What is a normal patient volume?

[Tigerstang]

What about radiation oncologists in Florida doing things like BID 60 Gy in 60 Fx for curable breast cancer? Or similar for lung, rectal and head neck?

Let's re-phrase your inflammatory comment - "Because some radiation oncologists from certain regions of the country are greedy, other radiation oncologists have to deal with prior authorization and those that work on the PA end take a very low salary to help "educate" physicians."

You can insult me if you want, but I know I'm not the problem. My position would not exist if it weren't for the scoundrels.

Please keep on keeping on tho, the non-EBM wildness is what keeps me employed. I really do enjoy the work; would be sad if everyone practiced standard of care and I got canned.

Yes yes you are the holy one, denying cancer patients their care at worst, delaying at best. Whatever helps you sleep at night in that newly finished basement.

Also I love the hubris "other companies are bad but mine is good." This is all very believable

---

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[medgator]

Yes yes you are the holy one, denying cancer patients their care at worst, delaying at best. Whatever helps you sleep at night in that newly finished basement.

Also I love the hubris "other companies are bad but mine is good." This is all very believable

 

[A_DeMichele]

we don’t like to use the M word, but what do we call waiting for > 3 m to start treatment for advanced H&N Ca?

 

[OTN]

lol imagine thinking a finished basement in the Midwest was a luxury. Simul after today's exchange:

 

[deleted1111261]

lol imagine thinking a finished basement in the Midwest was a luxury. Simul after today's exchange:

View attachment 379972

literal LOL

 

[MidwestRadOnc]

Way to not address anything I said Insulting me is operating out of bad faith and not interested in discussion and finding amenable solutions.

I'm saying this as a non-anonymous person and you are calling me a liar to my face? I'm not holy. I'm not religious at all, but I do appreciate those that are.

This whole line of thought reminds of my friends with ultra-wealthy physician parents that thinks the world was owed to them. And it was really hard when they found it wasn't.

Finally, Florida Man, let's get one thing straight. We don't sleep in our own basements. Midwestern people use basements for that 4 times a year where your houseguests have like a zillion kids or you are having a Diwali party or something and need all the delicious (but at times, pungent) food down there on burners. And, occasional ping pong.

Tigerstang, while not very tactful, has a point. I am confused whether you know this looks bad as you seem pretty brazen in openly discussing it.

I do not know how much you can make working a few days a week for these companies, but I bet it's > 100k/year (feel free to be specific), and I have the time to do it, and frankly could use the money right now, and I have thought about it, but I am not sure I could sleep at night and would honestly be embarrassed when it came time serve as a reviewer for the people who trained me.

There is really no getting around the fact that you are profiting from a system that actively harms patients. Sure, your system protects the profit margins of payors from unethical profit-driven doctors who also harm patients with overtreatment. However, I am literally looking at UHC prostate cancer guidelines right now, which don't allow for the treatment of the prostate only (without nodes) with conventional fractionation. There are absolutely indications when this is appropriate. We all know plenty of other reasonable treatments are routinely denied and months are wasted kicking the can down the road hoping the patient either progresses/dies or the doctor gives up in the meantime.

Also, back when I owned a house, I regularly slept in the basement in the summer. Much cooler. Yes, they are nice luxuries in the midwest, except bizarrely in the Tornado-occupied states of Oklahoma and Texas where nobody knows how to build them for some reason, but come on, you don't need to do peer reviews to be able to afford as a rad onc to hang some sheetrock, run some wires, and put in a bar and pool table.

 

[Ray D. Ayshun]

Tigerstang, while not very tactful, has a point. I am confused whether you know this looks bad as you seem pretty brazen in openly discussing it.

I do not know how much you can make working a few days a week for these companies, but I bet it's > 100k/year (feel free to be specific), and I have the time to do it, and frankly could use the money right now, and I have thought about it, but I am not sure I could sleep at night and would honestly be embarrassed when it came time serve as a reviewer for the people who trained me.

There is really no getting around the fact that you are profiting from a system that actively harms patients. Sure, your system protects the profit margins of payors from unethical profit-driven doctors who also harm patients with overtreatment. However, I am literally looking at UHC prostate cancer guidelines right now, which don't allow for the treatment of the prostate only (without nodes) with conventional fractionation. There are absolutely indications when this is appropriate. We all know plenty of other reasonable treatments are routinely denied and months are wasted kicking the can down the road hoping the patient either progresses/dies or the doctor gives up in the meantime.

Also, back when I owned a house, I regularly slept in the basement in the summer. Much cooler. Yes, they are nice luxuries in the midwest, except bizarrely in the Tornado-occupied states of Oklahoma and Texas where nobody knows how to build them for some reason, but come on, you don't need to do peer reviews to be able to afford as a rad onc to hang some sheetrock, run some wires, and put in a bar and pool table.

It seems like what I tell my patients who don't want to do chemo: if it makes you sick and miserable, you can always stop. The system is what it is. I don't mind too much when I talk to reasonable people. Beats unreasonable people. I got GC down the road doing lot's of questionable ****. Need somebody to keep em in check.

 

[OTN]

Tigerstang, while not very tactful, has a point. I am confused whether you know this looks bad as you seem pretty brazen in openly discussing it.

I do not know how much you can make working a few days a week for these companies, but I bet it's > 100k/year (feel free to be specific), and I have the time to do it, and frankly could use the money right now, and I have thought about it, but I am not sure I could sleep at night and would honestly be embarrassed when it came time serve as a reviewer for the people who trained me.

There is really no getting around the fact that you are profiting from a system that actively harms patients. Sure, your system protects the profit margins of payors from unethical profit-driven doctors who also harm patients with overtreatment. However, I am literally looking at UHC prostate cancer guidelines right now, which don't allow for the treatment of the prostate only (without nodes) with conventional fractionation. There are absolutely indications when this is appropriate. We all know plenty of other reasonable treatments are routinely denied and months are wasted kicking the can down the road hoping the patient either progresses/dies or the doctor gives up in the meantime.

Also, back when I owned a house, I regularly slept in the basement in the summer. Much cooler. Yes, they are nice luxuries in the midwest, except bizarrely in the Tornado-occupied states of Oklahoma and Texas where nobody knows how to build them for some reason, but come on, you don't need to do peer reviews to be able to afford as a rad onc to hang some sheetrock, run some wires, and put in a bar and pool table.

Counterpoint: Simul's company is much, much better than Evicore, so he's actively working to improve the PA process by working with a competitor who is better than Evi(L)core

 

[MidwestRadOnc]

It seems like what I tell my patients who don't want to do chemo: if it makes you sick and miserable, you can always stop. The system is what it is. I don't mind too much when I talk to reasonable people. Beats unreasonable people. I got GC down the road doing lot's of questionable ****. Need somebody to keep em in check.

I have never once attempted to do anything like 60 fractions IMRT to breast. Do I believe it happens? Yes. Do I believe it is common? No. Yet, I waste countless hours having to defend (usually futilely) very reasonable plans such as:

1. Conventional fractionation to a large, obstructed prostate
2. Ablative radiation to nodal and bone oligomets in otherwise healthy, excellent PS patients
3. IMRT for left-sided breast when DIBH not available
4. More than 10 fractions (typically 13-15) of palliative radiation for radioresistant histologies and other situations where more durable control is important
5. IMRT for things like NSCLC and rectal cancer
6. Hard limit of 30 fractions for anything in the chest
7. Spine SBRT for palliation
8. Liver SBRT only for certain histologies, other histologies palliative chemo is good enough because that's definitely how cancer works in everybody.

Etc.

It is not a good faith argument to say you are doing the good work by keeping the 30 fraction IMRT asymptomatic prostate met in a rib guys in check when we all know the majority of it is the above and the reviewer states they are powerless to overturn the guidelines at best, and at worst chastises you and lumps you in with bone-met-IMRT-guy for wanting to give IMRT to the breast to get the mean heart dose from 600 to 300 cGy.

 

[RickyScott]

for plans that are not Medicare advantage, the employer is almost always the ultimate payor not the insurance company. Um is offered by the insurance to ensure quality. For Medicare advantage, the insurance company does profit from limiting utilization. The problem in healthcare is hospital prices, and the blunt hammer of um inconveniences us all. Participating in um is 1000x more ethical than charging patients 10xcms at mdacc.

 

[deleted1111261]

See below

I have never once attempted to do anything like 60 fractions IMRT to breast. Do I believe it happens? Yes. Do I believe it is common? No. Yet, I waste countless hours having to defend (usually futilely) very reasonable plans such as:

1. Conventional fractionation to a large, obstructed prostate - WE DON'T DENY CONVENTIONAL FX FOR ANY CURATIVE PROSTATE
2. Ablative radiation to nodal and bone oligomets in otherwise healthy, excellent PS patients - THIS IS CASE BY CASE, AND I AM PRO-OLIGO-TX
3. IMRT for left-sided breast when DIBH not available - HUH? ALL LEFT SIDE NODES ARE FINE FOR IMRT
4. More than 10 fractions (typically 13-15) of palliative radiation for radioresistant histologies and other situations where more durable control is important. PEOPLE GIVE 13 FOR BREAST. 15 FOR ESOPHAGEAL. NOT MY CUP OF TEA, BUT REASONABLE
5. IMRT for things like NSCLC and rectal cancer - IMRT FOR BOTH ALWAYS FOR ME
6. Hard limit of 30 fractions for anything in the chest - I DO 60 / 40 FOR SCLC; WOULD NOT DENY THAT
7. Spine SBRT for palliation - THERE IS A POSITIVE STUDY FROM CANADA. WHY WOULD I DENY?
8. Liver SBRT only for certain histologies, other histologies palliative chemo is good enough because that's definitely how cancer works in everybody. HAS NOT COME UP, BUT IF DOC IS MAKING A CASE FOR OLIGO-MET, WHY WOULD I DENY?

Etc.

It is not a good faith argument to say you are doing the good work by keeping the 30 fraction IMRT asymptomatic prostate met in a rib guys in check when we all know the majority of it is the above and the reviewer states they are powerless to overturn the guidelines at best, and at worst chastises you and lumps you in with bone-met-IMRT-guy for wanting to give IMRT to the breast to get the mean heart dose from 600 to 300 cGy.

It is not good faith to assume you know what I am doing on the inside to make things better for the doctors. Review what I said above and we can go back and forth. But, I am not assuming anything about you, as you are to me. Every single example you gave - I agree with you.

Your issue is with Evicore and United. Really. I'm not the enemy, as much as you and Tiger want to paint me in that light.

 

[MidwestRadOnc]

See below


It is not good faith to assume you know what I am doing on the inside to make things better for the doctors. Review what I said above and we can go back and forth. But, I am not assuming anything about you, as you are to me. Every single example you gave - I agree with you.

Your issue is with Evicore and United. Really. I'm not the enemy, as much as you and Tiger want to paint me in that light.

Can you share which company you work for / payors you approve for, how many hours per week, and approximate $/hr?

You sound more ethical than most, but I'm still not sure I could do it. You are right to be defensive about this as at least you realize it looks bad.

Yes, I definitely have an issue with Evicore and UHC. They are basically practicing medicine as corporations with their guidelines. It's pretty clear to me the waste and harm they cause through inefficiencies far outweighs the waste caused by the <5% of rad oncs that are unethically delivering unnecessary treatment for extra profit.

 

[Tigerstang]

Way to not address anything I said Insulting me is operating out of bad faith and not interested in discussion and finding amenable solutions.

I'm saying this as a non-anonymous person and you are calling me a liar to my face? I'm not holy. I'm not religious at all, but I do appreciate those that are.

This whole line of thought reminds of my friends with ultra-wealthy physician parents that thinks the world was owed to them. And it was really hard when they found it wasn't.

Finally, Florida Man, let's get one thing straight. We don't sleep in our own basements. Midwestern people use basements for that 4 times a year where your houseguests have like a zillion kids or you are having a Diwali party or something and need all the delicious (but at times, pungent) food down there on burners. And, occasional ping pong.

I'm not sure Norm Anderson and his practice justifies the harm you and your company do. That's why I didn't address your nonsensical nonsequitor.

 

[Tigerstang]

I see where you are coming from. I also had some of these thoughts before starting.

At the interview, I said I would never deny something on NCCN / ASTRO guidelines. They said "we don't want you to do that". And, I haven't. I haven't denied anything that I would treat myself - I hear the Evicore person telling me (multiple times) - "Yeah, I agree with you, but our guidelines say .. " I think that is reprehensible. I would never agree with a doctor and then not let them do what was right. I would never work for a company with it's own internal guidelines unless they are able to superceded by national ones. I will quit if that happens. I'm not aware of any of our cases going past 2 weeks or so.

I don't know what to tell you all that assume I'm just screwing people over. Ask people that have got me on the phone. We go through the case, I give them my personal cell to call me if there ever any issues and that I'm truly here to help. A chairman told me "This is the best P2P that I've had" (I had him modify his case). But, I'm just not going to get rolled over. If you say something that would fail your boards, I'm not approving that. Sorry. But, I'm done reviewing IMRT for node positive breast cases. We have to trust the doctors on this one. Treating comprehensive? Do what you gotta do. I'm not going to review IGRT. This makes zero sense from P2P perspective. I'm not doing to make someone do complex isodose for anything if they have a CT scanner. There are comments I've made on SoMe, and then bam, Evicore changed what they were doing to match what I said we were doing. I have a platform and I will use it to benefit docs and patients.

I live in a low cost city in the midwest. I do not need a part time job to finish the basement. That was a joke. The expensive part was marrying the woman who is finishing the basement. She's not quite "FrillsNDrills" yet, but on her way. She framed it, waterproofed it, sealed it herself. Unlike Florida docs making $1.5-2.0m driving exotic cars, screwing over people and never making them partner, and what not - we live a simple life.

One thing that should be apparent is I have values and ideals that I simply will not violate. I'd rather quit (anything) than do that. I'm sorry it offends some of that I do this job, but based on what I see 1) I improve quality of care 2) I catch up with old friends 3) I keep up with the literature.

My group does not make that kind of money, nor do we screw people out of partnership. The only group I was part of that screwed people out of partnership was in the MidWest (I also got screwed). Your generalizations, in addition to being false, are at best weak attempts to justify your morally corrupt endeavors.

 

[MidwestRadOnc]

You can Google me and find the company.

And no, not unless you tell me your name, employer, salary, favorite ice cream, which investment funds you are currently considering. Why do you think that’s appropriate to ask? I’ve said enough and been nice to someone that has not been nice to me.

Take care

It's appropriate to ask because you claim to be doing this work for altruistic reasons and it would be helpful to know from a system-wide standpoint what the cost of this kind of work is. We know ballpark what rad oncs get paid per unit of clinical work because that data is published by MGMA, and it's obviously useful for us to know this as well as to give credence that you aren't doing this for the money but to change the system from the inside.

Your responses have been reasonable, but I just came on here to say that it was a little shocking to see a peer, especially you, brazenly admitting to doing peer reviews like this kind of work wasn't clouded in a noxious plume of you know what. You seem very defensive, and I'm sure you know why, and I have to wonder, who are you really trying to convince? Many are going to come at you pretty hard off the bat for this. I'm not sure I could do it even for your company, which I do believe is you better than Evicore and UHC/Optum (how could it be any worse), as I don't think I could handle the "Dude... Really???" comments and eye rolls over and over.

That said, I certainly believe you are more reasonable than most. But I have talked to Evicore reviewers who were nice enough and basically apologized they couldn't do anything, and I wanted to ask, so why are you taking their money? Is the small lifestyle bump you can now afford worth it?

Like Tigerstang, I was also screwed in the Midwest by an exploitative partnership track program.

 

[ramsesthenice]

Wow. Can we turn down the personal attacks already?

 

[deleted1111261]

Man, these dudes come in hot talking about my ethics and morality. I can't help but be defensive. I did not personally attack any one except I have been harsh on Florida rad oncs. I am not the only one, but they are not a protected class and no individuals were named by me.

I took this job for a variety of reasons. The number one reason is to learn about payors/insurance industry.

I talked to Keole about this a long time ago. He said I'd be perfect for Payor Relations. So, I swallowed my pride, rejoined ASTRO to try to make things better. Then, the board, I believe it was a woman named Arnone claimed I was too controversial, so they stole my membership money and never allowed me to be on that committee. They are manipulative, deceitful vipers, the lot of them.

Anyway, I tried to find so many non PA-ways to get into this world. Honestly, there is no way for an entry level guy like me to do pretty much anything non-clinical. This company does prior auth, but the big game is in our digital app for patient supportive care. It is awesome and we just scored a $30m deal with BCBS MI and I'm super excited about that. It doesn't matter, "sticks and stones" and all that. People that get so worked up about others morality tend to have their own issues they are working through (think about those people that can't stop railing about gay people and then you find out that Joe and Steve aren't just hunting buddies). I don't worry at all - even my mentor gave me so much **** about working PA. I don't need your external validation.

Because there are nice people on this board, as I learn more, I will disseminate that information. I had a post in the business section and I have tweeted about things. People on this board and from others have texted/emailed me, asking advice about PA, and I'm in a position where I can actually help. I'm not an altruist.

It makes me happy to do the things I do. So I do them.

 

[MidwestRadOnc]

Wow. Can we turn down the personal attacks already?

Color me surprised that it's a majority opinion here that asking questions and providing criticism of profiting financially from doing peer reviews is not only not reasonable but a personal attack. The problem is not the person, the problem is the job.

I would think, at least, that even if you felt morally justified doing this kind of work, then you would anticipate some heavy criticism and not seem totally blindsided that it raised some eyebrows. It's a free country and the work you are doing is legal, but you are taking money for something I have until this point not felt comfortable considering. If you're comfortable with it, that's your business but I would consider it a professional risk not worth taking regardless at this point in my career. I say that out of genuine concern that you may not appreciate the negative ramifications of advertising this.

 

[deleted1111261]

Color me surprised that it's a majority opinion here that asking questions and providing criticism of profiting financially from doing peer reviews is not only not reasonable but a personal attack. The problem is not the person, the problem is the job.

I would think, at least, that even if you felt morally justified doing this kind of work, then you would anticipate some heavy criticism and not seem totally blindsided that it raised some eyebrows. It's a free country and the work you are doing is legal, but you are taking money for something I have until this point not felt comfortable considering. If you're comfortable with it, that's your business but I would consider it a professional risk not worth taking regardless at this point in my career.

Your criticisms of what I would deny are inaccurate though, and you don’t address that.

You say “more ethical”. What am I doing that is unethical?

Why does how much I earn matter? If it’s $0 does it make me better or worse? If it’s a $1000 an hour does it make me better or worse? I make less money than you do overall, what does it matter?

You could have asked many of these questions in a nice way, in a curious way, in a way to learn and educate. But, instead you already have your opinion and your mind made up, and it’s up to us to change it.

None of you have addressed what is unethical about what I’m doing - not the industry, not evicore, not united - but about me. You’re calling me unethical based on your view of the industry.

People take advantage of my kindness. I let them do that, I get called guileless or gullible or whatever. But, there is zero pretense. If you did this in a reasonable way, I’d have probably called you up and told you everything and would have given useful advice on how to avoid a lot of hassle from Pa. I do that with many people. But come in guns blazing… I d k. You want to insult me, it’s fine. But why not try .. to learn something.

Each example you give - every single one of them - you were wrong about how I would adjudicate. Does this mean nothing to you - that every example was incorrect?

 

[communitydoc13]

Color me surprised that it's a majority opinion here that asking questions and providing criticism of profiting financially from doing peer reviews is not only not reasonable but a personal attack. The problem is not the person, the problem is the job.

Just present Simul with a case here that you have had issues getting approval for and see how he would adjudicate such a case.

I'm sure he'll respond right here, publicly. I actually trust that what he presents here would be how he would do the job privately.

Simul has allowed himself to be a bit of a public figure in our field on his own terms. This has it's upside and downside of course. But, it should protect him from a certain type of online abuse IMO. He's given a pretty solid defense of what he does.

While I'm happy to denigrate proton therapy in general and the MDACCs in particular on this board, I would be wrong to criticize a particular doctor for advocating for protons or working for MDACC. (If only I would have been offered such a job).

If Steven Lin came on here to defend total toxicity burden as an endpoint, I'd feel obligated to be nice to him and to figure out why what he's doing is right.

 

[MidwestRadOnc]

Your criticisms of what I would deny are inaccurate though, and you don’t address that.

You say “more ethical”. What am I doing that is unethical?

Why does how much I earn matter? If it’s $0 does it make me better or worse? If it’s a $1000 an hour does it make me better or worse? I make less money than you do overall, what does it matter?

You could have asked many of these questions in a nice way, in a curious way, in a way to learn and educate. But, instead you already have your opinion and your mind made up, and it’s up to us to change it.

None of you have addressed what is unethical about what I’m doing - not the industry, not evicore, not united - but about me. You’re calling me unethical based on your view of the industry.

People take advantage of my kindness. I let them do that, I get called guileless or gullible or whatever. But, there is zero pretense. If you did this in a reasonable way, I’d have probably called you up and told you everything and would have given useful advice on how to avoid a lot of hassle from Pa. I do that with many people. But come in guns blazing… I d k. You want to insult me, it’s fine. But why not try .. to learn something.

Each example you give - every single one of them - you were wrong about how I would adjudicate. Does this mean nothing to you - that every example was incorrect?

I don't know you personally and have never met you, but I think part of what motivated me to respond to this was the fact that you have publicly stuck your neck out to do and say many good things for community rad oncs in the past and this could harm the credibility of what you have done or the arguments you have made in the past that I have found helpful. If you feel cyberbullied by criticism of doing PA work I don't know what to tell you, and I honestly don't even think I was that harsh. I think you will continue to take heat, far more than I or even Tiger gave you, if you continue to openly advertise you do this without acknowledging that you are operating in what many consider ethically murky territory regardless of whether you approve reasonable requests or not. Don't shoot the messenger.

 

[RickyScott]

Historically um pay is awful. Most full timers are radoncs with no job prospects because of geographic limitations. Would love to hear how it’s worse than academics treating prostate with protons. (I absolutely would push protons for prostate before moving out of state away from my family) Evercore is horrible, but radoncs don’t make the rules. I assume those 2 fine ladies in Miami don’t have any local opportunities.

 

[Mandelin Rain]

[Sigh]

 

[deleted1111261]

I don't know you personally and have never met you, but I think part of what motivated me to respond to this was the fact that you have publicly stuck your neck out to do and say many good things for community rad oncs in the past and this could harm the credibility of what you have done or the arguments you have made in the past that I have found helpful. If you feel cyberbullied by criticism of doing PA work I don't know what to tell you, and I honestly don't even think I was that harsh. I think you will continue to take heat, far more than I or even Tiger gave you, if you continue to openly advertise you do this without acknowledging that you are operating in what many consider ethically murky territory regardless of whether you approve reasonable requests or not. Don't shoot the messenger.

I found your initial posts to be rude and later ones to be less so. I still don’t think you really want to learn / understand / improve things. At this stage of my career, I just want it better for everyone that comes after me.

You still haven’t addressed that every single example you presented was incorrect - I would not deny any of those.

As I said, IGRT is a huge sticking point for many of you. Breast IMRT. Oligo Mets. Other curative sites. Every single thing you’re saying - I’m working on that or have fixed in my little part of the world.

Would you rather some malpractice-laden retiree do this and just algo everything and not try to provide the best care possible?
Are people like you able to find positives? Maybe not - that’s okay, too - skeptics are needed to balance optimists like me.

Don’t worry about me! Everyone who hates me will continue to do so, everyone that likes me will know that I am intentional and doing right and helping other ROs. I can do more from here than you think. I asked my superiors before I took job - they said same thing - good learning experience, report back what you learn.

There is nothing I can say or do to change your mind, even if 100% of your examples are incorrect. That’s too bad. I like finding consensus.

 

[MidwestRadOnc]

You're completely missing the point. You are defending the concept of PA by cherry picking a few examples of egregious behavior. I responded to point out that the vast majority is delaying care to have to defend very reasonable requests that should not have to be defended on the phone as they are very clearly defended in the A&P with literature citations (what's the point of even writing the A&P then?), not the ridiculous hyperfractionated stuff. The point was not to try and accuse you personally of denying reasonable treatment plans but rather participating in a system that engenders the time-suck that puts me on the phone with your peers in the first place, which actively does harm patients. I completely believe you that you routinely approve all of the above. I never implied you don't. My rationale is documented in my written plan, very clearly. I will explain to the reviewer on the phone the exact same thing I have written. We all know this game.

If you're making things better for a small network of payors in your region, that's great. Reviewers for your bigger competitors are all cookbook and function basically to obstruct and delay. But it's still PA. There's a solution out there that doesn't involve PA at all.

There's really no tip-toeing around the fact that you work for money (as we all do), so I'm not sure why we can openly say that the average rad onc clinician makes $550k/year, but it's offensive to ask what the compensation of rad onc PA work is. If saying that makes me rude, so be it. Is it more ethical than making money from 30 fraction bone met treatment, IO-until-the-last-hour-of-life, prostate proton therapy, etc? Probably, but the point wasn't to create a hierarchy of badness if the response is going to be well what about this and what about that?

 

[RickyScott]

You're completely missing the point. You are defending the concept of PA by cherry picking a few examples of egregious behavior. I responded to point out that the vast majority is delaying care to have to defend very reasonable requests that should not have to be defended on the phone as they are very clearly defended in the A&P with literature citations (what's the point of even writing the A&P then?), not the ridiculous hyperfractionated stuff. The point was not to try and accuse you personally of denying reasonable treatment plans but rather participating in a system that engenders the time-suck that puts me on the phone with your peers in the first place, which actively does harm patients. I completely believe you that you routinely approve all of the above. I never implied you don't. My rationale is documented in my written plan, very clearly. I will explain to the reviewer on the phone the exact same thing I have written. We all know this game.

If you're making things better for a small network of payors in your region, that's great. Reviewers for your bigger competitors are all cookbook and function basically to obstruct and delay. But it's still PA. There's a solution out there that doesn't involve PA at all.

There's really no tip-toeing around the fact that you work for money (as we all do), so I'm not sure why we can openly say that the average rad onc clinician makes $550k/year, but it's offensive to ask what the compensation of rad onc PA work is. If saying that makes me rude, so be it. Is it more ethical than making money from 30 fraction bone met treatment, IO-until-the-last-hour-of-life, prostate proton therapy, etc? Probably, but the point wasn't to create a hierarchy of badness if the response is going to be well what about this and what about that?

The what about this/ that “hierarchy of badness” is very pertinent here. The majority of radoncs work for large academic centers billing outrageous rates. healthcare is already something like 1/3 of the economy.
mskcc can charge the school teachers and firemen of New York 300k for a course of radiation, but no one should be able to review their utilization?
In what world could utilization review not exist? At some point we will face formalized rationing as costs are just not sustainable.

 

[deleted1111261]

You're completely missing the point. You are defending the concept of PA by cherry picking a few examples of egregious behavior. I responded to point out that the vast majority is delaying care to have to defend very reasonable requests that should not have to be defended on the phone as they are very clearly defended in the A&P with literature citations (what's the point of even writing the A&P then?), not the ridiculous hyperfractionated stuff. The point was not to try and accuse you personally of denying reasonable treatment plans but rather participating in a system that engenders the time-suck that puts me on the phone with your peers in the first place, which actively does harm patients. I completely believe you that you routinely approve all of the above. I never implied you don't. My rationale is documented in my written plan, very clearly. I will explain to the reviewer on the phone the exact same thing I have written. We all know this game.

If you're making things better for a small network of payors in your region, that's great. Reviewers for your bigger competitors are all cookbook and function basically to obstruct and delay. But it's still PA. There's a solution out there that doesn't involve PA at all.

There's really no tip-toeing around the fact that you work for money (as we all do), so I'm not sure why we can openly say that the average rad onc clinician makes $550k/year, but it's offensive to ask what the compensation of rad onc PA work is. If saying that makes me rude, so be it. Is it more ethical than making money from 30 fraction bone met treatment, IO-until-the-last-hour-of-life, prostate proton therapy, etc? Probably, but the point wasn't to create a hierarchy of badness if the response is going to be well what about this and what about that?

It’s not rude to ask what a PA reviewer makes

You are asking me - my hours, my hourly salary, my company. This is personal.

PA in America, based on a 40 hour work week makes about $175-400k a year depending on your position.

RadOncs in PA make around 50% or less of an hourly salary of a median income earning doc. This is very easy to find on the internet.

I make less than evicore and evolent and the other one. I don’t get bonuses. My evaluation has nothing to do with how much money I saved.

 

[OTN]

You're completely missing the point. You are defending the concept of PA by cherry picking a few examples of egregious behavior. I responded to point out that the vast majority is delaying care to have to defend very reasonable requests that should not have to be defended on the phone as they are very clearly defended in the A&P with literature citations (what's the point of even writing the A&P then?), not the ridiculous hyperfractionated stuff. The point was not to try and accuse you personally of denying reasonable treatment plans but rather participating in a system that engenders the time-suck that puts me on the phone with your peers in the first place, which actively does harm patients. I completely believe you that you routinely approve all of the above. I never implied you don't. My rationale is documented in my written plan, very clearly. I will explain to the reviewer on the phone the exact same thing I have written. We all know this game.

If you're making things better for a small network of payors in your region, that's great. Reviewers for your bigger competitors are all cookbook and function basically to obstruct and delay. But it's still PA. There's a solution out there that doesn't involve PA at all.

There's really no tip-toeing around the fact that you work for money (as we all do), so I'm not sure why we can openly say that the average rad onc clinician makes $550k/year, but it's offensive to ask what the compensation of rad onc PA work is. If saying that makes me rude, so be it. Is it more ethical than making money from 30 fraction bone met treatment, IO-until-the-last-hour-of-life, prostate proton therapy, etc? Probably, but the point wasn't to create a hierarchy of badness if the response is going to be well what about this and what about that?

"There's a solution out there that doesn't involve PA at all."

What's that?

 

[drowsy12]

"There's a solution out there that doesn't involve PA at all."

What's that?

Moving away from fee for service

I also don’t think simul should be free from criticism (or any other of the big names around here) so I welcome MRO’s opinion, personally

 

[deleted1111261]

Moving away from fee for service

I also don’t think simul should be free from criticism (or any other of the big names around here) so I welcome MRO’s opinion, personally

I welcome reasonable criticism!
I’ve addressed every thing people have said.
Then the goalposts change.

You are mad at me for things other people do, even though my company is not doing those things,

If I criticize you @drowsy12 for something @MidwestRadOnc does, would you find that fair?

Literally every criticism you have is of some amalgam of the worst reviewer at Evicore and United.

 

[evilbooyaa]

I think folks are right on the border here of being personal attacks. People can dislike each other without it necessarily being moderatable (word?)

That being said, I'd much rather my reviewer be Simul than most of the Evicore folks - THAT BEING SAID, there are a fraction of people at Evicore that are similarly thoughtful in their evaluations based on my limited interactions with the UM space. Guess I just do a lot of reasonable stuff.

I have felt Simul to be very reasonable, based on his posts here as a UM person. I wish MORE companies, including Evicore (which is the main player in this space and notably does NOT approve all the things he mentioned in his reply to MRO) would act like his company. Then, perhaps, I would have less of a negative view of folks who work UM. Thus, if all reviewers were like Simul, we'd be in a better spot. Based on his posts, I get why PA exists (BID for breast/prostate?? protons for prostate? DCIS?) and I'm OK w/ it.

To say that Simul is bad b/c he works PA and then cite Evicore and UHC (which are basically the same as UHC contracts out their RO UM to EviCore) as examples of people doing PA bad.... is a bit of transitive property that doesn't compute. There is a world to PA beyond the EviCore's of the world, not only in terms of name of company but in terms of practice, and honestly, Simul has been important in opening my eyes to that. I guess that's maybe a portion of the reason that I don't ever hear from an insurer that Simul's company contracts with.

Hell, I wish Simul's PA company all the success in the world to push out the EviCore's of the world that do deny all the things that MRO mentioned.

Carry on.

 

[deleted1111261]

I think folks are right on the border here of being personal attacks. People can dislike each other without it necessarily being moderatable (word?)

That being said, I'd much rather my reviewer be Simul than most of the Evicore folks - THAT BEING SAID, there are a fraction of people at Evicore that are similarly thoughtful in their evaluations based on my limited interactions with the UM space. Guess I just do a lot of reasonable stuff.

I have felt Simul to be very reasonable, based on his posts here as a UM person. I wish MORE companies, including Evicore (which is the main player in this space and notably does NOT approve all the things he mentioned in his reply to MRO) would act like his company. Then, perhaps, I would have less of a negative view of folks who work UM. Thus, if all reviewers were like Simul, we'd be in a better spot. Based on his posts, I get why PA exists (BID for breast/prostate?? protons for prostate? DCIS?) and I'm OK w/ it.

To say that Simul is bad b/c he works PA and then cite Evicore and UHC (which are basically the same as UHC contracts out their RO UM to EviCore) as examples of people doing PA bad.... is a bit of transitive property that doesn't compute. There is a world to PA beyond the EviCore's of the world, not only in terms of name of company but in terms of practice, and honestly, Simul has been important in opening my eyes to that. I guess that's maybe a portion of the reason that I don't ever hear from an insurer that Simul's company contracts with.

Hell, I wish Simul's PA company all the success in the world to push out the EviCore's of the world that do deny all the things that MRO mentioned.

Carry on.

Thanks!

It’s OncoHealth - I’m on LinkedIn and searchable.

You should all write letters to your payors and request we take the contract !

 

[drowsy12]

I welcome reasonable criticism!
I’ve addressed every thing people have said.
Then the goalposts change.

You are mad at me for things other people do, even though my company is not doing those things,

If I criticize you @drowsy12 for something @MidwestRadOnc does, would you find that fair?

Literally every criticism you have is of some amalgam of the worst reviewer at Evicore and United.

I’m not speaking about any of the details nor am I criticizing you nor am I co-signing his/her posts. Just saying that no one should be beyond criticism here. There is no little SDN and big SDN, even though it seems like that sometimes, my only point.

 

[deleted1111261]

Call at 6pm today from Evicore for P2P. NSCLC with ... bone mets. No rush on this case, at the moment.

I am treating for pain control. I like SBRT based on MDACC study (12-16/1 vs 30/10) and Canadian study (24/2 vs 20/5). I understand that this is not standard of care everywhere and there is a chance this will get denied. I'm sure many of you may feel similarly.

I explained that it was not oligometastatic treatment, that this was for pain. Two separate studies have shown benefit for pain. An additional study from Sloan showed benefit to treating asymptomatic mets.

"We don't allow that."

"Why? I quoted 2 positive studies and 1 study similar, that was positive, as well."

"Well, this is a controversial topic. There are negative studies."

"I am unaware - please educate me."

"Let me look at our guidelines."

"I've read the guidelines, you do not have a reference that shows negative outcome for SBRT for bone mets"

"Well... that is the policy."

"Can you provide a medical rationale? You just told me it was because it was controversial and you told me there were negative studies."

"You've treated bone mets with 30/10, right?"

"There is no study comparing 30/10 to placebo, so how do we know that is a standard based on evidence?"

"I don't know what point you're trying to make."

"I'm saying there is positive evidence to do what I recommend and no negative studies, despite you telling me there are."

"Well --- WHATEVER -- " (He literally said WHATEVER) "That's what the policy says. You can appeal."

Now, this didn't go well for me. But, this is an MD on the other end that is unfortunately hamstrung by his company.

What I will do: 1) Appeal 2) Request a call to CMO about the "WHATEVER" comment. This is a human being, let's be decent. 3) Present the case to appeal and likely get denied. 4) Take it to ALJ if it gets denied. 5) Present it and explain the evidence and ask them to provide negative evidence. I don't think my case is that strong, but honestly, the evidence is on my side.

What Evicore should do:

1) Hire full time physicians, not retirees that know nothing
2) Have monthly meetings going over new data and denials where a physician presented strong evidence.
3) Constantly update guidelines based on new information

They won't do this, so we will all suffer.

I am trying to help change things that benefit physicians and patients. If you cannot see the difference between what I do and what they do, then I don't know what to tell you.

 

[medgator]

"There's a solution out there that doesn't involve PA at all."

What's that?

Moving away from fee for service

I also don’t think simul should be free from criticism (or any other of the big names around here) so I welcome MRO’s opinion, personally

Payment bundles would put evilcore and the like out of business overnight

 

[deleted1111261]

Payment bundles would put evilcore and the like out of business overnight

How to get each individual payor to do this?

The proposals so far have been pure Medicare.

People say these things, but it’s not easy.

A national proposal for bundles for all commercial insurers will rile up the masses.

Without just saying, “End PA, do bundles” what is your actual plan?

 

[Reaganite]

I did reviews many years ago to learn how to game the system. It was made clear when I signed up that my job was to enforce the guidelines. I was forbidden from exercising any kind of clinical judgment outside of the health plan policy. When I was assigned a new case, I would always receive a pop up reminding me that I was to approve/deny solely based on the guidelines. Simul should be given some credit for even trying to work around the policy because most of these jobs forbid you from doing so. These health plans are confident their guidelines will stand up to medicolegal scrutiny at least in a net positive financial manner for the company.

 

[medgator]

How to get each individual payor to do this?

The proposals so far have been pure Medicare.

People say these things, but it’s not easy.

A national proposal for bundles for all commercial insurers will rile up the masses.

Without just saying, “End PA, do bundles” what is your actual plan?

Easier said than done, i agree. But it would solve so many things.... Would fix the shady Florida boomers and greedy PA companies simultaneously.

If bundles had taken off a decade ago, hypofrac probably would not have been the financial killer it has been for some some places.

The per fx, imrt bad 3d/complex isodose good reimbursement model is just dumb in the modern era

 

[Palex80]

6. Hard limit of 30 fractions for anything in the chest

Patients with LD-SCLC may benefit from 40 x 1.5 Gy bid.

 

[taserlaser]

Call at 6pm today from Evicore for P2P. NSCLC with ... bone mets. No rush on this case, at the moment.

I am treating for pain control. I like SBRT based on MDACC study (12-16/1 vs 30/10) and Canadian study (24/2 vs 20/5). I understand that this is not standard of care everywhere and there is a chance this will get denied. I'm sure many of you may feel similarly.

I explained that it was not oligometastatic treatment, that this was for pain. Two separate studies have shown benefit for pain. An additional study from Sloan showed benefit to treating asymptomatic mets.

"We don't allow that."

"Why? I quoted 2 positive studies and 1 study similar, that was positive, as well."

"Well, this is a controversial topic. There are negative studies."

"I am unaware - please educate me."

"Let me look at our guidelines."

"I've read the guidelines, you do not have a reference that shows negative outcome for SBRT for bone mets"

"Well... that is the policy."

"Can you provide a medical rationale? You just told me it was because it was controversial and you told me there were negative studies."

"You've treated bone mets with 30/10, right?"

"There is no study comparing 30/10 to placebo, so how do we know that is a standard based on evidence?"

"I don't know what point you're trying to make."

"I'm saying there is positive evidence to do what I recommend and no negative studies, despite you telling me there are."

"Well --- WHATEVER -- " (He literally said WHATEVER) "That's what the policy says. You can appeal."

Now, this didn't go well for me. But, this is an MD on the other end that is unfortunately hamstrung by his company.

What I will do: 1) Appeal 2) Request a call to CMO about the "WHATEVER" comment. This is a human being, let's be decent. 3) Present the case to appeal and likely get denied. 4) Take it to ALJ if it gets denied. 5) Present it and explain the evidence and ask them to provide negative evidence. I don't think my case is that strong, but honestly, the evidence is on my side.

What Evicore should do:

1) Hire full time physicians, not retirees that know nothing
2) Have monthly meetings going over new data and denials where a physician presented strong evidence.
3) Constantly update guidelines based on new information

They won't do this, so we will all suffer.

I am trying to help change things that benefit physicians and patients. If you cannot see the difference between what I do and what they do, then I don't know what to tell you.

I don’t have to deal with insurance companies, but we do a lot of local peer review and general consensus for indications such as spine SBRT, oligomets, etc.

I am quite looking forward to when those new ASTRO bone nets guidelines get published. Assuming minimal changes from the draft that was circulated for public comment, the conditional recommendation with upfront SBRT for good ECOG palliation as opposed to the conventional palliation of 8-20 Gy will represent a large paradigm shift. I expect it still to remain controversial, but this will give upfront SBRT some more legs (and let’s me to continue to stir the pot locally haha). A rapid access clinic for bone SBRT sounds great to me.

 

[MidwestRadOnc]

I did reviews many years ago to learn how to game the system.

What did you learn?

 

[MidwestRadOnc]

Just curious. I’m early out of residency and just not sure what is normal for a community type hospital based practice. I see about 10-15 consults a week, and about 30-40 followups, with about 20-25 on treatment. Averaging about 70 patient visits per week. Also have tumor board at 630am on 3 days per week (not helping with my energy levels). We also do a lot of brachy and spaceoar, sbrt. Suppose I’d just like to know if this is normal, because then I can go with it. But if not normal, then I probably need to figure out some options. Residency was abnormal from day 1 so not a good comparison for me.

12.5 consults x 46 weeks a year = 575 consults.

For reference, the last rolling 12 month period I have data I saw 410 consults and earned 15,500 wRVU. 15500/410 = 37.8
So, 37.8 wRVU/consult x 575 consult = 21,735 wRVU.
This is >95th percentile volume.
You should be getting paid at least $65/wRVU.
21,735 x $65/wRVU = 1.4M

That's what your work as a physician is worth. If you're not getting it, someone else is.

 

[deleted1111261]

Such a variation ! In my neck of woods, no one doing that much.

I keep 6-15 on beam, 3 Miles north is the busy center, 18-23 or so, 25 miles south similar to my numbers (sl higher than me on average)

There a few guys with 25-30 on beam in Detroit, but contracts so unfavorable.

I doubt anyone practicing within 45 miles of city earns more than 800-900.

 

[madchemist89]

Can we please move this to business forum?

 

[MidwestRadOnc]

Such a variation ! In my neck of woods, no one doing that much.

I keep 6-15 on beam, 3 Miles north is the busy center, 18-23 or so, 25 miles south similar to my numbers (sl higher than me on average)

There a few guys with 25-30 on beam in Detroit, but contracts so unfavorable.

I doubt anyone practicing within 45 miles of city earns more than 800-900.

Yeah. The way it usually goes is:
1. Low volume but high salary guarantee and/or $70-80/wRVU.
Or
2. High volume eat-what-you-kill but $40-50/wRVU.

I've done both of the above. High volume with fair $/wRVU is a hard gig to come by.

Compensation comes out to be the same but you do double the work in #2. Sometimes that is preferrable just so you don't get bored and/or atrophy your skills. But it's rough knowing your masters are taking a big cut for basically allowing you to work there.

 

[NotMattSpraker]

How to get each individual payor to do this?

The proposals so far have been pure Medicare.

People say these things, but it’s not easy.

A national proposal for bundles for all commercial insurers will rile up the masses.

Without just saying, “End PA, do bundles” what is your actual plan?

We should talk more about how, some how and some way, we've all accepted the big lie of prior authorization as a quality improvement intervention. PA has always been about "utilization review" not care quality, and is rooted in fear that physicians decide who needs the treatment and the price of the treatment.

Haha, could you imagine having that kind of practical day to day autonomy?

Now if you all want to talk costs and profits, dive in to the financials of UHC and Prime Health, MSKCC and MDACC... Ill bring the beers.

In the mean time, you should review Beckta's podcast about how that guy from that society with that bonkers national bundling proposal actually tried bundling once before with a private payer! It didn't... uh... well... no spoilers

 

[JustAdocInBox]

12.5 consults x 46 weeks a year = 575 consults.

For reference, the last rolling 12 month period I have data I saw 410 consults and earned 15,500 wRVU. 15500/410 = 37.8
So, 37.8 wRVU/consult x 575 consult = 21,735 wRVU.
This is >95th percentile volume.
You should be getting paid at least $65/wRVU.
21,735 x $65/wRVU = 1.4M

That's what your work as a physician is worth. If you're not getting it, someone else is.

😂😂 at least $65 per wRVU for 21k wRVUs. Maybe in the midwest?

 

[RickyScott]

😂😂 at least $65 per wRVU for 21k wRVUs. Maybe in the midwest?

I generate a sht load of rvus, but they just adjust dollars/rvu so that I meet mgma metrics.

 

[drowsy12]

Simul may be the best PA in the world, I don’t know. But ultimately the job is to maximize profit margin for the insurance company, so there won’t be any parades thrown any time soon.

No shame in getting paid tho, $$$$$.

I couldn’t do it myself, I would be too embarrassed if I had to talk to someone I knew or who I shared mutual friends with. But that’s my own problem.

Agree that based on what he’s said here, sounds like the person you would rather talk to. Though I’ve mostly had good experiences with rad onc PA. I try to be nice, and have received the same from the other side.

 

[NotMattSpraker]

Simul may be the best PA in the world, I don’t know. But ultimately the job is to maximize profit margin for the insurance company, so there won’t be any parades thrown any time soon.

No shame in getting paid tho, $$$$$.

I couldn’t do it myself, I would be too embarrassed if I had to talk to someone I knew or who I shared mutual friends with. But that’s my own problem.

Agree that based on what he’s said here, sounds like the person you would rather talk to. Though I’ve mostly had good experiences with rad onc PA. I try to be nice, and have received the same from the other side.

I totally agree with this take. I could never do PA work for similar reasons plus others. I used to think these individuals should be banned from ASTRO and now I think everyone should drop their membership

What changed for me is learning how many people in medicine that are accepted as "good noble physicians" are just out there maximizing the profit margin for other companies.

There are a million examples of decent people doing enraging things either due to ignorance or conflicts of interest or both. I've never seen a single tweet about X academic hospital turning away an uninsured patient, but this is actually the single thing that made me most mad when I worked in academics.

Has anyone read Vinay's book Malignant? I read it after graduating residency and knew very few things in that book.

Recognize that we are taught fantasies about honor in medicine and several significant (appalling) conflicts of interest are just part of the system. I really believe that if we teach this point first we might actually fix the problems.

The insurance industry is perfectly happy to sit around counting money while watching us pile on other doctors.

My practical advice for PA relief:

1. Move to Colorado. I cant explain it but I do very few PAs and treat a lot of lung and rectal with IMRT, lots of SBRT. I have a few theories about why this might be, but no one seems to know anything specific about regional variation. This is across at least 2 independent billing/auth teams. We will be hiring end of 2024.

2. Keep a list of "the idiots" and reschedule. I have 2 individuals, both very rude and shockingly dumb/disingenuous. I never accept scheduling with them. Ive never waited more than a half a day for a new person.

(Don't name/shame online if employed, it's likely your company will side with the payers over helping you because money is important to hospitals)

3. Find out early if they can actually reverse a denial on the P2P. People always tell me, yes this for clarification or no here is the guideline. If "the guidelines" prevent it, hang up and spend your time on the letter. The P2P is not worth your time. I have been in a situation where I literally wrote the guideline and they do not care (Simul may, but Evicore did not). Again, the guidelines are not a quality measure, they are telling you what they decided they will pay for or not.