Best sub-specialty for lifestyle?

[Prehealth1011]

Ik a GI doc where I work that doesn't see patients in clinic. It's either the NP or a resident if he has one. He scopes then goes home 1-2, and I'm assuming he clears 500k easily. Practicing poorly/unethically, GI is a great lifestyle and money specialty.

I've seen somethine similar in a heme-onc practice as well, with doc while in-house basically just signing off NP notes. The only difference I guess is that many of the patients insisted on being seen by the doc.

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[Splenda88]

I've seen somethine similar in a heme-onc practice as well, with doc while in-house basically just signing off NP notes. The only difference I guess is that many of the patients insisted on being seen by the doc.

I guess cancer is too serious... There is no BS like "my NP listens to me."

 

[Ubba]

Currently deciding between GI and oncology... my goal is to make over 1M a year and Fat FIRE as soon as possible. Would you recommend GI or oncology for this? Location does not matter, days/week does not matter, and honestly satisfaction with my work environment does not matter as this would be a temporary position as I work to build a sizable nest egg and pay off debt. My goal would to work as hard as possible, even if that includes 120 hr weeks.

It seems from these numbers and > $100/RVU for oncology vs ~$65-70/RVU in GI, oncology would theoretically have a better $/hr ratio. But what I don't understand is that, if an oncologist wanted to grind and become an RVU machine is that theoretically possible? Or are they limited by acillary staff/office hours, etc? What's stopping an oncologist from working 6am - 10pm in the clinic 7 days a week, seeing 60-70 patients a day to generate as many RVU via 99214.5 as possible? Are there oncologists that do this with the current $/RVU set up?

Won't work for Onc. It can take 15 minutes of going through EMR notes just to dig up a patient's tumor stage. GI handily wins here.

In truth, if you can work efficiently, general IM can be quite lucrative once you start thinking outside the box, but if someone who's trained in IM is dead-set against practicing general IM, there's a strong case to be made for training in PM&R instead of a fellowship. There are absolute boatloads to be made in rounding on these low-acuity patients both inpt and in SNFs. A hustler couldn't really ask for a better field in terms of malpractice risk and coding earning potential balance (derm is solid, but comes with the risk of missing melanomas and the like if you cut corners). And you could moonlight during training.

 

[Ubba]

Imagine cards got $500 each time they prescribed Brilinta, that’s essentially what’s happening with chemo.

The fact that this could be written by a physician means that Heme/Onc clearly needs to do a better job in helping other physicians understand what chemotherapy (and immunotherapy) risks entail. A more-apt analogy might be a combination of amiodarone and digoxin with toxicity an order of magnitude higher than those of the individual components.

 

[bronx43]

In truth, if you can work efficiently, general IM can be quite lucrative once you start thinking outside the box, but if someone who's trained in IM is dead-set against practicing general IM, there's a strong case to be made for training in PM&R instead of a fellowship. There are absolute boatloads to be made in rounding on these low-acuity patients both inpt and in SNFs. A hustler couldn't really ask for a better field in terms of malpractice risk and coding earning potential balance (derm is solid, but comes with the risk of missing melanomas and the like if you cut corners). And you could moonlight during training.

Why would you have to do pmr to round in SNFs? Most ppl doing that are IM and FM.

 

[bronx43]

The fact that this could be written by a physician means that Heme/Onc clearly needs to do a better job in helping other physicians understand what chemotherapy (and immunotherapy) risks entail. A more-apt comparison might be a combination of amiodarone and digoxin with toxicity an order of magnitude higher than those of the individual components.

Ok… sure but that’s not the point. We all know $ and risk do not go hand in hand in the logical world of medicine that we live in.
The point here is the presence or lack of a “soft kickback” for prescription of pharmacotherapy.

 

[Ubba]

Why would you have to do pmr to round in SNFs? Most ppl doing that are IM and FM.

Yes, but not as consultants. And also, IM and FM attendings in SNFs are technically responsible for catching that MI in the 86-year-old woman who's feeling a little nauseated this morning. PM&R has a very different role. I think there's an sdn member who wrote up his workflow a few years ago on the subject.

 

[Ubba]

Ok… sure but that’s not the point. We all know $ and risk do not go hand in hand in the logical world of medicine that we live in.
The point here is the presence or lack of a “soft kickback” for prescription of pharmacotherapy.

well, firstly, maybe the two ought to go hand-in-hand. I was certainly not implying that all is well in medicine just because Heme/Onc is remunerated for the risks attendant to chemo and immunotx administration.

Not all pharmacotherapies are equivalent. In an indirect way, an anesthesiologist is being compensated for prescribing and administering propofol, ketamine, pressors, etc. I mean, is that *technically* what is being reimbursed...? Maybe not. But it's really semantic, because we all know that part of the acuity and medical risk of anesthesiology is the administration of medications that are putting patients into respiratory arrest. Should (s)he be begrudged for that? I say no.

Essentially, while the administration of medications with such toxicities is not hands-on like a chole or a hemicraniectomy, in terms of morbidities, they are not dissimilar to procedures.

 

[bronx43]

well, firstly, maybe the two ought to go hand-in-hand. I was certainly not implying that all is well in medicine just because Heme/Onc is remunerated for the risks attendant to chemo and immunotx administration.

Not all pharmacotherapies are equivalent. In an indirect way, an anesthesiologist is being compensated for prescribing and administering propofol, ketamine, pressors, etc. I mean, is that *technically* what is being reimbursed...? Maybe not. But it's really semantic, because we all know that part of the acuity and medical risk of anesthesiology is the administration of medications that are putting patients into respiratory arrest. Should (s)he be begrudged for that? I say no.

Essentially, while the administration of medications with such toxicities are not hands-on like a chole or a hemicraniectomy, in terms of morbidities, they are not dissimilar to procedures.

Ought, could, should - unfortunately these are pointless statements and essentially removed from the real world of medicine. Maybe we all agree that a high risk medication or surgical procedure should be highly reimbursed, but the business of it is that it isn't. If it is, then there would have to be a very specific mathematical model for which reimbursement and statistical "risk" would be calculated and then paid out. Such a model would be rife with glaring confounding factors, but you get the point. Heck, if that were the case, I would see my pay increase from all the immunosuppressives I dish out.

Heme onc isn't remunerated for the risks attendant to chemo and immunotherapy administration. You may think that. But it's simply false.

Heme onc is remunerated by the exorbitant prices charged by pharmaceutical companies (Y) and the corresponding reimbursement paid out by government and private payers for the delivery of said product within healthcare facilities (X).
In other words, your (I assume you're heme onc?) pay is literally X - Y.
And the profits are high because X and Y are so mind bogglingly high. Furthermore, pharma does not price their product based on the risk it confers to patients.

If tomorrow laws were passed that slashed pharma drug pricing or negated large profit margins by buyers (in the buy and bill model), then heme onc income would crater. None of your risk would have changed, but the business of it would be drastically different.
On the other hand, if a miracle immunotherapy came out tomorrow that cured cancers with absolutely zero risk and the pharma charged the GDP of a small country for it, you guys would all be millionaires with a significant reduction in risk.

 

[Splenda88]

Yes, but not as consultants. And also, IM and FM attendings in SNFs are technically responsible for catching that MI in the 86-year-old woman who's feeling a little nauseated this morning. PM&R has a very different role. I think there's an sdn member who wrote up his workflow a few years ago on the subject.

Lol about FM/IM responsible to catch MI...

@sloh is a PM&R doc and I believe he rounds in SNF and makes a boatload of $$$ doing it.

 

[Ubba]

Ought, could, should - unfortunately these are pointless statements and essentially removed from the real world of medicine. Maybe we all agree that a high risk medication or surgical procedure should be highly reimbursed, but the business of it is that it isn't. If it is, then there would have to be a very specific mathematical model for which reimbursement and statistical "risk" would be calculated and then paid out. Such a model would be rife with glaring confounding factors, but you get the point. Heck, if that were the case, I would see my pay increase from all the immunosuppressives I dish out.

Heme onc isn't remunerated for the risks attendant to chemo and immunotherapy administration. You may think that. But it's simply false.

Heme onc is remunerated by the exorbitant prices charged by pharmaceutical companies (Y) and the corresponding reimbursement paid out by government and private payers for the delivery of said product within healthcare facilities (X).
In other words, your (I assume you're heme onc?) pay is literally X - Y.
And the profits are high because X and Y are so mind bogglingly high.

If tomorrow laws were passed that slashed pharma drug pricing or negated large profit margins by buyers (in the buy and bill model), then heme onc income would crater. None of your risk would have changed, but the business of it would be drastically different.
On the other hand, if a miracle immunotherapy came out tomorrow that cured cancers with absolutely zero risk and the pharma charged the GDP of a small country for it, you guys would all be millionaires with a significant reduction in risk.

You can call it a "useless" statement because it address a non-reality in terms of medicine as a whole, but then one could turn right around and say that the posts questioning infusion reimbursements are also useless. If we agree that higher risk should be compensated accordingly, then let's simply agree on that point and do what we can to expand that attitude. And yes, you should be reimbursed for the risk you take in giving immunosuppressives. Certainly those infused in-house, and maybe also the PO ones.

Please define "exorbitant." Are these ROI figures also exorbitant? New drug classes don't grow on trees. Pharma R&D return on investment at highest level in 8 years.

When those laws were passed, if the reimbursement model didn't quickly adjust to balance at least most of the deficit, Heme/Onc would temporarily crater in reimbursement, that's true. But if you want to know what would happen after that, take a look at the Rad Onc forum. Except it would be worse, because for them, the "sky is falling!" scenario is that they're now *only* being paid 500k. In Heme/Onc, you'd be really hard-pressed finding non-marginal grads investing 3 years of training and a career requiring many hours of reading a week just to stay above water knowledge-wise just to make, say, 200k for the privilege of destroying pts' immune systems.

If that miracle immunotx does come out, oncologists will be obsolete and PCPs will be able to manage cancer.

 

[Ubba]

Anyway, re: the point of the thread, the answer is clearly Allergy/Immunology You'll have to be a bit of a nerd for molecular-level science to enjoy its research, though

 

[PikminOC]

To be honest, this sounds like a terrible “strategy”. Where I did residency, there was a hospitalist/GIM guy who apparently hated being a doctor and was trying to do this “FIRE” stuff as soon as possible-so he took every single spare moonlighting shift he could possibly sign up for, as well as working in an outpatient clinic. It wasn’t clear when he actually slept. Regardless, whether it was from apathy, sleep dep or actual mental illness stimulated from this insane strategy, he was a terrible clinician and his overall affect and mannerisms deteriorated dramatically during the time I was there to the point that the state PHP was called on him by his colleagues because they thought he may have had schizophrenia.

So no. Don’t do this.

So he was abusing stimulants then.

 

[PikminOC]

This is really horrible practice. his practice should be reported and suspended

In psych, nps have their own practices with "collaborative" physicians over 60 miles away. And the collaboration doesn't have to be a psychiatrist.

 

[PikminOC]

GI is not a lifestyle specialty as most of us practice it. It can be I suppose. There are 50% time outpatient only practices out there.

My friend works gi academics. Has residents to do many things. It's a lifestyle field for him.

 

[bronx43]

You can call it a "useless" statement because it address a non-reality in terms of medicine as a whole, but then one could turn right around and say that the posts questioning infusion reimbursements are also useless. If we agree that higher risk should be compensated accordingly, then let's simply agree on that point and do what we can to expand that attitude. And yes, you should be reimbursed for the risk you take in giving immunosuppressives. Certainly those infused in-house, and maybe also the PO ones.

The point made in this thread is that oncologists (and some rheumatologists), due to the buy and bill model as well as the high prices of the drugs, are essentially given a "soft kick back" whereas other specialties don't. Your argument essentially is that due to the risk of chemotherapies and immunotherapies, profits generated by this model are morally justified. My response to this is that if we are going to use "risk" as a determinant for reimbursement, then it should be applied broadly and not solely on buy and bill. And it sounds like you actually agree with this sentiment.
And if you do, then I'm not sure what the point is of your response to CCM-MD in regards to getting money for Brilinta. Perhaps you disagree with the dollar amount? $500 is too much? How about a cardiologist pocketing $100?

Please define "exorbitant." Are these ROI figures also exorbitant? New drug classes don't grow on trees. Pharma R&D return on investment at highest level in 8 years.

By "exorbitant," I mean high. Don't read any moral statement into this adjective, as I didn't mean any.
Though, I'm not sure what the point of the link is. Increasing ROI would actually support some arguments for "exorbitant," especially when the article itself states falling R&D costs. In other words, the article says pharma is making more profit on less investment in R&D.

If that miracle immunotx does come out, oncologists will be obsolete and PCPs will be able to manage cancer.

Sure, but that wasn't my point. Whether oncologists or PCPs give the treatment is irrelevant. The point is risk then would be completely decoupled from reimbursement.

 

[Ubba]

The point made in this thread is that oncologists (and some rheumatologists), due to the buy and bill model as well as the high prices of the drugs, are essentially given a "soft kick back" whereas other specialties don't. Your argument essentially is that due to the risk of chemotherapies and immunotherapies, profits generated by this model are morally justified. My response to this is that if we are going to use "risk" as a determinant for reimbursement, then it should be applied broadly and not solely on buy and bill. And it sounds like you actually agree with this sentiment.
And if you do, then I'm not sure what the point is of your response to CCM-MD in regards to getting money for Brilinta. Perhaps you disagree with the dollar amount? $500 is too much? How about a cardiologist pocketing $100?


By "exorbitant," I mean high. Don't read any moral statement into this adjective, as I didn't mean any.
Though, I'm not sure what the point of the link is. Increasing ROI would actually support some arguments for "exorbitant," especially when the article itself states falling R&D costs. In other words, the article says pharma is making more profit on less investment in R&D.

Sure, but that wasn't my point. Whether oncologists or PCPs give the treatment is irrelevant. The point is risk then would be completely decoupled from reimbursement.

We do agree on that point. The reason I felt compelled to respond to that post is that (no offense to the poster) the likening of the buy-and-bill model for chemo to a hypothetical payback for simply rxing Brilinta is nonsensical. It also happens to fail on its face because oncs (and PCPs) prescribe antiplatelet agents and anticoagulants all the time without separate reimbursement. Maybe a rational delineation for these purposes would be between medications that require professional supervision for their administration vs those that can be quite reasonably taken easily at home with the proverbial "follow-up in 2 months, sooner if necessary."

Ignore the headline. To me, ROI of 6-7% doesn't sound obscene, but this is subjective. I was curious what you mean by "exorbitant", that's all. I'm far from a corporatist, but I also know that companies that produce useful items or services exist to generate profits, so carrots need to be dangled from time to time.

I'm quite sure that if the magical risk-free cure-all is developed, there will be no reimbursement schemes for the physicians who prescribe it, onc-trained or not.

 

[dozitgetchahi]

You can call it a "useless" statement because it address a non-reality in terms of medicine as a whole, but then one could turn right around and say that the posts questioning infusion reimbursements are also useless. If we agree that higher risk should be compensated accordingly, then let's simply agree on that point and do what we can to expand that attitude. And yes, you should be reimbursed for the risk you take in giving immunosuppressives. Certainly those infused in-house, and maybe also the PO ones.

Please define "exorbitant." Are these ROI figures also exorbitant? New drug classes don't grow on trees. Pharma R&D return on investment at highest level in 8 years.

When those laws were passed, if the reimbursement model didn't quickly adjust to balance at least most of the deficit, Heme/Onc would temporarily crater in reimbursement, that's true. But if you want to know what would happen after that, take a look at the Rad Onc forum. Except it would be worse, because for them, the "sky is falling!" scenario is that they're now *only* being paid 500k. In Heme/Onc, you'd be really hard-pressed finding non-marginal grads investing 3 years of training and a career requiring many hours of reading a week just to stay above water knowledge-wise just to make, say, 200k for the privilege of destroying pts' immune systems.

If that miracle immunotx does come out, oncologists will be obsolete and PCPs will be able to manage cancer.

Rheumatology here.

Please clarify what you mean by “risk” in this context. I don’t think you’re talking about the financial risk of buy and bill - so I’m assuming you’re referring to the “risk” associated with using medication with potentially toxic side effects.

By that reasoning, you are aware that the “highest risk” drugs out there are statistically opioids, right? And also NSAIDs…oh and what about digoxin, some antiarrythmics, and hell good old potassium (don’t give it by IV push!) etc etc?

In rheumatology, this reasoning would mean that cyclophosphamide and maybe azathioprine or tacrolimus or something should be reimbursed best…but they’re not…and a lot of what is reimbursed well (Rituxan, Simponi Aria, IV Orencia, IVIG, and such) isn’t actually all that risky to administer compared to Cytoxan.

Let’s face it, the profit of buy and bill is really something of a fluke in the system, and an externality that doesn’t benefit the patient or really anyone else in the process aside from the doc and whomever is selling the drugs. I’m happy to benefit from it as much as anyone else in rheumatology, but I’m also not surprised to see that CMS and the insurers are trying to make it go away.

 

[Ubba]

Rheumatology here.

Please clarify what you mean by “risk” in this context. I don’t think you’re talking about the financial risk of buy and bill - so I’m assuming you’re referring to the “risk” associated with using medication with potentially toxic side effects.

By that reasoning, you are aware that the “highest risk” drugs out there are statistically opioids, right? And also NSAIDs…oh and what about digoxin, some antiarrythmics, and hell good old potassium (don’t give it by IV push!) etc etc?

In rheumatology, this reasoning would mean that cyclophosphamide and maybe azathioprine or tacrolimus or something should be reimbursed best…but they’re not…

Those logistical risks exists too, of course.

Ha, my post wasn't a treatise on how to rank drugs by risk, but remember that there are plenty of opiates and NSAIDs also prescribed by onc, rheum, etc. In terms of AEs, I think everyone on the thread can probably agree that chemo is on a different level than dig. (I wish it weren't so. In a century or two, chemo will be comparatively barbaric relative to what will be available.)

Well, as I wrote above, they should. I'm not pitting specialty against specialty here. Rheum prescribes and administers some powerful and therapeutically-toxic medications, and ought to be reimbursed accordingly. I think bronx has kind of implied that this makes me a dreamer, though

 

[bronx43]

We do agree on that point. The reason I felt compelled to respond to that post is that (no offense to the poster) the likening of the buy-and-bill model for chemo to a hypothetical payback for simply rxing Brilinta is nonsensical. It also happens to fail on its face because oncs (and PCPs) prescribe antiplatelet agents and anticoagulants all the time without separate reimbursement. Maybe a rational delineation for these purposes would be between medications that require professional supervision for their administration vs those that can be quite reasonably taken easily at home with the proverbial "follow-up in 2 months, sooner if necessary."


I'm quite sure that if the magical risk-free cure-all is developed, there will be no reimbursement schemes for the physicians who prescribe it, onc-trained or not.

You JUST said a post ago that you would agree PO immunosuppressive meds should be reimbursed if there is risk involved.

And now you're saying it's nonsensical because everyone prescribes antiplatelet agents without separate reimbursement. Ok, but that is literally the point being made by CCM-MD - that these are profits made specifically made by a loophole in the system called buy and bill. You are the one who came in here saying it's ok, because it's actually about risk. Antiplatelets and anticoagulation are not without risk. Just like PO immunosuppressives are with risk.

You're moving the goalpost here big time. "Professional" supervision vs taking meds at home is a big time reach. We all know the vast majority of the toxicities of these meds is what happens after you go home, and some of the most toxic drugs on earth are taken PO at home.

The problem here is that you're essentially taking the apologist approach on this. You start with the conviction that facility administered chemotherapy and immunotherapy should be highly reimbursed. Then, you work backwards and fill the gap with whatever logically inconsistent argument you can think of. First, it's risk, now it's about office vs home.
Ultimately, it's ok to get yours while the going is good. There was a time when a lot of private rheumatologists were making millions on Remicade. Heck, a lot still make damn good cash. There is no reason other than buy and bill. No difference from the at-home subcutaneous TNF alpha inhibitors in terms of risk.
No need to insert any apologist argument. Just smile, nod, and say "it is what it is."

 

[CCM-MD]

Too much BS to sift through. The bottom line is that employed oncologists get paid almost double annually and per unit of work, in comparison to other similar outpatient focused non-procedural IM subspecialties. In private practices, ordering a chemo infusion directly leads to $ into an oncologists pocket. This type of incentivization is unusual, not equitable and can be problematic. My wife's an endo and uses the same E&M codes, and for the same amount of "work" she gets paid significantly less than an oncologist.

Lets use some expensive and toxic medications in critical care as an example to demonstrate how problematic "prescription for $" is: Imagine I got $500 directly in my pocket for ordering etomidate+rocuronium, $750 for an angiotensin II infusion, $850 for tPA, or $1000 for andexanet alfa? This type of incentivization would be a problematic and have potential for patient harm.

"Despite their high costs and potential toxicities, anticancer treatments may be subject to overuse, defined as the provision of medical services that are more likely to harm than to benefit a patient. - Medication overuse in oncology: current trends and future implications for patients and society

 

[Zendo]

In truth, if you can work efficiently, general IM can be quite lucrative once you start thinking outside the box, but if someone who's trained in IM is dead-set against practicing general IM, there's a strong case to be made for training in PM&R instead of a fellowship.

Can you expand on how general IM can be lucrative by thinking outside the box?

 

[Drrrrrr. Celty]

Can you expand on how general IM can be lucrative by thinking outside the box?

You practice predominately outside of generic hospital or clinic medicine. I.e do cosmetics, oversee a bunch of midlevels, add a nursing home to your oversight, work for pharmaceutical companies, etc.

Basically stuff that your more academic residency folks would frown upon.

 

[dozitgetchahi]

Some academic FM and IM folks round in nursing homes, so that’s not a huge issue to them lol.

Cosmetics etc? Yeah, you could get in trouble that way.

 

[Drrrrrr. Celty]

Some academic FM and IM folks round in nursing homes, so that’s not a huge issue to them lol.

Cosmetics etc? Yeah, you could get in trouble that way.

Idk, I think the biggest thing is working in cooperate and close with pharm. I've seen physicians make a killing in this.

Similarly concierge, it's not unreasonable to have a have a pay population/pool of individuals in basically any field even outside of primary care.

 

[Kaustikos]

You practice predominately outside of generic hospital or clinic medicine. I.e do cosmetics, oversee a bunch of midlevels, add a nursing home to your oversight, work for pharmaceutical companies, etc.

Basically stuff that your more academic residency folks would frown upon.

Some academic FM and IM folks round in nursing homes, so that’s not a huge issue to them lol.

Cosmetics etc? Yeah, you could get in trouble that way.

🤢🤢🤢🤢🤮🤮🤮🤮🤮🤮🤮🤮🤮🤮🤮🤮🤮🤮🤮🤮🤮🤮🤮🤮🤮

 

[Drrrrrr. Celty]

🤢🤢🤢🤢🤮🤮🤮🤮🤮🤮🤮🤮🤮🤮🤮🤮🤮🤮🤮🤮🤮🤮🤮🤮🤮

I'm certainly not going to.

Tbh my idea is still pretty heavy on doing concierge.

 

[dozitgetchahi]

I'm certainly not going to.

Tbh my idea is still pretty heavy on doing concierge.

Oh yeah I’d never round in a nursing home either.

Concierge sounds good though

 

[Ubba]

🤢🤢🤢🤢🤮🤮🤮🤮🤮🤮🤮🤮🤮🤮🤮🤮🤮🤮🤮🤮🤮🤮🤮🤮🤮

It's all about how you play the game But if someone is the kind of doctor who has to sit down and chat when talking to patients, this model is totally impossible

 

[Ubba]

You JUST said a post ago that you would agree PO immunosuppressive meds should be reimbursed if there is risk involved.

And now you're saying it's nonsensical because everyone prescribes antiplatelet agents without separate reimbursement. Ok, but that is literally the point being made by CCM-MD - that these are profits made specifically made by a loophole in the system called buy and bill. You are the one who came in here saying it's ok, because it's actually about risk. Antiplatelets and anticoagulation are not without risk. Just like PO immunosuppressives are with risk.

You're moving the goalpost here big time. "Professional" supervision vs taking meds at home is a big time reach. We all know the vast majority of the toxicities of these meds is what happens after you go home, and some of the most toxic drugs on earth are taken PO at home.

The problem here is that you're essentially taking the apologist approach on this. You start with the conviction that facility administered chemotherapy and immunotherapy should be highly reimbursed. Then, you work backwards and fill the gap with whatever logically inconsistent argument you can think of. First, it's risk, now it's about office vs home.
Ultimately, it's ok to get yours while the going is good. There was a time when a lot of private rheumatologists were making millions on Remicade. Heck, a lot still make damn good cash. There is no reason other than buy and bill. No difference from the at-home subcutaneous TNF alpha inhibitors in terms of risk.
No need to insert any apologist argument. Just smile, nod, and say "it is what it is."

Back from my ABIM break...

First, this is my underlying view: the administration of a medication that is designed to assault the immune system and is *by definition* (highly) toxic is akin to the performance of a procedure with respect to risk. At least a low-level surgery, though, of course, not a CABG or hemicolectomy. There are gradations, and infliximab, MTX, cisplatin, and nivolumab aren't equivalent. But there needs to be appropriate compensation for the risk a specialty takes on a day-to-day basis. There are PO meds to which this approach is relevant, absolutely. That's what I meant when I expressed a point of agreement earlier.

(I'm not sure which meds you're referencing when you say that "some of the most toxic drugs on earth are taken PO at home." Can you specify what you meant? Point of curiosity.)

Of course the system as it's designed is Rube Goldberg-esque and a bit of a Gordian Knot. And no, I'm not in love with the current reimbursement structure. It's beyond opaque.

But let's cut through the bull**** and come down to brass tacks with which we are all familiar: doctors (whether at the M4 level or the senior resident level), when acting rationally, seek to maximize their income:risk and income:effort ratios. Period. They will also take good, hard looks at whether additional fellowship training is worth the many opportunity costs. All the three-year IM subspecialties, to my knowledge, make good money. Each has its unique features and mechanisms by which its practice leads to good remuneration. The billing procedures for Heme/Onc are bizarre compered to those in GI, sure, but so are the billing procedures in CC vs those in Cardio.

I can apply this skepticism and frankly unprofessional suspicion to literally any specialty. A critical care doctor could, theoretically, pad billing by accepting unnecessary ICU upgrades or exaggerating the amount of "criticial care decision-making time." A dermatologist could biopsy obviously benign lesions. A cardiologist could perform unnecessary invasive angiographies. Etc. But I don't make those accusations, because I have respect for my colleagues in other specialties. (Even for Rad Onc, despite the fact that I'm extremely jealous of their incomes, residency lifestyles, and coolness of their day-to-day work .) Again, respect.

If you have a solution to the problem of how to administer IV chemotherapy in a way that's profitable to whichever entity is delivering it, be it an office or a hospital, please discuss it. But that's a sticking point - someone who provides a service can expect to profit from that service. Whether it's by taking a single right turn or three left turns is more a matter of systemic inefficiency than it is about whether the doctor at the end of the line deserves his or her income.

 

[chessknt]

Back from my ABIM break...

First, this is my underlying view: the administration of a medication that is designed to assault the immune system and is *by definition* (highly) toxic is akin to the performance of a procedure with respect to risk. At least a low-level surgery, though, of course, not a CABG or hemicolectomy. There are gradations, and infliximab, MTX, cisplatin, and nivolumab aren't equivalent. But there needs to be appropriate compensation for the risk a specialty takes on a day-to-day basis. There are PO meds to which this approach is relevant, absolutely. That's what I meant when I expressed a point of agreement earlier.

(I'm not sure which meds you're referencing when you say that "some of the most toxic drugs on earth are taken PO at home." Can you specify what you meant? Point of curiosity.)

Of course the system as it's designed is Rube Goldberg-esque and a bit of a Gordian Knot. And no, I'm not in love with the current reimbursement structure. It's beyond opaque.

But let's cut through the bull**** and come down to brass tacks with which we are all familiar: doctors (whether at the M4 level or the senior resident level), when acting rationally, seek to maximize their income:risk and income:effort ratios. Period. They will also take good, hard looks at whether additional fellowship training is worth the many opportunity costs. All the three-year IM subspecialties, to my knowledge, make good money. Each has its unique features and mechanisms by which its practice leads to good remuneration. The billing procedures for Heme/Onc are bizarre compered to those in GI, sure, but so are the billing procedures in CC vs those in Cardio.

I can apply this skepticism and frankly unprofessional suspicion to literally any specialty. A critical care doctor could, theoretically, pad billing by accepting unnecessary ICU upgrades or exaggerating the amount of "criticial care decision-making time." A dermatologist could biopsy obviously benign lesions. A cardiologist could perform unnecessary invasive angiographies. Etc. But I don't make those accusations, because I have respect for my colleagues in other specialties. (Even for Rad Onc, despite the fact that I'm extremely jealous of their incomes, residency lifestyles, and coolness of their day-to-day work .) Again, respect.

If you have a solution to the problem of how to administer IV chemotherapy in a way that's profitable to whichever entity is delivering it, be it an office or a hospital, please discuss it. But that's a sticking point - someone who provides a service can expect to profit from that service. Whether it's by taking a single right turn or three left turns is more a matter of systemic inefficiency than it is about whether the doctor at the end of the line deserves his or her income.

The solution would be to reimburse the cost of IV administration at what it costs to hire the staff to infuse it rather than allowing a profit on buy + bill so large that it more than doubles your unit value. Rheum, nephro, congenital cards, advanced CHF see complex sick patients all the time that require enormous amounts of cognitive effort. They prescribe expensive drugs too. What they don't get is extra reimbursement for the extensive imaging/lab workup that needs to be sent on these patients. Their income comes from their E/M coding rather than selling drugs to people.

It is a reach when you have to try to imagine fraud to compare the other specialites to oncology's day to day operations. No other specialty earns income this way and that is a problem.

 

[HemeOncHopeful19]

The solution would be to reimburse the cost of IV administration at what it costs to hire the staff to infuse it rather than allowing a profit on buy + bill so large that it more than doubles your unit value. Rheum, nephro, congenital cards, advanced CHF see complex sick patients all the time that require enormous amounts of cognitive effort. They prescribe expensive drugs too. What they don't get is extra reimbursement for the extensive imaging/lab workup that needs to be sent on these patients. Their income comes from their E/M coding rather than selling drugs to people.

It is a reach when you have to try to imagine fraud to compare the other specialites to oncology's day to day operations. No other specialty earns income this way and that is a problem.

So…

GI can get paid well to scope,
Cards can get paid well to cath,
Ortho can get paid well to replace a hip, Anesthesia can get paid well to anesthetize,
Ophtho can get paid well for cataracts,
Rad Onc can get paid well to radiate,
Derm can get paid well to biopsy all day,
Rads can get paid well to read imaging,
Pulm/Crit can get paid well thanks to a special billing code for just doing their job,

But when Heme/Onc gets paid well for giving chemo it’s somehow “fraud”?

This whole derail is exactly what is wrong with our profession, instead of advocating for the other cognitive specialties to get paid fairly everyone wants to somehow twist it into Heme/Onc being unjustly paid despite the fact that outside a few select specialties we all make relatively less than the previous generation did.

 

[Mehena]

But when Heme/Onc gets paid well for giving chemo it’s somehow “fraud”?

This whole derail is exactly what is wrong with our profession, instead of advocating for the other cognitive specialties to get paid fairly everyone wants to somehow twist it into Heme/Onc being unjustly paid despite the fact that outside a few select specialties we all make relatively less than the previous generation did.

These same physicians who regularly paint oncology here as villian for expensive healthcare system, i bet are nowhere to be found in real frontline advocacy at their institution,region or national forums.

 

[chessknt]

So…

GI can get paid well to scope,
Cards can get paid well to cath,
Ortho can get paid well to replace a hip, Anesthesia can get paid well to anesthetize,
Ophtho can get paid well for cataracts,
Rad Onc can get paid well to radiate,
Derm can get paid well to biopsy all day,
Rads can get paid well to read imaging,
Pulm/Crit can get paid well thanks to a special billing code for just doing their job,

But when Heme/Onc gets paid well for giving chemo it’s somehow “fraud”?

This whole derail is exactly what is wrong with our profession, instead of advocating for the other cognitive specialties to get paid fairly everyone wants to somehow twist it into Heme/Onc being unjustly paid despite the fact that outside a few select specialties we all make relatively less than the previous generation did.

No, the poster I was responding to painted the other specialties as committing fraud (over billing CCM, performng inappropriate caths etc) to bill more while all oncogy has to do is their regular job. That posters argument is that high risk fields deserve appropriate compensation which is fair but where is that for rheum, congenital cards, and nephro? I occasionally give chemotherapy for very sick people with ILD in the hospital with little information and if I am wrong they could die; I get to bill a 1.5 rvu follow up code, where is my 10k bonus for prescribing that? Getting legal kickbacks for prescribing expensive therapies is not appropriate period. If Ortho got to sell the hip implant to the patient we would have an issue with that right? How is it different for an infusion??

We need an overhaul to e/m billing with a special code to capture subspecialty decision making to recognize the expertise needed to achieve that is my opinion.

 

[Splenda88]

I am not sure why some in here are bashing heme/onc for finding a way to make money. The average heme/onc doc makes 550-600k/yr... It's not like they are making 1m+

 

[Ubba]

No, the poster I was responding to painted the other specialties as committing fraud (over billing CCM, performng inappropriate caths etc) to bill more while all oncogy has to do is their regular job. That posters argument is that high risk fields deserve appropriate compensation which is fair but where is that for rheum, congenital cards, and nephro? I occasionally give chemotherapy for very sick people with ILD in the hospital with little information and if I am wrong they could die; I get to bill a 1.5 rvu follow up code, where is my 10k bonus for prescribing that? Getting legal kickbacks for prescribing expensive therapies is not appropriate period. If Ortho got to sell the hip implant to the patient we would have an issue with that right? How is it different for an infusion??

We need an overhaul to e/m billing with a special code to capture subspecialty decision making to recognize the expertise needed to achieve that is my opinion.

I most certainly did not paint other specialties as committing fraud. You need to re-read the post. I presented hypotheticals, not accusations. And my point stands: people in any specialty can make "clinical decisions" that are self-interested. Hell, a generalist in adult or peds could increase f/u frequency to generate more billings, too. A mechanic could recommend a 3,000-mile oil change when he just used a synthetic blend and knows full well that 5,000 would be more than ok. Etc.

I've already written above that people of any specialty who have to sling meds as toxic as chemo should be reimbursed accordingly. This is not about any special carve-outs for heme/onc.

As I also write earlier, if you can come up with an alternative model for heme/onc being appropriately compensated for the risks and opportunity costs of the specialty, I'm all ears. But the recommendation that services should be done at cost is a non-starter.

 

[Ubba]

I am not sure why some in here are bashing heme/onc for finding a way to make money. The average heme/onc doc makes 550-600k/yr... It's not like they are making 1m+

100-150k less than that, and the future looks much bleaker when you consider all the PPs being swallowed up by health systems. Not a woe restricted to h/o, of course.

 

[chessknt]

I most certainly did not paint other specialties as committing fraud. You need to re-read the post. I presented hypotheticals, not accusations. And my point stands: people in any specialty can make "clinical decisions" that are self-interested. Hell, a generalist in adult or peds could increase f/u frequency to generate more billings, too. A mechanic could recommend a 3,000-mile oil change when he just used a synthetic blend and knows full well that 5,000 would be more than ok. Etc.

I've already written above that people of any specialty who have to sling meds as toxic as chemo should be reimbursed accordingly. This is not about any special carve-outs for heme/onc.

As I also write earlier, if you can come up with an alternative model for heme/onc being appropriately compensated for the risks and opportunity costs of the specialty, I'm all ears. But the recommendation that services should be done at cost is a non-starter.

Yes but in your hypothetical situation you are thinking of ways that these fields can increase their unit counts to increase income while in oncology that is not needed since their units values are so high. Higher paying fields generate more units (which is a separate problem) but their unit values are all relatively close to each other. Oncology has unit values that are 2-3x other IM fields, meaning to achieve income parity by FFS a rheumatologist would need to see 2.5x the number of patients an oncologist would.

Oncology isn't reimbursed by med toxicity, they are reimbursed by how much of a profit margin is legally allowed on buy + bill. Since very few of these drugs ever get to generic form (and seem to still get used), have prices rising in to the stratosphere while under brand protection, and seem to be approved with the lowest bar of any medication class by the FDA it links pharma profits and the oncology field together. This relationship literally does not exist for any other field to this degree where the overwhelming majority of their income is dependent on brand name drugs being expensive. To think this is not a problem somehow means you are benefiting from the result or are of the libertarian pro-capitalist medicine school of thought in which case you are ignoring how much of this profit is provided by CMS by their (until recent) refusal to negotiate any drug prices with pharmacy.

I would again advocate for a subspecialty billing code (could even make it specific to the number of years required to achieve certification) to better capture risk and cognitive difficulty in management instead of literally link

 

[Ubba]

Yes but in your hypothetical situation you are thinking of ways that these fields can increase their unit counts to increase income while in oncology that is not needed since their units values are so high. Higher paying fields generate more units (which is a separate problem) but their unit values are all relatively close to each other. Oncology has unit values that are 2-3x other IM fields, meaning to achieve income parity by FFS a rheumatologist would need to see 2.5x the number of patients an oncologist would.

Oncology isn't reimbursed by med toxicity, they are reimbursed by how much of a profit margin is legally allowed on buy + bill. Since very few of these drugs ever get to generic form (and seem to still get used), have prices rising in to the stratosphere while under brand protection, and seem to be approved with the lowest bar of any medication class by the FDA it links pharma profits and the oncology field together. This relationship literally does not exist for any other field to this degree where the overwhelming majority of their income is dependent on brand name drugs being expensive. To think this is not a problem somehow means you are benefiting from the result or are of the libertarian pro-capitalist medicine school of thought in which case you are ignoring how much of this profit is provided by CMS by their (until recent) refusal to negotiate any drug prices with pharmacy.

I would again advocate for a subspecialty billing code (could even make it specific to the number of years required to achieve certification) to better capture risk and cognitive difficulty in management instead of literally link

I don't disagree with your last point.

 

[Siggy]

No, the poster I was responding to painted the other specialties as committing fraud (over billing CCM, performng inappropriate caths etc) to bill more while all oncogy has to do is their regular job. That posters argument is that high risk fields deserve appropriate compensation which is fair but where is that for rheum, congenital cards, and nephro? I occasionally give chemotherapy for very sick people with ILD in the hospital with little information and if I am wrong they could die; I get to bill a 1.5 rvu follow up code, where is my 10k bonus for prescribing that? Getting legal kickbacks for prescribing expensive therapies is not appropriate period. If Ortho got to sell the hip implant to the patient we would have an issue with that right? How is it different for an infusion??

We need an overhaul to e/m billing with a special code to capture subspecialty decision making to recognize the expertise needed to achieve that is my opinion.

Devils advocate... it sounds like you're "providing care that involves decision making of high complexity to assess, manipulate, and support... ...respiratory failure, ... to prevent further deterioration."

Why not 99291 those patients?

 

[CCM-MD]

Devils advocate... it sounds like you're "providing care that involves decision making of high complexity to assess, manipulate, and support... ...respiratory failure, ... to prevent further deterioration."

Why not 99291 those patients?

99291 still wouldn’t get him anywhere close to an oncology style mega kick back.

 

[Siggy]

99291 still wouldn’t get him anywhere close to an oncology style mega kick back.

That's true, but still 3-4x a 99232.

 

[aafisahar]

Other physicians have to basically commit fraud to get what oncology gets by doing their job. I wish I got a kick back from Novartis every time I prescribed entresto...

 

[HemeOncHopeful19]

Other physicians have to basically commit fraud to get what oncology gets by doing their job. I wish I got a kick back from Novartis every time I prescribed entresto...

Well seeing as how your field actually does make more money than Oncology, exactly how much fraud are you committing?

 

[aafisahar]

Well seeing as how your field actually does make more money than Oncology, exactly how much fraud are you committing?

There's a good chance I may have committed some light fraud

 

[berenjena89]

Best IM lifestyle specialities: Endocrinology, Rheumatology and Allergy. You won’t make much money like GI, Cardio,Onc but once you have a mature/established practice you can make around 300 k in those seeing around 15-20 pts, you can even make more if you are willing to see more patients and hit 350-400k which is pretty good money specially if you live outside Ny/ california/ . Most importantly, choose what you enjoy the most even in Cardiology you can have a good/ decent lifestlye depending on hospital, group

 

[bobow98]

Other physicians have to basically commit fraud to get what oncology gets by doing their job. I wish I got a kick back from Novartis every time I prescribed entresto...

Why does everyone keep comparing oral drugs and kickbacks?
We prescribe a lot of expensive oral drugs and we get 0 kickbacks. We get the same for managing capecitabine as what you get for managing entresto, 99214/5 essentially.

A better comparison would be our buy and bill model with 6% profit margin equated to cardiology billing patients for TAVR and the surgicenter/cath lab billing for the device and making a profit on that. Or outpatient neurosurgery at the surgicenter with spinal stimulator profits, and I'm sure the margins on those surgeries are way higher than me giving carboplatin/paclitaxel and bevacizumab for 6 cycles and then putting a patient on maintenance bev.

In short, oncology gets non E/M earnings in 2 ways: 1) infusion drug margin 2) Procedure billing for management of chemotherapy during the infusion if you are not employed by a hospital. If you are employed your hospital that owns you will take #1 and #2 and trickle down money to you as RVU based on your productivity from E/M for the most part. I think there's an unnecessary back and forth going on here distracting from the fact that corporate overlords aka the hospital adds substantial fees and costs to the administration of cancer care while potentially taking 340b advantages.

Do not work as an employed physician if you can help it, partner with your colleagues and form large specialty groups for bargaining power with payors. If you're in a desirable city you're SOL because you can't prevent your colleagues desperate to be there from selling out to the hospital system. But in any other area you should look into market dynamics and see if you can find a job with a group that positions itself this way.

 

[HemeOncHopeful19]

Why does everyone keep comparing oral drugs and kickbacks?
We prescribe a lot of expensive oral drugs and we get 0 kickbacks. We get the same for managing capecitabine as what you get for managing entresto, 99214/5 essentially.

They're actually arguing that because Onc typically can negotiate a higher $/RVU rate that we get a "kickback" and we get $200 for that visit but they only get $100 for the visit.

They are of course ignoring the fact that the cath lab and reading echos generate an ungodly amount of RVUs compared to anything we do (which of course has nothing to do with Cardiology having a permanent seat at the RVU committee table) such that his or her overall compensation is higher anyway.

But more to your point I agree on avoiding hospital employment but I have seen some questionable multi-specialty groups. I feel like when they start to get large you end up with multi-tiered partnerships and a pyramid structure that is not an attractive look as a new grad.

 

[Splenda88]

Best IM lifestyle specialities: Endocrinology, Rheumatology and Allergy. You won’t make much money like GI, Cardio,Onc but once you have a mature/established practice you can make around 300 k in those seeing around 15-20 pts, you can even make more if you are willing to see more patients and hit 350-400k which is pretty good money specially if you live outside Ny/ california/ . Most importantly, choose what you enjoy the most even in Cardiology you can have a good/ decent lifestlye depending on hospital, group

More $$$ ia almost always better.

 

[chessknt]

Why does everyone keep comparing oral drugs and kickbacks?
We prescribe a lot of expensive oral drugs and we get 0 kickbacks. We get the same for managing capecitabine as what you get for managing entresto, 99214/5 essentially.

A better comparison would be our buy and bill model with 6% profit margin equated to cardiology billing patients for TAVR and the surgicenter/cath lab billing for the device and making a profit on that. Or outpatient neurosurgery at the surgicenter with spinal stimulator profits, and I'm sure the margins on those surgeries are way higher than me giving carboplatin/paclitaxel and bevacizumab for 6 cycles and then putting a patient on maintenance bev.

In short, oncology gets non E/M earnings in 2 ways: 1) infusion drug margin 2) Procedure billing for management of chemotherapy during the infusion if you are not employed by a hospital. If you are employed your hospital that owns you will take #1 and #2 and trickle down money to you as RVU based on your productivity from E/M for the most part. I think there's an unnecessary back and forth going on here distracting from the fact that corporate overlords aka the hospital adds substantial fees and costs to the administration of cancer care while potentially taking 340b advantages.

The hospital passes that on to oncology though. That is why the unit value for oncology is 2x that for endocrine. It isn't like this for any other subspecialty. I have never met a cardiology group that owns its own cath lab and TAVR billing is based on the massively inflated RVU value of that stupid procedure rather than on kickbacks for actually putting a specific device in. They are incentivized to do the procedure but are agnostic as to the device. In oncology the buy + bill incentivizes brand name drugs. That is a unique relationship in the entire medical field and one that should not be ignored.

They're actually arguing that because Onc typically can negotiate a higher $/RVU rate that we get a "kickback" and we get $200 for that visit but they only get $100 for the visit.

They are of course ignoring the fact that the cath lab and reading echos generate an ungodly amount of RVUs compared to anything we do (which of course has nothing to do with Cardiology having a permanent seat at the RVU committee table) such that his or her overall compensation is higher anyway.

But more to your point I agree on avoiding hospital employment but I have seen some questionable multi-specialty groups. I feel like when they start to get large you end up with multi-tiered partnerships and a pyramid structure that is not an attractive look as a new grad.

RUC and the ridiculous RVU for certain procedures and the overuse of those procedures is a different issue. Creating a different issue where oncology is in bed with pharma directly as part of routine and nth line chemo is the norm for drugs that have to show the lowest version of clinical efficacy of any class on the market for approval is an entirely different problem. Both of them are wrong but one doesn't make the other right. If my orthopod was selling me the implant they planned to put in my body I would have huge ethical concerns over that practice, wouldn't you?.