ASTRO Town Hall Discussion (Poll % on site)

[NotMattSpraker]

Radon! More people die just from radon causing lung cancer (independent of tobacco) than the total number of gastric cancer deaths.

Doesn’t explain young folks getting cancer but, depending on where you live and your lifestyle, having your basement inspected for radon is probably the most important way to mitigate risk of dying from cancer.

Really interesting way to frame it, never thought about it that way.

I have a good continuous monitor that was $150.

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[evilbooyaa]

Workforce growing at 4.1% per year. Job openings growing at 4.2% per year. That was the headline I took from it. I'm not a numbers guy, but seems like supply is growing with demand?

If you take 2 jobs that pay $750k a year and split them into 5 jobs that pay $300k a year, you'd have an increase in job openings as well. Not saying it's that dramatic of a shift just in this small time frame, but the number of people making 7 figures in Rad Onc is (likely) less now than it was 20 years ago.

 

[RickyScott]

If you take 2 jobs that pay $750k a year and split them into 5 jobs that pay $300k a year, you'd have an increase in job openings as well. Not saying it's that dramatic of a shift just in this small time frame, but the number of people making 7 figures in Rad Onc is (likely) less now than it was 20 years ago.

That’s really the academic model.

 

[drowsy12]

That’s really the academic model.

This sort of misses the point in my view. It’s not the academic model. It’s the corporate model. There are fewer small business jobs more employed jobs. People making 7 figures routinely in the past were not W2.

 

[RickyScott]

This sort of misses the point in my view. It’s not the academic model. It’s the corporate model. There are fewer small business jobs more employed jobs. People making 7 figures routinely in the past were not W2.

"corporate" , "academic" "nonprofit" are largely the same for our specialty.
Department chairs are essentially middle managers.

 

[pikachu]

If you take 2 jobs that pay $750k a year and split them into 5 jobs that pay $300k a year, you'd have an increase in job openings as well. Not saying it's that dramatic of a shift just in this small time frame, but the number of people making 7 figures in Rad Onc is (likely) less now than it was 20 years ago.

Where though is the corporate interest in paying additional insurance/benefits for each of these additional employees? That runs 100k+ per year. It seems like it would be cheaper to pay fewer people to treat an equal number of patients, but perhaps I am missing something.

 

[BobbyHeenan]

Where though is the corporate interest in paying additional insurance/benefits for each of these additional employees? That runs 100k+ per year. It seems like it would be cheaper to pay fewer people to treat an equal number of patients, but perhaps I am missing something.

That is an extreme example (going from 2 jobs to 5) but make no mistake, in all my interactions with hospital/health care admins...they are willing to eat more admin/benefits/insurance cost in order to avoid a "power dynamic" of having one or two very busy docs instead of having 2-4 moderately busy ones.

I don't know for sure but I think they're being trained to play it this way. I suspect it stems more from the (elective) surgical/procedural side of things where a high volume doc can take their ball to another competitor and massively impact things if they leave. It may also stem from admins (incorrectly) applying other surgical/elective case principals to rad onc where they think fi they hire more rad oncs they will see higher volumes or additional service lines.

But the principles above are being applied to employed rad onc clinics (or even pressure applied in PSA's for groups to hire more docs) in my experience.

* If I remember correctly, there was a poster on here maybe about a year ago that was a busy employed solo doc and seemingly happy and his hospital was basically forcing a partner on him. These things happen.

 

[Chartreuse Wombat]

Where though is the corporate interest in paying additional insurance/benefits for each of these additional employees? That runs 100k+ per year. It seems like it would be cheaper to pay fewer people to treat an equal number of patients, but perhaps I am missing something.

Can these benefits can be written off?

 

[wandering star]

Can these benefits can be written off?

Benefits and salaries are both equally "written off." If a business makes $100M in revenue and spend $90M in salaries/benefits, then their profit that they are taxed on is $10M. It doesn't matter if it's in salaries or benefits. The law is complex and there are exceptions (in the news recently, you can "buy" a green card by creating American jobs ... that would incentivize splitting an 80 hr/wk job into two 40 hr/wk jobs, unless Trump gets his gold card idea passed), but this is the general rule.

The structure of the benefits matters too. Something like a 5% retirement match, doesn't matter if you pay one person 800k or two people 400k. Payroll taxes do matter some because of the weird cliff in the system, where earnings above 170k are exempt from some of these taxes. Overhead can matter if you need to get a second office.

There may be something to the "power dynamic" story, but having someone work 80 hrs/wk to earn double the wages could be bad for safety also, perhaps more in a procedural setting than in rad onc.

 

[RickyScott]

Benefits and salaries are both equally "written off." If a business makes $100M in revenue and spend $90M in salaries/benefits, then their profit that they are taxed on is $10M. It doesn't matter if it's in salaries or benefits. The law is complex and there are exceptions (in the news recently, you can "buy" a green card by creating American jobs ... that would incentivize an 80 hr/wk job into two 40 hr/wk jobs, unless Trump gets his gold card idea passed), but this is the general rule.

The structure of the benefits matters too. Something like a 5% retirement match, doesn't matter if you pay one person 800k or two people 400k. Payroll taxes do matter some because of the weird cliff in the system, where earnings above 170k are exempt from some of these taxes. Overhead can matter if you need to get a second office.

There may be something to the "power dynamic" story, but having someone work 80 hrs/wk to earn double the wages could be bad for safety also, perhaps more in a procedural setting than in rad onc.

I have had some very large pt loads, and almost never have worked an 80 hr week. Most docs at academic centers now see 3-5 new pts a week (5 new pts week is more than avg) per acr but 8-10 new mixed pts/week is very doable in 40-50 hrs. My first chairman explicity told me he likes to overhire because docs “somehow”find more pts to treat.

 

[wandering star]

I have had some very large pt loads, and almost never have worked an 80 hr week. Most docs at academic centers now see 3-5 new pts a week (5 new pts week is more than avg) per acr but 8-10 new mixed pts/week is very doable in 40-50 hrs. My first chairman explicity told me he likes to overhire because docs “somehow”find more pts to treat.

Yeah, a lot depends on how efficient you are. Your post brings to mind two competing definitions of efficiency: personal efficiency (hours/RVU), and societal efficiency (the rising costs of healthcare).

A healthcare economist once told me that whenever a healthcare system has excess capacity, it somehow gets consumed. Hospital has extra beds? It disappears after a few years. So I agree that your chairman's view is correct, but I'm not sure if it's a bug or a feature. Probably a feature for the department, a bug for American healthcare overall.

 

[RickyScott]

Yeah, a lot depends on how efficient you are. Your post brings to mind two competing definitions of efficiency: personal efficiency (hours/RVU), and societal efficiency (the rising costs of healthcare).

A healthcare economist once told me that whenever a healthcare system has excess capacity, it somehow gets consumed. Hospital has extra beds? It disappears after a few years. So I agree that your chairman's view is correct, but I'm not sure if it's a bug or a feature. Probably a feature for the department, a bug for American healthcare overall.

The healthcare Economist is right abt the elasticity for just about everything in health care but radonc. Medonc and primary care can always see another pt if they open a new time slot. That is not the case with us. I average abt 6-7 new pts a week and could easily see more, but that’s what the system gives me. Many days, I leave at 3 and am not that busy during working hrs. (I am 100% clinical).

 

[evilbooyaa]

Where though is the corporate interest in paying additional insurance/benefits for each of these additional employees? That runs 100k+ per year. It seems like it would be cheaper to pay fewer people to treat an equal number of patients, but perhaps I am missing something.

The ability to not have to worry about vacation coverage and having continuity in the clinic, the ability to not have a doc get 'too big for their britches' and think they are more important than the employing institution, the ability to steal more from the employees who aren't paying attention to the work they're doing, as it slowly increases back up to pre-job split levels, etc. etc.

 

[NotMattSpraker]

Simul posted 20 questions for the ASTRO town hall on his blog. Thought The Board might be interested.

BONUS: 20 Questions For the ASTRO ROCR Town Hall

Just in case you hadn't thought of any, I'm here to help!

radiationeconomics.substack.com

I liked this question a lot:

Given the potential for consolidation of practices under a bundled payment system, what protections or incentives exist within ROCR to maintain diversity and prevent monopolization by large hospital networks?

 

[RickyScott]

Simul posted 20 questions for the ASTRO town hall on his blog. Thought The Board might be interested.

BONUS: 20 Questions For the ASTRO ROCR Town Hall

Just in case you hadn't thought of any, I'm here to help!

radiationeconomics.substack.com

I liked this question a lot:

Given the potential for consolidation of practices under a bundled payment system, what protections or incentives exist within ROCR to maintain diversity and prevent monopolization by large hospital networks?

ROCR does not affect negotiated prices between hospitals and insurance companies, which is the primary driver of consolidation. Sameer completely ignores this and will continue to gaslight. Whatever prices/bundles ROCR sets, MSKCC and UPENN will still charge some insurers 10x that amount. Even if ROCR were to equalize CMS payments between freestanding and hospital settings, this would have almost no effect on consolidation.

 

[NotMattSpraker]

ROCR does not affect negotiated prices between hospitals and insurance companies, which is the primary driver of consolidation. Sameer completely ignores this and will continue to gaslight. Whatever prices/bundles ROCR sets, MSKCC and UPENN will still charge some insurers 10x that amount. Even if ROCR were to equalize CMS payments between freestanding and hospital settings, this would have almost no effect on consolidation.

I genuinely do not know if it is gaslighting or lack of knowledge/false assumptions.

 

[OTN]

I genuinely do not know if it is gaslighting or lack of knowledge/false assumptions.

Oh it's for sure gaslighting. He's a Mayo clinic doc, come on now. They're Patient Zero for M.D. Stockholm Syndrome.

 

[communitydoc13]

They're Patient Zero for M.D. Stockholm Syndrome.

Not a fan of ROCR (mostly due to proton carveout). But, I know several Mayo docs (not radoncs) who love it there. They love the mission and infrastructure. They like the organizational model.

Contributions to Medicine | Mayo Clinic History & Heritage

During the Mayo Clinic Sesquicentennial,150 milestones in medical practice, education and research were compiled as Mayo’s contributions to medicine in the past 150 years.

history.mayoclinic.org

Not everyone is out to make as much money as possible. This mindset is part of the reason that civil servants are presently vilified. I'm amazed at how many private sector folks imagine that second rate people must be occupying public jobs or academic jobs or any space (other non-profits) where income is not the chief motivator.

Lots of docs also like working for Kaiser.

The risk to the institutionalist is that they will at times support or parrot their institutions amoral stance. It is not the sublimation of their own personal desires to the collective goals of the institution...that can actually be kinda noble.

 

[NotMattSpraker]

Not a fan of ROCR (mostly due to proton carveout). But, I know several Mayo docs (not radoncs) who love it there. They love the mission and infrastructure. They like the organizational model.

Contributions to Medicine | Mayo Clinic History & Heritage

During the Mayo Clinic Sesquicentennial,150 milestones in medical practice, education and research were compiled as Mayo’s contributions to medicine in the past 150 years.

history.mayoclinic.org

Not everyone is out to make as much money as possible. This mindset is part of the reason that civil servants are presently vilified. I'm amazed at how many private sector folks imagine that second rate people must be occupying public jobs or academic jobs or any space (other non-profits) where income is not the chief motivator.

Lots of docs also like working for Kaiser.

The risk to the institutionalist is that they will at times support or parrot their institutions amoral stance. It is not the sublimation of their own personal desires to the collective goals of the institution...that can actually be kinda noble.

For what it's worth, I dont think Sameer is gas lighting intentionally, he is just parroting talking points he hears from people directly negotiating ROCR.

He is also not out there lobbying for "Mayo Rad Onc", which isn't a single entity anyways.

 

[medgator]

For what it's worth, I dont think Sameer is gas lighting intentionally, he is just parroting talking points he hears from people directly negotiating ROCR.

He is also not out there lobbying for "Mayo Rad Onc", which isn't a single entity anyways.

He led ASTRO PAC over a decade ago when they were trying to kill urorads and even rad onc ownership of linacs by petitioning CMS to get rid of the IOAE (in office ancillary exemption) for linac ownership. That would screw all physicians over equally and allow only non physician entities to own linacs.

The guy claims to have PP cred but worked for a pro group and was either ignorant or willfully complicit in said ridiculousity.

I'm going to go with unconsciously incompetent with maybe a little Upton Sinclair thrown in, personally

 

[RickyScott]

By carving out protons, rocr is actually accelerating consolidation. Other practices that can feed proton centers intstanly are more valuable to the proton centers than their present owners.

 

[thesauce]

Not a fan of ROCR (mostly due to proton carveout). But, I know several Mayo docs (not radoncs) who love it there. They love the mission and infrastructure. They like the organizational model.

Contributions to Medicine | Mayo Clinic History & Heritage

During the Mayo Clinic Sesquicentennial,150 milestones in medical practice, education and research were compiled as Mayo’s contributions to medicine in the past 150 years.

history.mayoclinic.org

Not everyone is out to make as much money as possible. This mindset is part of the reason that civil servants are presently vilified. I'm amazed at how many private sector folks imagine that second rate people must be occupying public jobs or academic jobs or any space (other non-profits) where income is not the chief motivator.

Lots of docs also like working for Kaiser.

The risk to the institutionalist is that they will at times support or parrot their institutions amoral stance. It is not the sublimation of their own personal desires to the collective goals of the institution...that can actually be kinda noble.

The problem is that they don’t understand that the hospital will never love them back and they can’t see how much they are being taken advantage of. Things like a cap are nothing more than exploitation.

 

[fiji128]

By carving out protons, rocr is actually accelerating consolidation. Other practices that can feed proton centers intstanly are more valuable to the proton centers than their present owners.

Astro going to astro

 

[OTN]

Not a fan of ROCR (mostly due to proton carveout). But, I know several Mayo docs (not radoncs) who love it there. They love the mission and infrastructure. They like the organizational model.

Contributions to Medicine | Mayo Clinic History & Heritage

During the Mayo Clinic Sesquicentennial,150 milestones in medical practice, education and research were compiled as Mayo’s contributions to medicine in the past 150 years.

history.mayoclinic.org

Not everyone is out to make as much money as possible. This mindset is part of the reason that civil servants are presently vilified. I'm amazed at how many private sector folks imagine that second rate people must be occupying public jobs or academic jobs or any space (other non-profits) where income is not the chief motivator.

Lots of docs also like working for Kaiser.

The risk to the institutionalist is that they will at times support or parrot their institutions amoral stance. It is not the sublimation of their own personal desires to the collective goals of the institution...that can actually be kinda noble.

You can be assured Mayo is out to make as much money as possible.

 

[communitydoc13]

You can be assured Mayo is out to make as much money as possible.

There is no doubt.

But this is a very tough question to answer....what is the right level of consolidation? What is the ideal distribution of health care practices in terms of size?

I have argued that academia in general should be focused on academic things....research and teaching, exceptional clinical cases and perhaps global health issues where reasonable market forces do not exist.

Academics of all flavors should be aware that they are working for corporate entities. This doesn't mean that they themselves cannot practice academic values.

 

[evilbooyaa]

He led ASTRO PAC over a decade ago when they were trying to kill urorads and even rad onc ownership of linacs by petitioning CMS to get rid of the IOAE (in office ancillary exemption) for linac ownership. That would screw all physicians over equally and allow only non physician entities to own linacs.

The guy claims to have PP cred but worked for a pro group and was either ignorant or willfully complicit in said ridiculousity.

I'm going to go with unconsciously incompetent with maybe a little Upton Sinclair thrown in, personally

I don't know how long ago he was part of PP but he holds onto it like he hasn' tworked for an academic monolith for.... a while? At least 5 years? 10 years?