If NPs and Midlevels Can Prescribe Chemotherapy, Why Can’t Radiation Oncologists Prescribe Immunotherapy?

[Beerus]

Advertisement - Members don't see this ad

Radiation oncologists complete 5 years of dedicated oncology training, yet they don't prescribe even immunotherapy!! when the same system already allows oncology NPs and PAs to prescribe and manage chemotherapy/systematic therapy in many settings. Oncology APPs already participate in prescribing and treatment management, and some centers even grant independent chemotherapy prescribing privileges, and i think you can get NP degree from online course or from watching YouTube videos.

 

[thesauce]

Radiation oncologists complete 5 years of dedicated oncology training, yet they don't prescribe even immunotherapy!! when the same system already allows oncology NPs and PAs to prescribe and manage chemotherapy/systematic therapy in many settings. Oncology APPs already participate in prescribing and treatment management, and some centers even grant independent chemotherapy prescribing privileges, and i think you can get NP degree from online course or from watching YouTube videos.

They can and some do. More of us should. The main reason most don’t is concern about angering referrings.

 

[Bequerel]

I’ve been preaching this for years! What about gynoncs who trained with carbo/taxol for a month or 2 and now prescribe immunotherapy and then there’s the neurologist who did some bs fellowship and are now neuro-oncologists and prescribe systemic therapy and dermatologists prescribe erivedge. We should absolutely make it a part of our training and use it. Why do we worry about referring physicians so much? We are such a timid field and it drives me nuts!

 

[medgator]

Could easily do this in cutaneous scc BCC

 

[Beerus]

I’ve been preaching this for years! What about gynoncs who trained with carbo/taxol for a month or 2 and now prescribe immunotherapy and then there’s the neurologist who did some bs fellowship and are now neuro-oncologists and prescribe systemic therapy and dermatologists prescribe erivedge. We should absolutely make it a part of our training and use it. Why do we worry about referring physicians so much? We are such a timid field and it drives me nuts!

I cringe every time I hear a neurologist call himself a neuro-oncologist. It is probably one of the most unnecessary fellowships and often one of the least valuable additions to the MDT. At least GynOnc surgeons are already directly involved in cancer treatment and surgery, so they are part of the game from the start. In CNS, I honestly think neurosurgery and radiation oncology cover the core of meaningful oncologic management. A lot of the added structure around neuro-oncology is overstated, and the systemic therapy used in that setting could absolutely be managed by radiation oncologists.

 

[medgator]

I cringe every time I hear a neurologist call himself a neuro-oncologist. It is probably one of the most unnecessary fellowships and often one of the least valuable additions to the MDT. At least GynOnc surgeons are already directly involved in cancer treatment and surgery, so they are part of the game from the start. In CNS, I honestly think neurosurgery and radiation oncology cover the core of meaningful oncologic management. A lot of the added structure around neuro-oncology is overstated, and the systemic therapy used in that setting could absolutely be managed by radiation oncologists.

Or standard med onc

 

[xrt123]

I agree. We are doing 500+ infusions of Radiopharm per year in our practice, managing ASEs which is basically chemo with an added danger due to radiation safety. Our practice is Med Onc and Rad Onc but when they complain of their workload I remind them I am happy to write an Rx for Temodar or immunotherapy.

 

[CaesarRO]

I agree. We are doing 500+ infusions of Radiopharm per year in our practice, managing ASEs which is basically chemo with an added danger due to radiation safety. Our practice is Med Onc and Rad Onc but when they complain of their workload I remind them I am happy to write an Rx for Temodar or immunotherapy.

Do they ever say yes?


Edited to Add: also, that does seem fairly high volume. Is your group getting anything other than the pro fees/RVUs for this service?

 

[Beerus]

I agree. We are doing 500+ infusions of Radiopharm per year in our practice, managing ASEs which is basically chemo with an added danger due to radiation safety. Our practice is Med Onc and Rad Onc but when they complain of their workload I remind them I am happy to write an Rx for Temodar or immunotherapy.

We also do radiopharma, although our volume is a bit lower than yours. Out of curiosity, within your practice, what proportion of cases are Pluvicto and Lutathera? We are already offering Pluvicto and other radiopharmaceutical agents, and we are planning to start Lutathera soon.

 

[OTN]

I cringe every time I hear a neurologist call himself a neuro-oncologist. It is probably one of the most unnecessary fellowships and often one of the least valuable additions to the MDT. At least GynOnc surgeons are already directly involved in cancer treatment and surgery, so they are part of the game from the start. In CNS, I honestly think neurosurgery and radiation oncology cover the core of meaningful oncologic management. A lot of the added structure around neuro-oncology is overstated, and the systemic therapy used in that setting could absolutely be managed by radiation oncologists.

Someone has to manage GBM patients after surgery and adjuvant radiation, and I for one am very happy there are specialists who exist who are willing to do so. I'm only speaking for myself here, but I am very, very happy they are willing to take on that very difficult task.

 

[drowsy12]

Someone has to manage GBM patients after surgery and adjuvant radiation, and I for one am very happy there are specialists who exist who are willing to do so. I'm only speaking for myself here, but I am very, very happy they are willing to take on that very difficult task.

im with you.

way too busy to want to spend lots of time on this

 

[TheWallnerus]

Radiation oncologists complete 5 years of dedicated oncology training,

Well it’s not 5

And it’s sure not 5 if Holman 👨🏼‍🔬

 

[MifflinDunder]

Do you really want to?

I’m a fellow. The rad onc PA added me to a chat today within 30 seconds of the hospitalist mentioning the words “clarify goals of care”. If you start prescribing cancer drugs, that will be you. You’re also making your inbox available for q3 weeks labs, and answering whether or not their toe pain is due to Keytruda.

 

[OTN]

Having to deal with labs is reason enough I'm glad I don't give systemic therapy

 

[metallica81788]

Having to deal with labs is reason enough I'm glad I don't give systemic therapy

Main reason why I don't want to do Pluvicto. There's enough garbage to deal with external beam only patients.

 

[GapCalc]

Main reason why I don't want to do Pluvicto. There's enough garbage to deal with external beam only patients.

Guys it’s not hard. Don’t cede this space to Nuc Med. We will never get it back.

 

[CaesarRO]

Guys it’s not hard. Don’t cede this space to Nuc Med. We will never get it back.

On the one hand I 100% agree with this... On the other hand, the pro reimbursement is such garbage relative to the hospital benefit

 

[medgator]

On the one hand I 100% agree with this... On the other hand, the pro reimbursement is such garbage relative to the hospital benefit

💯

Some places will subsidize to make it juicier.

 

[Neuronix]

Guys it’s not hard. Don’t cede this space to Nuc Med. We will never get it back.

110% Agree.

I heard a rumor that the nuc med guys at a big name cancer center are getting paid loads of money to give radiopharm now. There's a private group in my area focused on radiopharm that seems to be doing quite well. Why does our specialty want to destroy itself by not jumping on emerging trends?

 

[WildRivers]

The PSA and freestanding guys need to arrange for a fee for each injection. There are people doing this and it makes everyone happy - hospital gets a bunch of money from drug and the authorized user is compensated for time/expertise. Pro fees are simply not enough to make it work. Some of the private groups can get research money from the bridging companies, but otherwise a fee is the way to go. I am not sure what other way this can work and we can have some skin in the game.

 

[Neuronix]

The PSA and freestanding guys need to arrange for a fee for each injection. There are people doing this and it makes everyone happy - hospital gets a bunch of money from drug and the authorized user is compensated for time/expertise. Pro fees are simply not enough to make it work. Some of the private groups can get research money from the bridging companies, but otherwise a fee is the way to go. I am not sure what other way this can work and we can have some skin in the game.

I'm going to argue with a strawman here (i.e. not you) because I have heard repeatedly from rad onc chairs about pro fee reimbursement not being worth it to give radiopharm.

Are the med onc revenues based entirely on their pro fees? Of course not.

Using a different model for systemic therapy infusions is a no brainer for everyone involved because there is already a model for it. Rather than figure this out, we just give it away and shoot ourselves in the foot long term. This is among the stupidest things I've seen our specialty doing.

 

[drowsy12]

I'm going to argue with a strawman here (i.e. not you) because I have heard repeatedly from rad onc chairs about pro fee reimbursement not being worth it to give radiopharm.

Are the med onc revenues based entirely on their pro fees? Of course not.

Using a different model for systemic therapy infusions is a no brainer for everyone involved because there is already a model for it. Rather than figure this out, we just give it away and shoot ourselves in the foot long term. This is among the stupidest things I've seen our specialty doing.

To be less dramatic about this - this is easier said than done, clearly.

Most other specialties including med onc and all our surgical colleagues in hospital based settings have long been paid independently of pro fees. Rad onc has largely been different. Many people have pro fees based contracts. That doesn’t change overnight.

When you say ‘the field’ what you mean in part are indivdual LLC groups negotiating with hospitals. Not a monolith

 

[metallica81788]

I was told Pluvicto could be done at my site and I signed off on it
However that was >6mo ago and the hospital will need to make a contract with the cancer center which will need to make a contract with me and my group for what it's going to charge/pay etc...
No way I will do it just for wRVU charges - there needs to be a fee per injection
New meds will be out by the time the red tape is sorted

 

[TheWallnerus]

heard a rumor that the nuc med guys at a big name cancer center are getting paid loads of money to give radiopharm now.

To be less dramatic about this - this is easier said than done, clearly.

No way I will do it just for wRVU charges - there needs to be a fee per injection

Alright. Well. The next obvious question is why the centers aren’t paying rad oncs to deliver EBRT, especially if we were to say “no way I will deliver EBRT just for wRVUs.” Of course many have tried this and many have failed. You guys optimistic admin will capitulate on injected radiation and “give us some technical”? They often find creative ways to say this sort of thing is not legal (kicking in the back etc).

 

[Neuronix]

Alright. Well. The next obvious question is why the centers aren’t paying rad oncs to deliver EBRT, especially if we were to say “no way I will deliver EBRT just for wRVUs.” Of course many have tried this and many have failed. You guys optimistic admin will capitulate on injected radiation and “give us some technical”? They often find creative ways to say this sort of thing is not legal (kicking in the back etc).

They give it to med onc and nuc med, so why not us? We can essentially function as med onc and nuc med in this regard rather than having two physicians and departments involved.

 

[TheWallnerus]

They give it to med onc and nuc med, so why not us

Give us what… revenue beyond our professional? The problem I see is that historically hospitals and centers HAVE NOT done this in rad onc. Now we are asking them to; I won’t be surprised to see their prior demurrings brought into the present. But go for it! We miss 100 percent of the shots we never take. These days when you ask for huge loads of money people just generally give it. I am applying for a 5 million dollar per year grant to study the gender preferences of the arctic tern.

 

[medgator]

Give us what… revenue beyond our professional? The problem I see is that historically hospitals and centers HAVE NOT done this in rad onc. Now we are asking them to; I won’t be surprised to see their prior demurrings brought into the present. But go for it! We miss 100 percent of the shots we never take. These days when you ask for huge loads of money people just generally give it. I am applying for a 5 million dollar per year grant to study the gender preferences of the arctic tern.

Some of the rvu employment contracts do just that

 

[WildRivers]

So, anyway, yes it is happening this can be arranged it can be mutually beneficial. I know personally of someone that has arranged this. I think $1k a pop. It's worth asking. Or perhaps some sort of stipend/directorship. If they don't want to play ball, let them hire someone to do it. But, often times the private doc can bring many cases.

 

[TheWallnerus]

Some of the rvu employment contracts do just that

Indirectly and ostensibly they do it … because Medicare pays about 35 per RVU so any pay per RVU above that cuts into technical … but outright saying getting a cut of the technical? Not seen that in hospitals. Of course in private practice getting a percent of the global is common.

 

[TheWallnerus]

So, anyway, yes it is happening this can be arranged it can be mutually beneficial. I know personally of someone that has arranged this. I think $1k a pop. It's worth asking. Or perhaps some sort of stipend/directorship. If they don't want to play ball, let them hire someone to do it. But, often times the private doc can bring many cases.

How is getting paid a thousand per injection not violating Stark/anti kickback. I mean on its face the hospital and the MD are both getting incentivized based on volume and value of referrals.

 

[medgator]

How is getting paid a thousand per injection not violating Stark/anti kickback. I mean on its face the hospital and the MD are both getting incentivized based on volume and value of referrals.

Not sure. But I've seen it in contracts 🤷🏾

You're getting paid for work activity not for referrals

 

[TheWallnerus]

You're getting paid for work activity not for referrals

 

[medgator]

its clear as crystal to me

Someone refers pluvicto/Lutathera/Xofigo to you just like any beam case. You aren't generating your own referral, even more so with RIT IMO. At least with EBRT, we see pts back in f/u and sometimes recommend additional EBRT courses of Tx.

 

[drowsy12]

its clear as crystal to me

Someone refers pluvicto/Lutathera/Xofigo to you just like any beam case. You aren't generating your own referral, even more so with RIT IMO. At least with EBRT, we see pts back in f/u and sometimes recommend additional EBRT courses of Tx.

Yeah. I don’t see the confusion

 

[thecarbonionangle]

Do you really want to?

I’m a fellow. The rad onc PA added me to a chat today within 30 seconds of the hospitalist mentioning the words “clarify goals of care”. If you start prescribing cancer drugs, that will be you. You’re also making your inbox available for q3 weeks labs, and answering whether or not their toe pain is due to Keytruda.

We deal with the toe pain that started first day of radiation and patient is absolutely convinced it is that

 

[thecarbonionangle]

110% Agree.

I heard a rumor that the nuc med guys at a big name cancer center are getting paid loads of money to give radiopharm now. There's a private group in my area focused on radiopharm that seems to be doing quite well. Why does our specialty want to destroy itself by not jumping on emerging trends?

Turtle mentality, of which our field is replete.

 

[thecarbonionangle]

I'm going to argue with a strawman here (i.e. not you) because I have heard repeatedly from rad onc chairs about pro fee reimbursement not being worth it to give radiopharm.

Are the med onc revenues based entirely on their pro fees? Of course not.

Using a different model for systemic therapy infusions is a no brainer for everyone involved because there is already a model for it. Rather than figure this out, we just give it away and shoot ourselves in the foot long term. This is among the stupidest things I've seen our specialty doing.

Theres academic depts that gave it up already because basically nobody wanted to learn it and they didnt want to deal with labs, etc. Never getting it back.

 

[Neuronix]

Hi everyone, please keep details of revenues, contracts, etc in the business forum. I moved several posts from this thread regarding radiopharm. If you need access and are a current resident or attending, please PM me. Thanks

 

[JustAdocInBox]

In my area there are urologists that will give adjuvant Keytruda for renal cancer. Not many but I'm sure in time will see more. Radiopharm is a no-brainer for our specialty. Radiopharm will continue to grow with more indications and more patients. Right now radiology is so short staffed. Most of our radiologists are remote and the IR docs we have are too busy to bother with radiopharm.

 

[OTN]

Oh urologists in my city give Keytruda, concurrent cisplatinum with RT for bladder ca, try to advertise that they not medonc should be taking care of metastatic prostate cancer patients, etc, etc. It's actually impressive.

Radiopharm is 100% in our wheelhouse, we should absolutely own the space, and each and every department should forcefully argue for this. Makes zero sense to pass along to any other specialty. I would hope ASTRO would take a very strong stance on this, but I'm not expecting them to.

 

[radoncftw]

Oh urologists in my city give Keytruda, concurrent cisplatinum with RT for bladder ca, try to advertise that they not medonc should be taking care of metastatic prostate cancer patients, etc, etc. It's actually impressive.

Radiopharm is 100% in our wheelhouse, we should absolutely own the space, and each and every department should forcefully argue for this. Makes zero sense to pass along to any other specialty. I would hope ASTRO would take a very strong stance on this, but I'm not expecting them to.

the main uro onc in our hospital 100% knows more about systemic therapy in the GU space than the med oncs.

 

[medgator]

Home

www.lugpa.org

Urologists have been smarter than rad oncs for decades... They won the urorads war, rightly so

And they are just as savvy as med oncs when it comes to owning not only Linacs, but imaging, dispensing oral pharmacy etc