CMS proposed reimbursement cuts to Rad Onc by 20%?

[MOHS_01]

If I had to do it all over again, I would have gone to dental school and done a specialty like ortho or endo. You get the lifestyle and income of derm plus they're mostly cash-based but within reach for most people competitive enough to get into medical school.

Ain't hindsight a real bitch??

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[Palex80]

I am a bit troubled by some of the comments made in this thread.

p53 stated in one post:

If I was a 3rd and 4th year medical student right now. I would think long and hard at Radiology and Radiation Oncology because of these HUGE cuts. Instead I would target specialties such as Anesthesiology and Pain Medicine.

and then p53 stated a couple of posts later:

YOU HAVE TO CHOOSE A SPECIALTY BASED ON MATURE TRUE INNER EXAMINATION OF YOURSELF TO SEE IF YOU TRULY LIKE IT!!! IF YOU LIKE CARDIOLOGY GO FOR IT!! IF YOU GET WORN OUT YOU CAN GO DOWN TO WORK PART TIME. DO SOMETHING THAT YOU CAN LOOK BACK IN 30 YEARS AND SAY I DID WHAT I WANTED TO DO. YOUR LIFE WILL HAVE MEANING.

That doesn't make a lot of sense, since statement 1 is totally contradictory to statement 2.
Anyway:
Is money really the only motivation in the US for studying medicine and choosing a speciality? If yes, then perhaps we are better off in Europe, where most of the physicians make the same money, no matter what they specilize in.

The scary thing is that the huge cuts for radiology and radiation oncology will lead to a brain drain out of imaging and therapeutic radiation. With so much debt, medical students have to be practical.

So the smart guys are the ones that want to make the big bucks too?
Is it really so?

Ask yourself this question. Why would you train 5 years in Radiology or Radiation Oncology when you can make the same money in ER in 3 years?

Because:
1. Both specialities are totally different.
2. The life style of a radiation oncologist is superior to that of an ER specialist.
3. Not everyone likes blood.

For applicants/med students, here's a piece of advice. Go into a field that you enjoy doing and don't select one purely on reimbursement.

The smartest quote in the entire thread.

Name the last 10 drugs that made a difference in medicine. I'd say that 9/10 were developed at universities and then bought/marketed by drug companies.

But the industry paid for the development of the drugs and the Phase I-III trials of them as well.
Its more clever for the industry to fund the research they want to fund in universities than have their own research labs. Why?
Because you can't always hire the best guys to develop the drugs you are looking for. There are just too many different fields. You can however go out there and look at who is asking you for money and finance those who think will develop something you can bring into the market some day. It's safer and cheaper that way.

If I had to do it all over again, I would have gone to dental school and done a specialty like ortho or endo. You get the lifestyle and income of derm plus they're mostly cash-based but within reach for most people competitive enough to get into medical school.

And would you be happy with your every day work?

 

[radslooking]

s

 

[Taurus]

And would you be happy with your every day work?

Actually, yes I would be. I had a career for many years before going back to medical school. I've learned that no matter what you do, as long as you work for someone else or in this case be at the mercy of CMS, a job is a job. It's a means for me to do other things that I enjoy.

 

[Palex80]

Actually, yes I would be. I had a career for many years before going back to medical school. I've learned that no matter what you do, as long as you work for someone else or in this case be at the mercy of CMS, a job is a job. It's a means for me to do other things that I enjoy.

Well I work 55 hours/week and am supposed to read, learn and do research at home too. This brings the total of time spent on the job and related activities to about 65 hours/week. I sleep about 55 hours/week, cook and eat about 16 hours/week, spend about 10 hours in the bathroom per week.
This means that 146 hours/week are reserved for these activities, resulting in 22 hours/week that I have free.

So if someone is not doing what he/she really would like, but simply doing it for the money, then he/she is spending 65 hours/week in misery to have the means to enjoy 22 hours/week.
Thanks, I'll pass.

You have to enjoy what you do.
And you can be very happy working for someone else or at the mercy of a national health care system as long as you make sure the enviroment you work in is fine. I get along perfectly well with my boss and actually enjoy caring for the patients I see.

 

[deleted4401]

But the industry paid for the development of the drugs and the Phase I-III trials of them as well.
Its more clever for the industry to fund the research they want to fund in universities than have their own research labs. Why?
Because you can't always hire the best guys to develop the drugs you are looking for. There are just too many different fields. You can however go out there and look at who is asking you for money and finance those who think will develop something you can bring into the market some day. It's safer and cheaper that way.

People keep saying this. I'm not naive. What I'm talking about is that 9/10 of the most recent drugs that matter were not developed by drug/pharma money - it was NIH money, which is funded by the US taxpayer (i.e. yours and mine). The "research" that Big Pharma does is to change a cis to a trans on Prilosec to make Protonix or to find a better vasodilator to foster longer, harder ... whatever or to compare it to a placebo (instead of an effective medication) for some other complaint so they can find more off-label use. The "education" component of the spending is also, similarly, for lack of better words, crap.

Anyway, I know nobody is really listening and just kind of pontificating over each other, but in any case, here is an excerpt of the book by Dr. Angell (the NEJM editor) http://www.nybooks.com/articles/17244. The entire books is a good read, and it jolts a few "facts" that we take as sacred about Pharma.

Well ... still trying to figure out the meaning of the 50 --> 90% change.
-S

 

[G'ville Nole]

I'm still floored by the fact that Palex spends 10 hours per week in the bathroom.

I'm FedEx-ing you some All-Bran, my friend!

 

[MOHS_01]

I think the lack of answer to that question is because noone who reads or posts on this board understands it either.
I asked my chair to explain it to me the other day, but still don't understand it well enough to give a great explanation here. Nevertheless, I'll try.
A few of the points were that the whole utilization term/percentage only applies to machines > or = to $1 million. CMS then estimates how much the value of that machine depreciates on a yearly basis. They then adjust reimbursement accordingly to account for that decrease in value. If they assume only a 50% utilization rate (meaning you use it only about half of the potential "usable time") they have to increase reimbursement to account for the depreciation. If they bump up the utilization to assume a 90% rate, then the reimbursement does not have to be as high to cover the depreciation. As I understood it, it only applies to technical fees. It will be a huge deal for diagnostics, but obviously affect rad onc as well. Not just for treatment, but even more so for CT simulations, because we only do so many per day, as opposed to a diagnostic CT scanner where they jam as many people into the day as possible.
Hope that clears it up at least a little. If anyone else has anymore insight, feel free to chime in as I'm not claiming to be an expert on such matters.
Cheers.
Also, great use of the word pontificating

Correct. Technical fees are determined based upon acquisition costs and expected use, determined from data gathered through periodic (5 year cycle for most CPT codes) practice surveys. One portion of the formula used is the expected utilization; the higher the number, the lower the per case reimbursement. This is based on the fact that fixed costs represent a lower marginal percentage with higher utilization rates. This is also why it will be harder for smaller hospitals, private practices, rural areas, etc to continue to provide new technology.

Professional component does not have utilization rates per se, but they do factor in "operational efficiencies" and "technical efficiencies" as an excuse to offset the physician work and practice expense component, respectively, based in part upon CPT utilization frequencies (and trends). It's all an Enron accounting game to justify fee decreases........

 

[Impressions]

Correct. Technical fees are determined based upon acquisition costs and expected use, determined from data gathered through periodic (5 year cycle for most CPT codes) practice surveys. One portion of the formula used is the expected utilization; the higher the number, the lower the per case reimbursement. This is based on the fact that fixed costs represent a lower marginal percentage with higher utilization rates. This is also why it will be harder for smaller hospitals, private practices, rural areas, etc to continue to provide new technology.

Professional component does not have utilization rates per se, but they do factor in "operational efficiencies" and "technical efficiencies" as an excuse to offset the physician work and practice expense component, respectively, based in part upon CPT utilization frequencies (and trends). It's all an Enron accounting game to justify fee decreases........

Please please give us the bottom line, someone, how much can we expect rad onc salaries to drop in the next 5 years? 10 percent?? 50 percent?? Please do tell.

 

[medgator]

People keep saying this. I'm not naive. What I'm talking about is that 9/10 of the most recent drugs that matter were not developed by drug/pharma money - it was NIH money, which is funded by the US taxpayer (i.e. yours and mine).

It's not just drug companies getting the royalties from that, it's the universities too who continue collect royalty payments long after the drug is developed, according to your article.

But now universities, where most NIH-sponsored work is carried out, can patent and license their discoveries, and charge royalties. Similar legislation permitted the NIH itself to enter into deals with drug companies that would directly transfer NIH discoveries to industry.

Bayh-Dole gave a tremendous boost to the nascent biotechnology industry, as well as to big pharma. Small biotech companies, many of them founded by university researchers to exploit their discoveries, proliferated rapidly. They now ring the major academic research institutions and often carry out the initial phases of drug development, hoping for lucrative deals with big drug companies that can market the new drugs. Usually both academic researchers and their institutions own equity in the biotechnology companies they are involved with. Thus, when a patent held by a university or a small biotech company is eventually licensed to a big drug company, all parties cash in on the public investment in research.

 

[MOHS_01]

Please please give us the bottom line, someone, how much can we expect rad onc salaries to drop in the next 5 years? 10 percent?? 50 percent?? Please do tell.

Impossible to predict my friend, unfortunately. There simply are too many variables and we are in a very unstable reimbursement environment. It depends on individual practice compensation structure, the piss poor SGR formula, the redistributionist RVURUC arm of CMS...oops, I mean the AMA, etc. If you are already committed (in residency or practicing) all you can do is hope, pray, and cut expenses if need be.

A guess (albeit a somewhat educated one based upon years of self indulgence on reimbursement issues, policy issues, etc) is that every "high paid specialty" can expect to see incomes decrease dramatically. That is the political direction that CMS (the dictator of all things medical) is headed.

 

[Zap]

I agree that it is impossible to predict what salaries any MD, including rad oncs, will be making 5 or 10 years from now. The cuts to imaging hurt not only diagnostic radiology, but also other specialists who have been making significant amounts of money over the past few years by owning outpatient imaging/procedure centers (think orthopedics, cardiology, etc.) Thus, many of the top earners in these fields will likely see their income fall, and that's before the cuts that are directly targeting those fields.

Since rad onc gets lumped in with diagnostic imaging, we will feel the pain as well. That said, it's likely that in 5-10 years there will be new technology that (under the current system at least) would likely lead to higher reimbursement rates again (think IMRT in our case or robotic prostatectomy in urology). The wild card is Obamacare. We could have basically a single payer system 10 yrs from now. In these systems, physician salaries are usually repressed and relatively equal across specialties. Physicians will likely still make a decent living, but the incomes that our predecessors were used to making are probably on the way out. Unfortunately, the pace of scientific progress will likely slow dramatically as well, since few companies will want to push the development of the next scanner of linac when no MD will buy it since it doesn't make financial sense. Isn't socialism wonderful?

 

[Palex80]

I'm still floored by the fact that Palex spends 10 hours per week in the bathroom.

I'm FedEx-ing you some All-Bran, my friend!

Well let's see:
1. I shower at least once per day, in the summer often two times per day = 25 min/day including getting dressed on and off.
2. I go to the toilet once per day, sometimes reading the red journal or so = 15 min/day
3. I shave my face once per day = 20 min/day
4. Washing face, hands, fixing hair, peeing, cutting nails etc... = 10 min/day

That gives a grand total of 65 min per day, multiplied by 7 days you get 70 min per day. That's 8,16 hours per week.

Ok I agree, I may have overstated with saing 10 hours.
However I think 10 hours may not be exagerrated because:
a) Some people rather take a bath that shower.
b) Some people take longer to shave or shave other areas of the body than face too. For example women.
c) Some people have longer hair or need more time to fix their hair. For example women.

So, let's say I need 8 hours/week in the bathroom.
I forgot to enlist the time I need to clean up my appartment and do administrative work like shopping, paying bills, online banking, opening the mail, etc which probably absorb something like 5 hours per week.
If you calculate that too, then you are left with only 19 hours of free time / week.

 

[Palex80]

The wild card is Obamacare. We could have basically a single payer system 10 yrs from now. In these systems, physician salaries are usually repressed and relatively equal across specialties. Physicians will likely still make a decent living, but the gravy train that our predecessors have ridden is probably on its way out. Unfortunately, the pace of scientific progress will likely slow dramatically as well, since few companies will want to push the development of the next scanner of linac when no MD will buy it since it doesn’t make financial sense. Isn't socialism wonderful?

Welcome to Europe.

 

[Robert Pearson]

The problem with the promotion of primary care, and cuts in imaging, are that it ignores the whole way that our health care system is set up. Primary care physicians really don't do all that much, except to deal with very simple problems that frankly NPs or PAs can do, and deal patients out to specialists to fix real problems. PCPs have been marginalized, so they really shouldn't be paid as specialists.
Imaging is how all of medicine is based. Cardiologists do not do caths anymore, they image. General surgeons do not do ex laps any more, they image. When a patient comes to the ER, they get imaged and then a decision is made. On and on. I know we all like to be nostalgic about years ago when we were trained, but come on, physical diagnosis is useless and no one today even knows how to do it. It was the physician Gods at Johns Hopkins that were experts in physical diagnosis years ago, but any foreign doc with a CT can beat them anyday!
In the next 10 years, advances in imaging will help the cancer world more and more; the whole concept of targeted therapy is based on imaging. So why would you cut the one area that we NEED innovation and that is the backbone of medicine?
All congress does is say, look, this area is growing too quickly so lets make cuts there. But has anyone actually looked at WHY imaging is growing so fast? Because that is the backbone of medicine! Like it on not, all specialties are DEPENDANT on imaging, period. And any advances in any specialties are dependant on it as well. And do you actually think a patient who trusts a doctor who just put a couple of hands on him and said everything is ok? They want a CT or an MRI!

 

[Doctor&Geek]

<<<>>>
The problem with the promotion of primary care, and cuts in imaging, are that it ignores the whole way that our health care system is set up. Primary care physicians really don't do all that much, except to deal with very simple problems that frankly NPs or PAs can do, and deal patients out to specialists to fix real problems. PCPs have been marginalized, so they really shouldn't be paid as specialists.
Imaging is how all of medicine is based. Cardiologists do not do caths anymore, they image. General surgeons do not do ex laps any more, they image. When a patient comes to the ER, they get imaged and then a decision is made. On and on. I know we all like to be nostalgic about years ago when we were trained, but come on, physical diagnosis is useless and no one today even knows how to do it. It was the physician Gods at Johns Hopkins that were experts in physical diagnosis years ago, but any foreign doc with a CT can beat them anyday!
In the next 10 years, advances in imaging will help the cancer world more and more; the whole concept of targeted therapy is based on imaging. So why would you cut the one area that we NEED innovation and that is the backbone of medicine?
All congress does is say, look, this area is growing too quickly so lets make cuts there. But has anyone actually looked at WHY imaging is growing so fast? Because that is the backbone of medicine! Like it on not, all specialties are DEPENDANT on imaging, period. And any advances in any specialties are dependant on it as well. And do you actually think a patient who trusts a doctor who just put a couple of hands on him and said everything is ok? They want a CT or an MRI!
<<<>>>

 

[radslooking]

that's fine and all, but since we have such great technology why are our costs at least double everywhere else and our outcomes worse?

 

[MOHS_01]

that's fine and all, but since we have such great technology why are our costs at least double everywhere else and our outcomes worse?

Our costs are a function of relative disposable incomes, the fact that we finance much of the remaining world's costs indirectly, and related to our overall historic economic structure. Look at how healthcare pricing was set prior to the advent of MC, then through 1992, and from 1992 until now and you will have a greater understanding of how we got here.

Our "outcomes" are worse for two reasons largely: systematic statistical bias and errors (outcome measures do not have uniform criteria applied across systems, rendering comparisons invalid in large part).

We also have a less healthy populace. This is related to a virtual cornucopia of confounders, including lifestyle, living conditions, societal norms, etc -- NOT the medical care provided by our working professionals. I suppose we could bust kneecaps for having a high A1c or gaining weight... maybe knock a tooth out for eating too much, etc, but I somehow doubt that would fly with the PC types....

 

[radslooking]

Our costs are a function of relative disposable incomes, the fact that we finance much of the remaining world's costs indirectly, and related to our overall historic economic structure. Look at how healthcare pricing was set prior to the advent of MC, then through 1992, and from 1992 until now and you will have a greater understanding of how we got here.

Our "outcomes" are worse for two reasons largely: systematic statistical bias and errors (outcome measures do not have uniform criteria applied across systems, rendering comparisons invalid in large part).

We also have a less healthy populace. This is related to a virtual cornucopia of confounders, including lifestyle, living conditions, societal norms, etc -- NOT the medical care provided by our working professionals. I suppose we could bust kneecaps for having a high A1c or gaining weight... maybe knock a tooth out for eating too much, etc, but I somehow doubt that would fly with the PC types....

while i agree that our populace aint the fittest in the world, and that our drug costs are insanely high, we also do far too much crap. our end of life costs are disgusting. We consume 60% of the world's drugs. (its not absolute cost that plagues us, its overtreatment with meds in some cases) we have an unintegrated system where we duplicate tests done elsewhere, we have uninsured using er's constantly. etc etc. I appreciate the fact that the economic reasons you cited above have a large effect as well, however, I think there are other reasons out there too. Some (hopefully) prudent form of rationing will be inevitable.

 

[RadOncMegatron]

Let's not forget that medical school tuition is paid for (or subsidized a lot) in other countries, while many of us here will have $250,000 in loans to pay off by the time we are out.

Also, US physicians, work more hours then many (not all) of our foreign counterparts.

It's fine to have some cuts (what they're doing to rad onc seems excessive) to help bring down costs, but are these cuts really going to translate to savings to the patients (or should I say taxpayers)? We know that the quality of healthcare will go down, I'm just wondering if people will actually save any money.

Side note: Would it kill anyone to take some of my interest rates down if they are going to cut my future salary?? A word I have now grown to hate is "forbearance"