First off, thank you to everyone who put effort into this study. This should be the baseline, assessing our need so we don't misappropriate human capital.
Below is a not so quick recap and collection of thoughts.
Premise: Study the supply and demand by modelling 'supply' as defined as calculating # of current Rad Oncs and 'demand' by the number of Medicare beneficiaries and wRVU per (ie the quantification of billing efforts but NOT any billing of technical components),
General critiques (many by smarter people than myself and also many acknowledged in the HMA report or Red Journal paper)
1. They had a hard time quantifying the baseline number of practicing Rad Oncs - they state this as such in the paper. The discrepancy between their estimate and an estimate based on NPI/and the CMS Virtual Data Center (VRDC) was large - the study estimated 4700 as a starting point, NPI/VRDC suggests 5600.
2. Related to the above - they estimate the 'entrance' date and 'exit' date of radiation oncologists, which both could distort the current number of providers, but also obviously impacts future projections. They acknowledge specifically the 'exit' date source of error though also report only if 25% difference from their estimates (which they define as 'extreme' scenario) would error in this variable be meaningful to the model.
3. They only use wRVU and not technical RVU in modeling the impact of hypofractionation and loss of indications. Which means in terms of the effect of hypofractionation, they do not capture the actual loss of revenue a practice experiences. This is unfortunate because that revenue is needed to support a functioning linac and thus it is plausible that hypofractionation will have a large impact on 'demand' because it results in financially unviable low volume single linac sites (hint - rural) which may simply close. This is also a valid criticism because it is not a 'bi-directional' variable - ie guessing exits could go either way, but hypofractionation is less fractions, period. It can only negatively impact technical RVU. The error is only in the magnitude of revenue loss, it never swings to gain.
4. The projection they use for the increase in Medicare Beneficiaries is greater than that estimate by the Congressional Budget Office. This is noted in the discussion and becomes another one-way variable. I do not understand why.
5. There is no accounting for the impact of the APM, which decreases demand. No foul here, can't model something not currently existing. But APM is not dead, and APMs primary function is to decrease demand (especially measured by wRVU).
The strength of the study is that the model, in so much as possible, tries to account for differences in uptake of hypofractionation, loss of indications, wRVU per physician, and does provide different scenarios and has an ability to input some scenarios. This absolutely increases its utility and the ability to understand how many uncertainties exist.
Their conclusions:
In a 'simple model' only going from 2025 to 2030, we could be in a 'relatively balanced' scenario, but accounting for the variables they acknowledge, not the ones noted above, there could be a shortage of 900 Rad Oncs, or an excess of 1300 Rad oncs over 7 years.
That is crazy, and models are models, but from now to 2030 we could either be in balance or the entire residency classes of 2023, 2024, 2025, 2026, & 2027 are uneeded.
The biggest conclusion was slipped into the main HMA report, but better noted in the Red Journal paper. The biggest driver of 'demand' in their paper was growth in Medicare Beneficiary and from 2030 on, Medicare Beneficiary numbers slow dramatically. Unless we start allowing preferential immigration of a geriatric population, this is a demographic certainty no matter what. And they made this very clear in Figure 5 of the report, look at that trend line 🙂 From the Red Journal paper (not HMA report)
" As such, potential reductions in trainee positions are likely needed as soon as 2025, given the declining growth in Medicare beneficiaries by 2030."
My Conclusions
1. Grass roots / direct communication / reality still matters. I am so grateful to everyone who read any one of my sophomoric posts, and I enjoyed reading yours. The strain of the job market and the declining condition of this field is evident to many of us, and the advocacy from this social media starting point got us to this and hopefully has steered some human capital to more needed endeavors.
2. Thank you to the small number of insiders who used their voice in non-anonymity to help get this done.
3. The best-case scenario for an ASTRO-sponsored (should we say cajoled?) outside report is maybe we are OK until we fall off the cliff soon. A medical student applying today, for this match, has his/her most likely projection of being excess supply after 1 year of practice based on this report. Let that sink in. The people applying to this match will be excess supply 1 year after practice. Or in the model 'best case', they would be excess supply after 4 years of practice. What a career! In a the model worst case, the last 7 graduating resident classes are educated in a specialized medical field that society doesn't need them for.
In my opinion point 3 is why this is not generating any buzz among Big Rad Onc. I am not Big Rad Onc, I am not even worthy enough to contour a bladder for them. But I try and stay friendly with people, and no one wants to talk about it. The 'best' case scenario of this report, with all it's valid criticisms, is that excess capacity doesn't occur until 2034 (using the best case for over supply). The worst says we already have an oversupply now several years in the making with many current residents essentially not needed, and no matter what says from 2030 on demand growth is falling so far off due to demographic certainties that we are certain to be in massive oversupply going forward after the equally massive residency expansion that just occurred.
Will it change anything? I hope so. Every single applicant, domestic, international, first time, SOAP, out of the match, any ethnicities and/or genders, etc. can and should receive and read the HMA report and Red Journal response. Both are free. Every person who says 'Pfft those people online are such malcontents' can read through, put it down, read it again and conclude about their own future in this field. And that is a first step.
