and need to be followed

It is unlikely that an NP/PA will ever generate enough revenue via billing for them to be even close to "cost neutral." It is more of a quality of life enhancement for the supervising Rad Onc. The best NP/PAs are trained well by their supervising Rad Oncs - there is no specific certification or training that is required.

I was under the impression that NP/PAs can't see OTV's, do you mean see on treatment issues or actually bill the OTV charge? That would be news to me!

 

[medgator]

I've definitely worked with some extremely kind and capable NP's/PA's but comments like yours inadvertently call into question the value of medical education and residency training. If my dream was to "basically run a high volume Med Onc clinic" because I've always dreamed of being a Med Onc (and I didn't care about income or handling super complex cases), why choose medicine? Maybe you're on to something, or exaggerating, or maybe a little of both.

Why not ask the med oncs that have developed high-volume practices over the years and use extenders/NPs/PAs to keep the clinic moving? So because things get too busy and it's not feasible or viable to hire another doc, they should have gone into something else?

Seems like you may be aloof to the reality of the community practice of oncology

 

[elementaryschooleconomics]

You should question medical education and residency training. Either they need to be separate jobs, or they don't. Either there's a tangible benefit to the additional years and thousands of hours on training, or there isn't.

For me, in my experience, the difference is...well actually experience. It's the concept of "act like you've been there before". What I mean is that I'm not necessarily smarter than a mid-level or have access to knowledge/information that a mid-level doesn't have. What I do have is a deeper "bag of tricks" where it's less likely I get surprised.

Our jobs boil down to pattern recognition prompting decision and action right? Encountering novel stimuli eats up more brain power and energy and shortcuts decision making. You lean heavier on heuristics and might not consider things as carefully as you would if something was routine. There's a great paper from PNAS I think that examined court decisions by judges in the morning vs afternoon. As the day wore on their verdicts got less nuanced (or however the framed it, I'll try to find the paper).

Perhaps I'm totally wrong. But on that note, there are two versions of mid-level I've seen that I think are great:

1) The inpatient mid-level. This is more to Gfunk's "high volume" scenario and is usually seen in academia. The mid-level can spend more time on cases and I deeply believe that patients benefit from more "contact time". Probably not as relevant to the private practice sector.

2) The best community model I've seen is follow-ups/survivorship. I love that model, and so do patients. But a RadOnc practice with a mid-level quarterbacking long term follow-ups truly extends us beyond what we normally can do and benefits patient care.

 

[BobbyHeenan]

NPs or PAs are only beneficial if you have capacity problems. Like if are generating 15,000 RVUs and you cannot manage it alone. NP/PAs can be trained to:

1. See simple consults (think prostate and breast)
2. See OTVs
3. Perform preliminary contouring
4. Have their own survivorship clinic for patients you've definitely treated and need to be followed

It is unlikely that an NP/PA will ever generate enough revenue via billing for them to be even close to "cost neutral." It is more of a quality of life enhancement for the supervising Rad Onc. The best NP/PAs are trained well by their supervising Rad Oncs - there is no specific certification or training that is required.

Agree with this.

We use our NP for survivorship follow up, inpatient consult initial work up and inpatient "rounding," and dealing with non-OTV under treat issues. They also do smoking cessation and lung CT screening assessments. It is a lifestyle/work flow benefit. They will not generate revenue for the practice in my experience.

We may be wrong here, but it is our understanding that NP can't solely see an OTV. So all OTV's are seen by the doc still.

 

[TheWallnerus]

Agree with this.

We use our NP for survivorship follow up, inpatient consult initial work up and inpatient "rounding," and dealing with non-OTV under treat issues. They also do smoking cessation and lung CT screening assessments. It is a lifestyle/work flow benefit. They will not generate revenue for the practice in my experience.

We may be wrong here, but it is our understanding that NP can't solely see an OTV. So all OTV's are seen by the doc still.

NPs can see OTVs and bill at 85%

 

[medgator]

NPs can see OTVs and bill at 85%

So 77427 gets treated like any other e&m code? Figured it would have some definition that an RO needs to be involved given that it pays more

 

[Aphiah]

Why not ask the med oncs that have developed high-volume practices over the years and use extenders/NPs/PAs to keep the clinic moving? So because things get too busy and it's not feasible or viable to hire another doc, they should have gone into something else?

Seems like you may be aloof to the reality of the community practice of oncology

I’m definitely aloof. That’s why I’m trying to learn. Gfunk explained things pretty well. And I’m not saying any doc should’ve become an NP/PA instead. My analogy was about a premed student who’s interested in Med Onc. Based on what was said, they could basically run a Med Onc clinic without going to medical school, IM residency, or Med Onc fellowship by choosing nursing or PA instead. Maybe this really is the case (again I admit I am aloof and I should ask some med oncs how this works). Obviously I agree the Med Oncs are making it work. No one can deny that. My original questions are specific to Rad Onc though. I understand their value in academia. That’s why my questions are about non-academic settings.

You should question medical education and residency training. Either they need to be separate jobs, or they don't. Either there's a tangible benefit to the additional years and thousands of hours on training, or there isn't.

For me, in my experience, the difference is...well actually experience. It's the concept of "act like you've been there before". What I mean is that I'm not necessarily smarter than a mid-level or have access to knowledge/information that a mid-level doesn't have. What I do have is a deeper "bag of tricks" where it's less likely I get surprised.

Our jobs boil down to pattern recognition prompting decision and action right? Encountering novel stimuli eats up more brain power and energy and shortcuts decision making. You lean heavier on heuristics and might not consider things as carefully as you would if something was routine. There's a great paper from PNAS I think that examined court decisions by judges in the morning vs afternoon. As the day wore on their verdicts got less nuanced (or however the framed it, I'll try to find the paper).

Perhaps I'm totally wrong. But on that note, there are two versions of mid-level I've seen that I think are great:

1) The inpatient mid-level. This is more to Gfunk's "high volume" scenario and is usually seen in academia. The mid-level can spend more time on cases and I deeply believe that patients benefit from more "contact time". Probably not as relevant to the private practice sector.

2) The best community model I've seen is follow-ups/survivorship. I love that model, and so do patients. But a RadOnc practice with a mid-level quarterbacking long term follow-ups truly extends us beyond what we normally can do and benefits patient care.

Thanks for this perspective. It’s helpful.

 

[Sheldor]

So 77427 gets treated like any other e&m code? Figured it would have some definition that an RO needs to be involved given that it pays more

Ya, that seems crazy, but as with all billing I feel like a lot of the things we are told are "rules of thumb" not actually codified anywhere

 

[TheWallnerus]

So 77427 gets treated like any other e&m code? Figured it would have some definition that an RO needs to be involved given that it pays more

Just ‘cause an NP saw patient doesn’t mean that the RO was not also involved in the 77427

 

[evilbooyaa]

NPs or PAs are only beneficial if you have capacity problems. Like if are generating 15,000 RVUs and you cannot manage it alone. NP/PAs can be trained to:

1. See simple consults (think prostate and breast)
2. See OTVs
3. Perform preliminary contouring
4. Have their own survivorship clinic for patients you've definitely treated and need to be followed

It is unlikely that an NP/PA will ever generate enough revenue via billing for them to be even close to "cost neutral." It is more of a quality of life enhancement for the supervising Rad Onc. The best NP/PAs are trained well by their supervising Rad Oncs - there is no specific certification or training that is required.

1. I would not do this in my own practice. Prostate and breast have some of the most nuance amongst all diagnoses we see. If I was a referring who saw my patient saw a NP for consult I would not refer to you anymore.
2. NP acting as a scribe for a physician seeing the OTV, yes. Or seeing the OTV and staffing briefly with the physician, maybe, not clear on reimbursement portions of that. NPs seeing OTV on their own, no.
3. I would not. There is a job that does that called dosimetrists that actually has the training to be able to do that. I would not train a NP to draw GTV/CTV/PTVs.
4. This. NP being primary on all follow-ups for a high volume Rad Onc who wants to focus on seeing consults. Can gradually get into doing full spectrum evaluations include pelvics and scope exams as indicated based on volume, as is done by NPs in Gyn/Onc clinics and ENT clinics, respectively. Maintaining f/u for all those breast and prostates that one may otherwise punt back to referring would be a good use of a NP.

If you have an inpatient service, having a NP to do the initial hello and leg work of coordinating care would also be of value.

 

[Tigerstang]

NPs can see OTVs and bill at 85%

Citation? My billing team says otherwise.

 

[TheWallnerus]

Citation? My billing team says otherwise.

Then they’re right NPs can’t see patients. They can only supervise IGRT.

We are debating if an NP can see an OTV in America while therapists are contouring prostates and rectums for dose replanning in the UK without an MD ever seeing the new contours or replans.

 

[Gfunk6]

Billing is an art not a science. (Almost) anything is kosher until you are RAC-audited.

Also regarding NPs - I think a professional of their caliber can be trained to do just about anything in RO with enough experience. It won't obviate the need for a Radiation Oncologist but it can enhance your quality of life substantially.

I do think that referring docs care and don't view it kindly if mainly NPs see patients that they refer with no/minimal MD input. In a competitive market, this behavior could cost referrals.

 

[metallica81788]

Then they’re right NPs can’t see patients. They can only supervise IGRT.

But can they supervise IGRT in freestanding?

 

[RickyScott]

I just don’t know that many radoncs who are so busy they need an NP.

 

[TheWallnerus]

But can they supervise IGRT in freestanding?

No. Besides rad oncs only med oncs can do that.

 

[TheWallnerus]

I just don’t know that many radoncs who are so busy they need an NP.

In general I agree but for solo docs in rural locations if an NP could cover OTVs if doc is on vacation for a week… there would be a cost savings or at least financial argument to hire an NP.

 

[RickyScott]

In general I agree but for solo docs in rural locations if an NP could cover OTVs if doc is on vacation for a week… there would be a cost savings or at least financial argument to hire an NP.

Maybe in academic settings where they follow all prostate and breast for 20 years for database/research.

 

[metallica81788]

In general I agree but for solo docs in rural locations if an NP could cover OTVs if doc is on vacation for a week… there would be a cost savings or at least financial argument to hire an NP.

Solo busier rural positions - if could get NP to cover OTVs when on vacation, initially see any inpatients, survivorship follow ups, and cover machine for 1 day (to allow 4 day work week) would be gold

 

[sirspamalot]

This is the way.

 

[medgator]

1. I would not do this in my own practice. Prostate and breast have some of the most nuance amongst all diagnoses we see. If I was a referring who saw my patient saw a NP for consult I would not refer to you anymore.

I know a breast surgeon who tried using an extender for consults. Lost patients pretty quickly with that

 

[deleted1111261]

Makes sense to not have extender seeing initial consult. Strategic error

 

[TheWallnerus]

Makes sense to not have extender seeing initial consult. Strategic error

I wouldn’t see a big problem with it in Stage I low risk septuagenarians who I’m only gonna offer and give 5 fraction partial breast of 5.2 Gy per fraction in one week. Super easy consult.

 

[RickyScott]

I have never been so busy that I cant see a consult, same day.

 

[sirspamalot]

How many consults in a day have you ever seen? For me its 8 (twice in my career, long ago).

I know of another who did 12 (with a competent PA assisting).

 

[RickyScott]

How many consults in a day have you ever seen? For me its 8 (twice in my career, long ago).

I know of another who did 12 (with a competent PA assisting).

7 or 8 is the most I have ever had (bolus of 3 or 4 inpts) on top of regular schedule.

 

[RadOncDoc21]

ok let’s whip it out on the table. Anyone have any measuring tape?

I, personally don’t like having more then 5 consults in a day but that’s just my preference. I will not accept an add on unless it’s urgent and not sure what might count as something too urgent to not be able to take care of in the AM.

 

[sirspamalot]

The ghosts of Milton Berle and President LBJ have entered the chat

 

[TheWallnerus]

ok let’s whip it out on the table. Anyone have any measuring tape?

I, personally don’t like having more then 5 consults in a day but that’s just my preference. I will not accept an add on unless it’s urgent and not sure what might count as something too urgent to not be able to take care of in the AM.

If you could see 5 new prostate consults a day on average 5 days a week and prescribed them all 81 Gy/45 fractions, you would have 225 patients under beam per day. A man can dream.

 

[RadOncDoc21]

If you could see 5 new prostate consults a day on average 5 days a week and prescribed them all 81 Gy/45 fractions, you would have 225 patients under beam per day. A man can dream.

Too bad I’m still seeing the same or more patients but avg like 20 on beam. We do a lot of hypofx and SRS, SBRT. I’m employed so I’m sure the folks collecting the technicals are happy.

 

[Fpg1245]

If you could see 5 new prostate consults a day on average 5 days a week and prescribed them all 81 Gy/45 fractions, you would have 225 patients under beam per day. A man can dream.

It’s still a reality in urorads. But of course you’re making 350K with no bonus.

 

[medgator]

It’s still a reality in urorads. But of course you’re making 350K with no bonus.

I think you're confusing a **** urorads job salary with a **** nci pps exempt junior faculty job salary. You can definitely find a decent urorads gig that pays more than that if you look around, not sure that's the same for the latter

 

[imhopeful432]

It’s still a reality in urorads. But of course you’re making 350K with no bonus.

This is....not the reality for most urorads jobs

 

[Fpg1245]

I think you're confusing a **** urorads job salary with a **** nci pps exempt junior faculty job salary. You can definitely find a decent urorads gig that pays more than that if you look around, not sure that's the same for the latter

Agreed. But like most RO jobs there in places you’d never want to live.

 

[deleted1111261]

It’s still a reality in urorads. But of course you’re making 350K with no bonus.

No

 

[medgator]

Agreed. But like most RO jobs there in places you’d never want to live.

Again, incorrect. You really should try to research this a bit more. The goal is to incentivize you to treat and feed the machine. That isn't achieved with a low flat salary and no production incentives

 

[sirspamalot]

I know of a urorad guy doing like 60-70 for 1M year freestanding but he is CHAINED to the building due to supervision requirements 12 hour days. Doesn't have to draw anything (never treats nodes). Just sign and see on txs.

Brain melting. No thanks.

 

[medgator]

I know of a urorad guy doing like 60-70 for 1M year freestanding but he is CHAINED to the building due to supervision requirements 12 hour days. Doesn't have to draw anything (never treats nodes). Just sign and see on txs.

Brain melting. No thanks.

Bingo. Money isn't the issue at these jobs. It's essentially a lobotomy after a few years, probably worse than working at a non academic VA, but not by a lot. You basically are stuck at urorads or the VA if you spend more than a few years working there imo.

Exhibit A is the always gregarious and likeable Drew M going from VA to VA

 

[deleted1111261]

I know of a urorad guy doing like 60-70 for 1M year freestanding but he is CHAINED to the building due to supervision requirements 12 hour days. Doesn't have to draw anything (never treats nodes). Just sign and see on txs.

Brain melting. No thanks.

Like flying for 3-4 days a week of work

Or taking half of what you make to live/work/play in a high biryani density location.

It's all expensive haircuts anyway. He spends about the same amount of brain power as someone who is a ____ specialist.

 

[sirspamalot]

Well, the flying can be a bit dull at times (also sometimes quite demanding).

At least I get a variety of cases and do some interesting committee work.. along with some other stuff.

As the above poster said.. a couple years in UroRad and/or VAMC will effectively kill your career.

 

[salubalu]

I know of a urorad guy doing like 60-70 for 1M year freestanding but he is CHAINED to the building due to supervision requirements 12 hour days. Doesn't have to draw anything (never treats nodes). Just sign and see on txs.

Brain melting. No thanks.

feel like 1 M for 60-70 on treat is low...

 

[sirspamalot]

Well, of course it is... but those who take that job are grateful to have it, same as the ones who take 350k so they can live metro.

We each accept what it is.. until we don't.

#

 

[medgator]

feel like 1 M for 60-70 on treat is low...

So is 350k for running a full clinical service at an academic center on the eastern seaboard. I still think per pt, the urorads job is paying you more for easier work

 

[sirspamalot]

I think folks do what they believe is in "their best interest" and are not necessarily maximing their ability to earn as the top priority.

As for me, geographic arbitrage and a nice workplace with low workload stress is a great tradeoff. Would I talk half the income to have the exact some job otherwise within 5 miles of my home? Not quite yet. 5 years or so from now, definitive maybe.

 

[Fpg1245]

Again, incorrect. You really should try to research this a bit more. The goal is to incentivize you to treat and feed the machine. That isn't achieved with a low flat salary and no production incentives

It’s a saturated market nobody cares about your personal incentives. If you have a problem with the salary or the workload then you can ****ing leave, the owners won’t lose sleep. They’ll find some new grad to take your place. I’ve already seen this happen and I’m in a state that has them. They won’t even consider a separate PC Corp so the RO can collect their own fees why? Because they don’t have to and it’s take money out of the skim.

You have a problem with the pace of the work fine, they can and will replace you.

 

[deleted1111261]

It’s a saturated market nobody cares about your personal incentives. If you have a problem with the salary or the workload then you can ****ing leave, the owners won’t lose sleep. They’ll find some new grad to take your place. I’ve already seen this happen and I’m in a state that has them. They won’t even consider a separate PC Corp so the RO can collect their own fees why? Because they don’t have to and it’s take money out of the skim.

You have a problem with the pace of the work fine, they can and will replace you.

What region is someone paying a UroRad doc 350?