What is a normal patient volume?

[TheWallnerus]

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.

I want a guideline that if you’re over age 60 and have a stage one favorable breast cancer, the insurance company doesn’t have to pay for more than 5 RT fractions and will only pay for IMRT if you’re doing partial breast. Would save money versus all current guidelines AND be a quality measure that’s being implemented.

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[NotMattSpraker]

I want a guideline that if you’re over age 60 and have a stage one favorable breast cancer, the insurance company doesn’t have to pay for more than 5 RT fractions and will only pay for IMRT if you’re doing partial breast. Would save money versus all current guidelines AND be a quality measure that’s being implemented.

“Next year you’ll have a chance to preserve your future status on The Nice List through one of three society accreditation programs, your choice!”

-RadOnc Santa

 

[WanderingRad3]

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.

Lets move to business forum and then can transparently discuss this

 

[deleted1111261]

All of your complaints are tainted by Evicore, so every single complaint is not very really relevant to me.

The opinions read to me like

1) I should be able to do whatever I want and no one should be able to stop me

2) anyone that stops me is profit maximizing

Care to debate that?

Everyone above that’s posted that has done PA work will very quickly realize the need for PA. It becomes apparent after even a few days.

As far as QA, @NotMattSpraker and I have talked about this. I venture that I have more positively effected change via PA than Matt has during a year of chart rounds. He may disagree

If you’re pure Medicare, the chances of getting conventional fx for breast or prostate is higher, because of lack of PA. Profit maximizing has a very discrete economic definition. I assure you that we are not profit maximizing. Also keep in mind profit margins vs absolute profit - there is a big difference.

We are consistently aim for the right treatment technique and number of treatments. That bothers people, bc the vast majority of people are doing things appropriately, but because 5-10% don’t, the rest of us suffer.

We don’t exist solely because of the need for more money for the firm - we exist because of the need for more money for a small group of physicians. If that behavior didn’t exist, we wouldn’t either. If you treat standard of care, you will rarely interact with us.

PA exists. Saying that there isn’t a version that you prefer over another - well that’s your loss. You should prefer to have me on the line, rather than the Florida ladies or the other HoFers that we are subjected to.

 

[deleted1111261]

If you want to think about this constructively, there are ways to bypass our system.

BCBS MI / MROQC have created a program where if you meet certain metrics, you get Gold Carded. You also get a bonus on your reimbursements. As an example, if X% of your breast patients have a heart dose below Y, you’re meeting the metric. If your bone met fx are 10 or less, etc. There is room for deviation - does not have to be 100% - this allows for special cases.

I like these types of programs.

 

[medgator]

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

ASTRO has been part of the PA problem... Remember anti IMRT for breast, focused on hypofx for every indication possible, including prostate where the data isn't necessarily better.

Meanwhile silence on igrt while pushing protons. Really ridiculous that some of my lung pts don't get igrt approved while people are getting proton approvals for breast/prostate etc

 

[drowsy12]

PA exists. Saying that there isn’t a version that you prefer over another - well that’s your loss. You should prefer to have me on the line, rather than the Florida ladies or the other HoFers that we are subjected to.

Whoa, not sure if this is hypothetical or targeted towards someone; but quite literally no one here said this. This is a straw man loaded post.

If you prefer to think your company exists to promote quality, then that’s great. Re-read my post, I didn’t attack you in any way. I understand you may feel defensive, but you shouldn’t. I think that was the intent of mine and Matt’s posts.

And I agree there’s no question that left with zero rules, rad oncs would go wild.

 

[NotMattSpraker]

As far as QA, @NotMattSpraker and I have talked about this. I venture that I have more positively effected change via PA than Matt has during a year of chart rounds. He may disagree

I definitely disagree. Part of the problem is no one ever seems to care to define quality or in this case positive change.

PA is utilization review and chart rounds is peer review of some technical aspects of cases but not others.

The data also argues that a substantial portion of rad onc PA is overturned and causes significant delays. Even if you are doing the right thing in a case, you are still delaying it compared to some other PA-less system.

Everything has trade offs.

Regarding profit maximizing, try to envision what your company would say if you brought them a hypothetical policy change where 100% of physicians agreed the change benefited patients but it resulted in 100% chance of significant financial loss for your company for the next year.

You think they'd go for it?

 

[Mandelin Rain]

[sigh] the fact this discussion is taking place at all makes me sad.

 

[deleted1111261]

Whoa, not sure if this is hypothetical or targeted towards someone; but quite literally no one here said this. This is a straw man loaded post.

If you prefer to think your company exists to promote quality, then that’s great. Re-read my post, I didn’t attack you in any way. I understand you may feel defensive, but you shouldn’t. I think that was the intent of mine and Matt’s posts.

And I agree there’s no question that left with zero rules, rad oncs would go wild.

I wasn’t referring to you. I think you’ve been fair and reasonable. Apologies if it seemed directed at you.

No, no. We are not a QA company. Not at all. I still disagree with Matt that convincing people to do hypo fx for breast is not improving quality. It’s cheaper and better. Yes, it saves money but it’s also better care. How is not quality improvement?

 

[NotMattSpraker]

[sigh] the fact this discussion is taking place at all makes me sad.

Me too, but it is sorely needed. The alternative future with no discussion is going to be worse.

 

[radoncle]

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.

But ultimately the job is to maximize profit margin for the insurance company

This is only true if you're doing PA for an insurance company. I disagree with the notion that PA work is solely profit motivated for physicians working for third party independent review companies whose job it is to evaluate appeals from cases that were denied by Evicore/BCBS etc. We need actively practicing well-trained physicians to do this work. We need honest physicians who will approve IGRT/SBRT/IMRT appropriately and similarly deny protons for prostate/breast/lymphoma/basal cell cancers etc. I don't believe the small pay is a major motivation for most people who do this type of work on the side while maintaining a full time clinic.

 

[deleted1111261]

I will say … the frustration and rage is real. I am always rubbed the wrong way when I get yelled at, but the vast majority of ROs practice great medicine. And, when someone denies something legit, it seems borderline criminal.

One other thing I’d like to implement is to get the payor to pay for comparison plan, if we request it. I am going to bring that up to my boss.

 

[communitydoc13]

The opinions read to me like

1) I should be able to do whatever I want and no one should be able to stop me

2) anyone that stops me is profit maximizing

Care to debate that?

[sigh] the fact this discussion is taking place at all makes me sad.

There is some darkness here. I mean, I doubt Simul would be doing this if he was excited about his trade journal and had to read up on a new intervention every week...if he was struggling to keep up with clinical volume. I doubt I'd be reading the thread if I thought the red journal had good things to offer this month.

Docs cannot police themselves. Nor can law enforcement or the financial sector or lawyers or any other group of people with perverse incentives (this is compounded by professional indoctrination in our case).

But, we all know that personal level grift (or sometimes just misinterpretation of standards and good faith efforts to do what is best for the patient) is made an example of while large institutional grift becomes codified into our reimbursement structure.

I wonder what type of rates JHH was able to get out of CAREFIRST BC/BS.

The limiting case should concern us all.

Imagine a doc was as conservative as could be, meaning:

Strict adherence to CALGB breast radiation avoidance (forget about that 73 year old patient who wants everything done and forget about hedging with APBI).

Five fraction whole breast in women over 50 when offered.

No treatment of favorable intermediate risk or lower prostate cancers in men over 70 (or younger).

Emphasizing medical management over XRT in asymptomatic brain mets in many cases.

Single fraction palliative bone treatments almost always.

Minimal oligomet treatment with rare oligoprogressive disease treated.

Where would this take your volume? How many docs or staff could you cut from your practice?

How would it impact patient survival overall? LOL

None of the above even considers technical considerations.

Now I don't strictly practice as above, and I think I am doing some good by deviating a little from the above script, but the above behavior could be mandated by payors (and might be if the gvt becomes the sole payor).

The only way to de-incentivize excess treatment is to pay by patient seen, not patient treated.

Or just have everyone be a government employee... but I like my specialist docs being hustlers who want to see patients, not a VA style culture where turfing workup and thinking to the overburdened PCPs can be the norm.

 

[Ray D. Ayshun]

There is some darkness here. I mean, I doubt Simul would be doing this if he was excited about his trade journal and had to read up on a new intervention every week...if he was struggling to keep up with clinical volume. I doubt I'd be reading the thread if I thought the red journal had good things to offer this month.

Docs cannot police themselves. Nor can law enforcement or the financial sector or lawyers or any other group of people with perverse incentives (this is compounded by professional indoctrination in our case).

But, we all know that personal level grift (or sometimes just misinterpretation of standards and good faith efforts to do what is best for the patient) is made an example of while large institutional grift becomes codified into our reimbursement structure.

I wonder what type of rates JHH was able to get out of CAREFIRST BC/BS.

The limiting case should concern us all.

Imagine a doc was as conservative as could be, meaning:

Strict adherence to CALGB breast radiation avoidance (forget about that 73 year old patient who wants everything done and forget about hedging with APBI).

Five fraction whole breast in women over 50 when offered.

No treatment of favorable intermediate risk or lower prostate cancers in men over 70 (or younger).

Emphasizing medical management over XRT in asymptomatic brain mets in many cases.

Single fraction palliative bone treatments almost always.

Minimal oligomet treatment with rare oligoprogressive disease treated.

Where would this take your volume? How many docs or staff could you cut from your practice?

How would it impact patient survival overall? LOL

None of the above even considers technical considerations.

Now I don't strictly practice as above, and I think I am doing some good by deviating a little from the above script, but the above behavior could be mandated by payors (and might be if the gvt becomes the sole payor).

The only way to de-incentivize excess treatment is to pay by patient seen, not patient treated.

Or just have everyone be a government employee... but I like my specialist docs being hustlers who want to see patients, not a VA style culture where turfing workup and thinking to the overburdened PCPs can be the norm.

It's funny how in today's DEI culture in radonc nobody sees the hypocrisy in who's defining excess treatment.

 

[MidwestRadOnc]

It's funny how in today's DEI culture in radonc nobody sees the hypocrisy in who's defining excess treatment.

I don't know what this means. DEI is about pigeon-holing people into categories of oppressors and oppressees based on stuff out of their control and doling out punishments and rewards according to the high authority. It's other words, it's the exact opposite of a meritocracy, which is ironic given that it grew like a genital wart in academia since the 60s. So Evicore is what in this scenario? The high authority? They seem to be screwing everyone over quite equally and indiscriminately IMO.

Thought experiment: If every single MD refused to work as a reviewer, peer-to-peer PA would not exist. You can justify working in PA however you want to make yourself sleep at night, but there's really no way around it: If you're doing PA work, you are part of the problem. I don't think my opinion is going to change on that. You can argue that you are the least-worst-of, sure. Now we are back to hierarchies of badness. We should all boycott PA work.

Also, in what world are you all living that an extra (it sounds like) ~$200k/year as a reviewer taking calls at dinner time after your day job has ended (yes, I have been told by Evicore my only option for a peer review was between the hours of 5-6 PM, which was super convienent, and I finally get on the line with some chode from the University of XYZ (you know the one) and hear dinner cooking and kids in the background as he recites guidelines)... anyway, in what world is $200k/year "a little money." Not doing this for money? Give me a break. Nobody believes that.

 

[Ray D. Ayshun]

I don't know what this means. DEI is about pigeon-holing people into categories of oppressors and oppressees based on stuff out of their control and doling out punishments and rewards according to the high authority. It's other words, it's the exact opposite of a meritocracy, which is ironic given that it grew like a genital wart in academia since the 60s. So Evicore is what in this scenario? The high authority? They seem to be screwing everyone over quite equally and indiscriminately IMO.

Thought experiment: If every single MD refused to work as a reviewer, peer-to-peer PA would not exist. You can justify working in PA however you want to make yourself sleep at night, but there's really no way around it: If you're doing PA work, you are part of the problem. I don't think my opinion is going to change on that. You can argue that you are the least-worst-of, sure. Now we are back to hierarchies of badness. We should all boycott PA work.

Also, in what world are you all living that an extra (it sounds like) ~$200k/year as a reviewer taking calls at dinner time after your day job has ended (yes, I have been told by Evicore my only option for a peer review was between the hours of 5-6 PM, which was super convienent, and I finally get on the line with some chode from the University of XYZ (you know the one) and hear dinner cooking and kids in the background as he recites guidelines)... anyway, in what world is $200k/year "a little money." Not doing this for money? Pffttt, give me a break. Nobody believes that.

Equity is about letting a patient decide what an insignificant pfs detriment is

 

[communitydoc13]

Equity is about letting a patient decide what an insignificant pfs detriment is

Nice

 

[MidwestRadOnc]

Equity is about letting a patient decide what an insignificant pfs detriment is

Have you ever worked in an ED? Patients come in with a list of demands. You want an MRI of your pelvis and a ham sandwich? You're getting it. Patient leaves a decent 3 star review on the satisfaction survey. The bill evaporates into the aether. Quite equitable. You have a point.

 

[communitydoc13]

You want an MRI of your pelvis and a ham sandwich?

I'm thinking an U/S or CT happens first...but regardless, the indications for emergent CTs of the pelvis do not go well with ham sandwiches.

I do agree that the whole bill thing (as well as toxicity) does put a lower bound on what PFS benefit we should use to even entertain treatment.

 

[temujim]

Thought experiment: If every single MD refused to work as a reviewer, peer-to-peer PA would not exist.

In this thought experiment, peer-to-peer would be renamed provider-to-provider and we would be talking to APPs.

 

[MidwestRadOnc]

I'm thinking an U/S or CT happens first...but regardless, the indications for emergent CTs of the pelvis do not go well with ham sandwiches.

Fair enough. when the chief complaint is "broke penis, need scan of my stuff" (seen it), there probably isn't enough nuance to specify a specific MR protocol. PA is bad, sure. But at the end of the day I'll still deal with it vs. the stuff our EM colleagues deal with.

In this thought experiment, peer-to-peer would be renamed provider-to-provider and we would be talking to APPs.

My money is on AI-chatbots. Why does Evicore need to pay someone $200k/year to literally recite guidelines a few hours a day? I saw a clickbait article about a helicopter that flies itself the other day. Radformation draws normal structures better than I can already.

 

[deleted1111261]

I don't know what this means. DEI is about pigeon-holing people into categories of oppressors and oppressees based on stuff out of their control and doling out punishments and rewards according to the high authority. It's other words, it's the exact opposite of a meritocracy, which is ironic given that it grew like a genital wart in academia since the 60s. So Evicore is what in this scenario? The high authority? They seem to be screwing everyone over quite equally and indiscriminately IMO.

Thought experiment: If every single MD refused to work as a reviewer, peer-to-peer PA would not exist. You can justify working in PA however you want to make yourself sleep at night, but there's really no way around it: If you're doing PA work, you are part of the problem. I don't think my opinion is going to change on that. You can argue that you are the least-worst-of, sure. Now we are back to hierarchies of badness. We should all boycott PA work.

Also, in what world are you all living that an extra (it sounds like) ~$200k/year as a reviewer taking calls at dinner time after your day job has ended (yes, I have been told by Evicore my only option for a peer review was between the hours of 5-6 PM, which was super convienent, and I finally get on the line with some chode from the University of XYZ (you know the one) and hear dinner cooking and kids in the background as he recites guidelines)... anyway, in what world is $200k/year "a little money." Not doing this for money? Give me a break. Nobody believes that.

I do it during my work day. I’m super slow

I don’t make 200k (closer to half)

 

[Ray D. Ayshun]

Fair enough. when the chief complaint is "broke penis, need scan of my stuff" (seen it), there probably isn't enough nuance to specify a specific MR protocol. PA is bad, sure. But at the end of the day I'll still deal with it vs. the stuff our EM colleagues deal with.


My money is on AI-chatbots. Why does Evicore need to pay someone $200k/year to literally recite guidelines a few hours a day? I saw a clickbait article about a helicopter that flies itself the other day. Radformation draws normal structures better than I can already.

Instead of analogizing to Ed scenarios, why don't we talk about Hodgkin's?

 

[Tigerstang]

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

I just love the "numbers" people come up with on this board. It shows me 1) how little most of these docs know about how actually running a practice works 2) why they continue to be miserable

 

[MidwestRadOnc]

I just love the "numbers" people come up with on this board. It shows me 1) how little most of these docs know about how actually running a practice works 2) why they continue to be miserable

I think we are talking about hospital employed positions. I have been offered as high as $79/wRVU (initial offer). I have never once, in the 5 jobs I have had, received a dime for any extra RVUs or pro collections I brought in. I have always been, one way or the other, capped at some fixed daily/weekly/annual rate. I have met employed doctors paid per RVU at a fixed rate earning well into the 7 figures. Lucky them.

If you're an employee, what percentage of your pay comes out of pro and tech isn't something you even think about. If you ask, it's usually made crystal clear the financials/"running the practice" isn't your concern. Ideally you negotiate a fixed $/wRVU rate and you are paid every 2 weeks as those wRVUs are posted indefinitely. Instead, like Ricky said, what usually happens is the hospital pays you less per wRVU as you generate more. It's not like the payors are paying less, but that's not your concern, the deal is between you and the hospital. If you don't like the fact that you get paid less as you do more and it's a desirable location to live, they can just say take it or leave it and someone else will take it. In the Midwest, you are more likely to get a wRVU rate that's going to get you a piece of the TC vs. not even getting a reasonable portion of the PC in Ricky's setup. As an employee, do I care if my base salary represents 25% vs. 30% of global? No, money is fungible. What's the number, how many hours am I working, and what competition is knocking at the door? That's what I'm thinking about.

If you're a pro-only group trying to hire somebody in a competitive market with poor payor mix, I can see where that would be a problem. The value proposition there is going to be your patient volume. If your collections minus overhead leaves you able to pay $45/wRVU but have 15,000 wRVU, I'd be interested. If I can only generate 7k wRVU/yr, then the VA has better benefits.

 

[deleted1111261]

A low volume place that continues to allow you collect a median base is a sweet spot that many people I know have. They will never make a million but they will be comfortable

 

[deleted1111261]

Fair enough. when the chief complaint is "broke penis, need scan of my stuff" (seen it), there probably isn't enough nuance to specify a specific MR protocol. PA is bad, sure. But at the end of the day I'll still deal with it vs. the stuff our EM colleagues deal with.


My money is on AI-chatbots. Why does Evicore need to pay someone $200k/year to literally recite guidelines a few hours a day? I saw a clickbait article about a helicopter that flies itself the other day. Radformation draws normal structures better than I can already.

Well, we internally have a rule that a denial can’t be made by algo or a nurse. Has to be a doc in that specialty.

AI will likely get there, but far too much nuance. Also Evicore has a very “fuzzy” definition of medically necessary.

They think it’s what they say it is.

I think it is something that is “not wrong” - I.e. some large percentage of people would agree that it’s “a” standard if not “the” standard.

I had a case the other day, without getting into the details, the algo and the nurse would have denied. But 3 min on the call, I realized why they were doing it and it was approved.

I have one right now I was batting around with some friends (Matt is one of them) and the question everyone had was the location of the tumor and critical organs. I decided that it wasn’t my place to judge that.

 

[udrag14]

Well, we internally have a rule that a denial can’t be made by algo or a nurse. Has to be a doc in that specialty.

AI will likely get there, but far too much nuance. Also Evicore has a very “fuzzy” definition of medically necessary.

They think it’s what they say it is.

I think it is something that is “not wrong” - I.e. some large percentage of people would agree that it’s “a” standard if not “the” standard.

I had a case the other day, without getting into the details, the algo and the nurse would have denied. But 3 min on the call, I realized why they were doing it and it was approved.

I have one right now I was batting around with some friends (Matt is one of them) and the question everyone had was the location of the tumor and critical organs. I decided that it wasn’t my place to judge that.

My issue with PA is I have multiple peer to peers agree with me but can't approve the treatment because it isn't an option.

The guidelines have removed select cases will be decided by a case by case basis. It is just a game of delaying patients now.

 

[drowsy12]

Delaying patients generates cash

 

[medgator]

Delaying patients generates cash

Esp at current interest rates

 

[A_DeMichele]

I don’t think a single patient will be harmed if the whole specialty switches to practicing by Evicore guidelines. Sorry!!

 

[drowsy12]

I don’t think a single patient will be harmed if the whole specialty switches to practicing by Evicore guidelines. Sorry!!

For curative cases they’re pretty fair and straight forward as far as I remember. I think most people run into more issues when it comes to metastasis treatment, which is keeping rad onc at fighting weight right now

 

[deleted1111261]

I don’t think a single patient will be harmed if the whole specialty switches to practicing by Evicore guidelines. Sorry!!

If every stage 3 lung was 3D, over the course of ten years, we would see a decline in mortality..

 

[A_DeMichele]

If every stage 3 lung was 3D, over the course of ten years, we would see a decline in mortality..

they still enforce 3D on stage III??

 

[drowsy12]

I think evicore says imrt is standard for definitive NSCLC chemoRT

 

[deleted1111261]

I think evicore says imrt is standard for definitive NSCLC chemoRT

I’m having to fill out MLD, V20, etc on a form now from Evicore. It’s worse than it was in the past.

They do approve, but they still have denied gastric/esoph and rectal.

 

[drowsy12]

There may be regional variations based on contract, I luckily haven’t had that issue in 4-5 years or so

 

[NotMattSpraker]

I think we are talking about hospital employed positions. I have been offered as high as $79/wRVU (initial offer). I have never once, in the 5 jobs I have had, received a dime for any extra RVUs or pro collections I brought in. I have always been, one way or the other, capped at some fixed daily/weekly/annual rate. I have met employed doctors paid per RVU at a fixed rate earning well into the 7 figures. Lucky them.

If you're an employee, what percentage of your pay comes out of pro and tech isn't something you even think about. If you ask, it's usually made crystal clear the financials/"running the practice" isn't your concern. Ideally you negotiate a fixed $/wRVU rate and you are paid every 2 weeks as those wRVUs are posted indefinitely. Instead, like Ricky said, what usually happens is the hospital pays you less per wRVU as you generate more. It's not like the payors are paying less, but that's not your concern, the deal is between you and the hospital. If you don't like the fact that you get paid less as you do more and it's a desirable location to live, they can just say take it or leave it and someone else will take it. In the Midwest, you are more likely to get a wRVU rate that's going to get you a piece of the TC vs. not even getting a reasonable portion of the PC in Ricky's setup. As an employee, do I care if my base salary represents 25% vs. 30% of global? No, money is fungible. What's the number, how many hours am I working, and what competition is knocking at the door? That's what I'm thinking about.

If you're a pro-only group trying to hire somebody in a competitive market with poor payor mix, I can see where that would be a problem. The value proposition there is going to be your patient volume. If your collections minus overhead leaves you able to pay $45/wRVU but have 15,000 wRVU, I'd be interested. If I can only generate 7k wRVU/yr, then the VA has better benefits.

Good technical stuff in there.

This dismal view of employment under horrible leaders is absolutely real. A radiation oncologist, a doctor, once said a similar thing to me directly. “Not your concern”. What a joke.

I am the doctor with the license and the NPI, I pay your board and the state and do all the stupid stuff you make me do… and I still treat your patients. We both know it is absolutely my concern.

Luckily, I know a decent number of people that are treated with way more respect people get from Dr. “not your concern”. It’s not all bad.

Maybe one day we will have more power to toss trash leadership from bad clinics.

A good first step would be to stop the (literal?) racket that is intentionally creating an endless supply of people who have to choose between predatory clinical leadership and unemployment or locums.

Some things we can’t change, but we don’t have to be apathetic about everything and leave every great gig to luck.

I love my job, just wish I felt way less lucky.

 

[ramsesthenice]

Good technical stuff in there.

This dismal view of employment under horrible leaders is absolutely real. A radiation oncologist, a doctor, once said a similar thing to me directly. “Not your concern”. What a joke.

I am the doctor with the license and the NPI, I pay your board and the state and do all the stupid stuff you make me do… and I still treat your patients. We both know it is absolutely my concern.

Luckily, I know a decent number of people that are treated with way more respect people get from Dr. “not your concern”. It’s not all bad.

Maybe one day we will have more power to toss trash leadership from bad clinics.

A good first step would be to stop the (literal?) racket that is intentionally creating an endless supply of people who have to choose between predatory clinical leadership and unemployment or locums.

Some things we can’t change, but we don’t have to be apathetic about everything and leave every great gig to luck.

I love my job, just wish I felt way less lucky.

And herein lies a major downside to being in such a small field. Even without the supply/demand issues (which obviously compound the problem) many markets only have a few employment options. People who want/need to be in a particular place are unfortunately way more likely and willing to tolerate this kind of stuff.

 

[MidwestRadOnc]

Good technical stuff in there.

This dismal view of employment under horrible leaders is absolutely real. A radiation oncologist, a doctor, once said a similar thing to me directly. “Not your concern”. What a joke.

I am the doctor with the license and the NPI, I pay your board and the state and do all the stupid stuff you make me do… and I still treat your patients. We both know it is absolutely my concern.

Luckily, I know a decent number of people that are treated with way more respect people get from Dr. “not your concern”. It’s not all bad.

Maybe one day we will have more power to toss trash leadership from bad clinics.

A good first step would be to stop the (literal?) racket that is intentionally creating an endless supply of people who have to choose between predatory clinical leadership and unemployment or locums.

Some things we can’t change, but we don’t have to be apathetic about everything and leave every great gig to luck.

I love my job, just wish I felt way less lucky.

It's really something when this kind of stuff comes from your own peers, isn't it?
The amount of gaslighting out there is unreal.
I spent a year in a "partnership track" position at <5th percentile pay and was told to "trust" them and not ask questions about details about partnership at the time of the offer as they pull offers from people who ask questions like that because it seems like they "are only interested in money" Fast forward I eventually start gently asking some questions and was told absurd and insulting things like "you can't afford the buy-in" "no bank will give you a loan that high" etc.

No. You were having me do nearly 20k wRVU per year for 350k and essentially no vacation (because that looks bad to make someone else cover for you). That is a buy-in, and a big one. And you want (a lot) more on top of that? At the end of the day the rad onc partners had no interest in splitting the (very large) pie and I'm sure enjoyed the extra they kept from me. And it's not like they built the practice either, their interest was acquired through politics/pull/nepotism. You expect this kind of behavior/lying/greed from hospital admins, but honestly my own peers screwed me over more than any hospital has. I think I may have landed in the sweet spot now as previously alluded to with high base pay but low volume. I wish I were busier and had some skin in the game, but after bouncing all around this circus my bar of expectations has been dramatically lowered and try to consider myself lucky if there doesn't end up being another bait-and-switch. However, as noted above, this was only possible with geographic flexibility and willingness to have a very long commute.

 

[deleted1111261]

It's really something when this kind of stuff comes from your own peers, isn't it?
The amount of gaslighting out there is unreal.
I spent a year in a "partnership track" position at <5th percentile pay and was told to "trust" them and not ask questions about details about partnership at the time of the offer as they pull offers from people who ask questions like that because it seems like they "are only interested in money" Fast forward I eventually start gently asking some questions and was told absurd and insulting things like "you can't afford the buy-in" "no bank will give you a loan that high" etc.

No. You were having me do nearly 20k wRVU per year for 350k and essentially no vacation (because that looks bad to make someone else cover for you). That is a buy-in, and a big one. And you want (a lot) more on top of that? At the end of the day the rad onc partners had no interest in splitting the (very large) pie and I'm sure enjoyed the extra they kept from me. And it's not like they built the practice either, their interest was acquired through politics/pull/nepotism. You expect this kind of behavior/lying/greed from hospital admins, but honestly my own peers screwed me over more than any hospital has. I think I may have landed in the sweet spot now as previously alluded to with high base pay but low volume. I wish I were busier and had some skin in the game, but after bouncing all around this circus my bar of expectations has been dramatically lowered and try to consider myself lucky if there doesn't end up being another bait-and-switch. However, as noted above, this was only possible with geographic flexibility and willingness to have a very long commute.

Despicable.

There are jobs, but this type of story which we hear far too often gives insight on mismatch of supply and demand.

That **** not gonna happen to a radiologist or urologist

 

[MidwestRadOnc]

Despicable.

There are jobs, but this type of story which we hear far too often gives insight on mismatch of supply and demand.

That **** not gonna happen to a radiologist or urologist

It's scary out there. I know someone else who basically the exact same story just happened to.
Say what you want about making money from PA companies, and while I don't like it, it doesn't hold a candle to the depravity many of our peers are capable of when it comes to eating our young/stealing their labor.

 

[drowsy12]

I went far in interview process with a practice like this about 7 years ago before figuring out they were shady as hell and never make me a partner.

 

[ramsesthenice]

These posts make me so sad. Money is one thing, but just being appreciated and knowing you are appreciated should not be extra. I’m paid very well for an academic with a 50% clinical appointment. But that’s not the big reason I love my job. It’s the respect. I just took six weeks paternity leave. Thing is, we adopted. On a Monday. And didn’t find out about it until the Friday before. Chair simply said go be with your family and do what you need to do. RVUs obviously took a hit but I still made my full compensation for the period because I’m typically well over target.

I’m lucky. But not just because of the job I have. Organizational changes can ruin any good job. No, because my wife and I are both flexible with where we live and have enough money we don’t have to settle for a **** job.

 

[Ray D. Ayshun]

It's scary out there. I know someone else who basically the exact same story just happened to.
Say what you want about making money from PA companies, and while I don't like it, it doesn't hold a candle to the depravity many of our peers are capable of when it comes to eating our young/stealing their labor.

So you come here and denigrate realsimuld for pa stuff while expecting him to disclose his salary and employer yet you won't actually name the predatory practice that is presumably continuing to mislead new grads and early career docs? I'll pass...

 

[IonsAreOurFuture]

I don’t think a single patient will be harmed if the whole specialty switches to practicing by Evicore guidelines. Sorry!!

What will happen to technical innovation in that scenario?

Please remember that there are no clinical trials of radiation therapy where the vendor or hospital is providing active treatment for free, in the same way that pharma provides a new drug to participants.

Depending on study complexity, it also costs about 5,000$ per patient just to run a good long term trial, so something like COMPPARE can easily run over $5 million just to track PSA and QOL outcomes.

Evicore is not going to allow anyone on a trial for which there isn't already phase III confirmed superiority, hence, no need for the trial. Just keep on practicing like it's the pre-IMRT era in which many of their reviewers are familiar. Meanwhile, drug therapy advances result in at least one new indication per month...

 

[medgator]

I don’t think a single patient will be harmed if the whole specialty switches to practicing by Evicore guidelines. Sorry!!

Big igrt hater?

 

[TheWallnerus]

I don’t think a single patient will be harmed if the whole specialty switches to practicing by Evicore guidelines. Sorry!!

I don’t think evicore allows SRS if you have a solitary small cell brain met (no matter KPS or extra cranial disease status)

 

[communitydoc13]

I don’t think a single patient will be harmed if the whole specialty switches to practicing by Evicore guidelines. Sorry!!

Above examples are good.

Of course single patients will be harmed. Now, would cancer or toxicity outcomes be changed in a statistically significant way? Maybe not over the whole population?

I think most docs should strive for personal quality (not metric meeting) and personalized medicine. In other words, they should try to maximize outcomes for the individual patient while being cognizant of cost and futility.

Inflexible guidelines take the above option away.

Now a fair case based model will let the docs do more for a given patient. They just won't get paid more for it.