Compensation ceiling

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DrProtonX

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Is it still possible to earn 7-figure as a rad onc? If so, is it only possible in private practice or can it be achieved with hospital employed position?
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Yes. 90%ile MGMA is above $850 K. So there are a chunk of people making this.

In my experience this can happen a few ways, one or more of the below will e necessary...but getting harder to do

- bill pro and collect fees and be extremely busy and efficient
- have a nice $/RVU employment contract and be busy
- get a hefty "medical director" fee on top of revenue generated from patient care
- own brick and mortar office with equipment/capture technical revenue
 
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If you’re employed then no it’s not possible just seeing patients. You would have to climb the corporate ladder to be a chair and get out of the RVU game.

The money was transferred to hospitals and the admin suite over the last 20 years. So that’s where you need to go to get to that level.
 
If you make median $/wRVU, you need a little more than 18,000 wRVUs to reach $1,000,000. That's a little less than the work of two median-ly busy rad oncs.
 
DrProtonX said:
Rad oncs get less than $60/wRVU? Why does med onc get $100/wRVU but not rad onc?
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BobbyHeenan said:
Yes. 90%ile MGMA is above $850 K. So there are a chunk of people making this.

In my experience this can happen a few ways, one or more of the below will e necessary...but getting harder to do

- bill pro and collect fees and be extremely busy and efficient
- have a nice $/RVU employment contract and be busy
- get a hefty "medical director" fee on top of revenue generated from patient care
- own brick and mortar office with equipment/capture technical revenue
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Bequerel said:
Yes it is possible with both hospital based and private practice. Obviously not as much as it used to be, but it’s out there for those that are motivated enough to find it.
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With current job market, as a new grad, can you even negotiate such things? Is there anything you can use to your leverage to get that kind of contracts that allows you to hit 7-figure if you work hard enough?

I wanna work hard and more than the average rad onc while i’m in my 30s and 40s but I also wanna make sure I make enough to be able to slow down once i’m in my 50s
 
DrProtonX said:
With current job market, as a new grad, can you even negotiate such things? Is there anything you can use to your leverage to get that kind of contracts that allows you to hit 7-figure if you work hard enough?

I wanna work hard and more than the average rad onc while i’m in my 30s and 40s but I also wanna make sure I make enough to be able to slow down once i’m in my 50s
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As a new grad, not so much. Shortly thereafter, sure. Just run a smooth, profitable clinic for a couple years. That's the leverage.
 
DrProtonX said:
With current job market, as a new grad, can you even negotiate such things? Is there anything you can use to your leverage to get that kind of contracts that allows you to hit 7-figure if you work hard enough?

I wanna work hard and more than the average rad onc while i’m in my 30s and 40s but I also wanna make sure I make enough to be able to slow down once i’m in my 50s
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If there were groups where getting to 7-figure incomes were readily attainable:

1. Those radoncs would not be posting those facts on social media/SDN/anywhere, because there is significant possible downside to doing so and zero possible benefit.

2. Those groups would be large enough, powerful enough, and in-demand enough for employment and partnership that you would likely be offered a "take it or leave it" contract with very little room for meaningful negotiation, but a contract that you ultimately would sign without concern.
 
DrProtonX said:
Rad oncs get less than $60/wRVU? Why does med onc get $100/wRVU but not rad onc?
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Demand.

This is problematic though. Whether you believe in the interpretation of fair market value laws, the companies treat them as commandments haha

I know a couple local med oncs that got very sweet contracts in high demand times but are now facing pay cuts with companies citing lower volumes and FMV.

Along those lines I think it is extremely unlikely you could make 7 figures in an employed position doing clinical care alone. If you were that busy to not be limited by FMV, its possible. But many contracts have escalating $/RVU with volume, so theyd probably want to hire another to keep you at base.
 
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Doctorer said:
Yes, but probably not in places (most) people want to live.
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I hear a lot about these mythical rural clinics that throw money at people just to keep them staffed. I’m in the flyover Midwest and while that may have been true at one time, the rage now is to fill them with FMGs for more typical US salaries.
 
DrProtonX said:
Rad oncs get less than $60/wRVU? Why does med onc get $100/wRVU but not rad onc?
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You really can't compare RVUs between specialties. They mean completely different things.

As for RadOncs making 7 figures, it's possible but extremely rare with an employment model. Most that are have some other revenue streams or technical partnership. I know one person who has an RVU incentive and is pushing 20k RVUs in an extremely busy 5 day a week practice in Florida but not only is it extremely uncommon to have the volume to do that, it is a TON of work. I'm pushing 17k this year and it has been a very busy year. Won't make 7 figures but that would put me very high 6 figures.
 
ramsesthenice said:
I hear a lot about these mythical rural clinics that throw money at people just to keep them staffed. I’m in the flyover Midwest and while that may have been true at one time, the rage now is to fill them with FMGs for more typical US salaries.
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I know at least one in your (I believe) general geographic area.
 
ramsesthenice said:
I hear a lot about these mythical rural clinics that throw money at people just to keep them staffed. I’m in the flyover Midwest and while that may have been true at one time, the rage now is to fill them with FMGs for more typical US salaries.
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Bingo. The job postings here are proof of the pudding. Enough of us have been around since the turn of the century to know that places like Chilacoothe OH and Minot ND were paying well into the 6-figures more back then than they are now. Enough grads coming out to take lower salaries anywhere so that's no longer the case.

Dennis Hallahan effect.
 
medgator said:
Bingo. The job postings here are proof of the pudding. Enough of us have been around since the turn of the century to know that places like Chilacoothe OH and Minot ND were paying well into the 6-figures more back then than they are now. Enough grads coming out to take lower salaries anywhere so that's no longer the case.

Dennis Hallahan effect.
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I cannot believe that guy is still employed
 
Doctorer said:
I know at least one in your (I believe) general geographic area.
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Well, that would make the odds in a 3 state area about 1/20. And the one I know is not exactly rural. As someone said above, the employment model killed high rural pay. I can name exactly 2 non-employed free standing centers in my and 3 surrounding states. Eight years ago, there were 12.
 
The only employed rad onc I know making around that is very busy (probably 20K+ RVU's) and in an area that is "geographically not optimal" with a solid $/RVU rate.

I interviewed at places like @medgator mentioned (rural Ohio) about 10-15 years ago and salaries were around $750-900K. I believe those numbers have come downa lot.

I have had some extremely busy years where we had staffing issues and have had RVU's up in the high 20K or low 30K . I've worked my butt off though - 6:50 AM to 5:00 PM every day, 5 days a week, and put in some weekend time too. I made a lot of money but not sure it is sustainable for a decade.

I've done that though as a PSA without being employed and having our own say over staffing and number of docs. As @NotMattSpraker mentioned, a hospital admin would very likely try to push another doc into the practice if someone is pushing those very high RVU's in an employed model.
 
RSAOaky said:
You really can't compare RVUs between specialties. They mean completely different things.

As for RadOncs making 7 figures, it's possible but extremely rare with an employment model. Most that are have some other revenue streams or technical partnership. I know one person who has an RVU incentive and is pushing 20k RVUs in an extremely busy 5 day a week practice in Florida but not only is it extremely uncommon to have the volume to do that, it is a TON of work. I'm pushing 17k this year and it has been a very busy year. Won't make 7 figures but that would put me very high 6 figures.
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Agree it’s apples and oranges. The main reason Med Onc $/RVU is skewed higher is because chemo infusions generate zero RVUs that are attributable to the physician (maybe a small amount if you want to argue in increases the E/M complexity for the treatment visit but that’s a very small amount).

I don’t know if it would be possible for a Med Onc to generate 17k RVUs in a year without violating our current understanding of space-time.
 
HemeOncHopeful19 said:
Agree it’s apples and oranges. The main reason Med Onc $/RVU is skewed higher is because chemo infusions generate zero RVUs that are attributable to the physician (maybe a small amount if you want to argue in increases the E/M complexity for the treatment visit but that’s a very small amount).

I don’t know if it would be possible for a Med Onc to generate 17k RVUs in a year without violating our current understanding of space-time.
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Perhaps an interesting and germane nugget of info for a heme onc hopeful: radiation treatments (all codes for any and all RT treatments… standard, 3D, IMRT, protons, SBRT) generate zero wRVUs.
 
The point is that rad onc is a heavy RVU speciality. I would venture to guess one of the highest if not the highest.

Trying to compare dollar per RVU or even RVU totals between specialities isn’t really sensible - especially in the era of employment
 
Does anyone have a rough estimate of what percentage of a radiation oncologist's wRVUs come via technical codes vs professional codes?

It's just a world I don't know much about.
 
Mandelin Rain said:
Does anyone have a rough estimate of what percentage of a radiation oncologist's wRVUs come via technical codes vs professional codes?

It's just a world I don't know much about.
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If you mean as a by-product of treatment delivery, I'd say 80-85% is technical. That is to say, 99XXX codes plus laryngoscopy accounts for about 15-20% of my productivity. It's all prof of course.
 
Mandelin Rain said:
Does anyone have a rough estimate of what percentage of a radiation oncologist's wRVUs come via technical codes vs professional codes?

It's just a world I don't know much about.
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For me about 20-25% of my RVU's come from E/M clinic visits or inpatient consults . I do have a very busy follow up clinic though and inpatient service.

Across our group it's closer to 15-20%.
 
BobbyHeenan said:
For me about 20-25% of my RVU's come from E/M clinic visits or inpatient consults . I do have a very busy follow up clinic though and inpatient service.

Across our group it's closer to 15-20%.
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Yeah, ive had to start seeing fewer follow-ups and less frequently given new patient busyness and lack of support. Local med onc sort of sees people overly often, so nbd. I am doing what op asked in an employed rvu model but this is the first year pulling it off so remains to be seen how long they'll allow it.
 
Mandelin Rain said:
Does anyone have a rough estimate of what percentage of a radiation oncologist's wRVUs come via technical codes vs professional codes?

It's just a world I don't know much about.
Click to expand...

Not sure what you mean here. wRVUs are by definition purely professional. Reviewing plans, reviewing imaging, seeing patients, OTVs, generate wRVUs. Delivering a fraction of IMRT is a technical code that does not generate wRVUs. In general, for every professional dollar generated we generate 3-4 technical dollars.

I generate 17% of my wRVUs from E&M visits (consults/follow ups).
 
drowsy12 said:
The point is that rad onc is a heavy RVU speciality. I would venture to guess one of the highest if not the highest.

Trying to compare dollar per RVU or even RVU totals between specialities isn’t really sensible - especially in the era of employment
Click to expand...

This is probably the most important point. RVUs really matter most if you are billing payors directly.

If you are employed, RVUs are just best viewed as how the hospital quantifies your work, specific to your specialty and contract.

It is pointless to compare RVUs across specialties if you are employed. If you are billing directly, go calculate out the RVUs a PCP may generate in a full clinic day and compare it to yours (E/M, sim/treatment planning, image review). You will be surprised.

As an example, reviewing 2 CBCT films "pays" more than a 20-29 minute follow up visit.
 
DrProtonX said:
Rad oncs get less than $60/wRVU? Why does med onc get $100/wRVU but not rad onc?
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Salaries are determined by supply/demand -just like any other service/good in the economy 2) $/RVU are then back adjusted to match the salary.
ie a rural community center with 3/4 consults a week will pay 100$/RVU so that radonc pay is at the median.
Astro/Sameer put out a lot of misinformation about RVUs/CMS professional pay and its (false) relationship to CMS rates.
 
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A decent option for new grads is to take a rural job, let's say 2.5 hrs from a desirable city you like. Negotiate a base/salary of ~600k on a 2 year contract. Let's say they have 6-7 on treat per day. Have a 4 day work week and travel lots, M-H 9-5. Great schedule for family life.

Be a decent long term dr and increase it to 11 on tx. Then 2 years later you go and interview at some high volume rural place that promises a big salary. Then you go to your rural clinic and say if you lose me you're going to lose lots of revenue because your volume will decrease back to what if you staffed with locums. I want you to match this big salary.

In some ways, employed positions can be a poor man's technical ownership because you'll get paid more than the professional fees. And the hospital has more revenue and you're a good dr and pts are happy so everyone wins.

This only works if you're ok with rural-ish
 
maxwellradonc said:
A decent option for new grads is to take a rural job, let's say 2.5 hrs from a desirable city you like. Negotiate a base/salary of ~600k on a 2 year contract. Let's say they have 6-7 on treat per day. Have a 4 day work week and travel lots, M-H 9-5. Great schedule for family life.

Be a decent long term dr and increase it to 11 on tx. Then 2 years later you go and interview at some high volume rural place that promises a big salary. Then you go to your rural clinic and say if you lose me you're going to lose lots of revenue because your volume will decrease back to what if you staffed with locums. I want you to match this big salary.

In some ways, employed positions can be a poor man's technical ownership because you'll get paid more than the professional fees. And the hospital has more revenue and you're a good dr and pts are happy so everyone wins.

This only works if you're ok with rural-ish
Click to expand...
`Is solo practice with every Fri WFH a common thing in 2025? Anecdotally, places that I'm familiar with are balking at the idea big time
 
A_DeMichele said:
`Is solo practice with every Fri WFH a common thing in 2025? Anecdotally, places that I'm familiar with are balking at the idea big time
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it is all market driven and domes back to supply and demand. Dosimetrists almost never worked from home until there was a shortage and they began to demand it. Now you cant hire a dosimetrist without allowing them to at least partially work from home.
 
A_DeMichele said:
`Is solo practice with every Fri WFH a common thing in 2025? Anecdotally, places that I'm familiar with are balking at the idea big time
Click to expand...
RickyScott said:
it is all market driven and domes back to supply and demand. Dosimetrists almost never worked from home until there was a shortage and they began to demand it. Now you cant hire a dosimetrist without allowing them to at least partially work from home.
Click to expand...

Yes, all market driven.

All our dosimetrists after covid went from 5/day week in office to now only 2-3 days in person.

But if you're making a bunch of $ on top of your pro collections, admins start to wonder what they're paying for if you're at home instead of at work. Even if "baby sitting" and we all know not being there while the linac is one sometimes is perfectly fine, some admins don't like it.

I do know a lot of groups (med onc too) and employed docs are 4 days/week though right now, though work is legit being done at home on that "off day" in my experience - fielding phone calls, charting, contouring, etc.
 
BobbyHeenan said:
Yes, all market driven.

All our dosimetrists after covid went from 5/day week in office to now only 2-3 days in person.

But if you're making a bunch of $ on top of your pro collections, admins start to wonder what they're paying for if you're at home instead of at work. Even if "baby sitting" and we all know not being there while the linac is one sometimes is perfectly fine, some admins don't like it.

I do know a lot of groups (med onc too) and employed docs are 4 days/week though right now, though work is legit being done at home on that "off day" in my experience - fielding phone calls, charting, contouring, etc.
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I am in clinic 4 days a week. It should be the standard and has had an unimaginable improvement on my quality of life and mental health. On weeks when I am covering a partner and in the office 5 days my quality of life is notably worse.
 
RSAOaky said:
I am in clinic 4 days a week. It should be the standard and has had an unimaginable improvement on my quality of life and mental health. On weeks when I am covering a partner and in the office 5 days my quality of life is notably worse.
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This is my dream but it's tougher when solo
I make strides toward it every year, though, maybe one day soon...
 
A couple thoughts in response to multiple posts above:

1. OP seems primarily focused on money. This is not going to end well. I took the highest paying job I could out of residency (650k with 125k signing bonus) in a very rural area. It was one of the biggest mistakes of my life. I would have been better off taking a lower paying job upfront and working on building up my income later as I gained experience and value to employers. Remember that you are touching the top marginal tax bracket at these income levels. An extra 100k sounds like a fortune to a resident. After 40-50% to the tax man, it's not going to meaningfully move the needle on your lifestyle. Don't move to the middle of nowhere because they are offering you an extra 100k base or signing bonus. Big luxury houses in the middle of nowhere? Not likely. Housing options will not be anything you are interested in (think the entire town being small 1960s ranch houses with zero rental options), and if you do decide to build a fancy doctor house, good luck selling it for anywhere near what it cost to build.

2. Yes, employed positions can earn > 1M. You can check this at Marithealth.com. Someone recently posted a 1.6M employed income in west Virginia. Of course, this is all coming from productivity and this person is probably working 12 hours days 5 days a week plus catch up on the weekends. Nobody is going to base you at 7 figures (the highest I've ever heard of is low 800s). It is critical for employed positions that your contract pays you a flat rate per RVU (eat what you kill) without a limit. Unless you are in a low volume clinic, this is the most important number in your negotiations. Ideally your RVU numbers will be paid out on a monthly basis.

3. I believe employed positions are often the most bang for your buck these days. If you are in a rural area, your RVU rate will likely be paying you out of technical collections. Add in benefits and a medical director stipend, and you are basically accessing a decent portion of the technical without any buy-in. The downside is of course you aren't a partner and there is no buy-out. You can be let go at any time.

4. Technical codes do not contribute to wRVUs. When I did these calculations in the past, of all RVUs produced, 21.5% of mine were wRVUs (or put another way 21.5% of global collections were professional collections).

5. Agree with <5 day workweek for employed positions. Employers are coming around on this and not chaining solo docs to the machine anymore. At this point in my career, there is no way I would ever consider a 5 day a week position only for the purpose of direct supervision (if they are so busy 5 days of consults are needed and I am paid per RVU, that's a different story).

6. Please don't hide all of this info in the private forum. It's important for graduating residents to understand. I wish I did. The paranoia from some about trying to hide subspecialist income is a little extreme. We have recently experienced pretty wild inflation. The $650k salary I had 6 years ago when I started would now be equivalent to $828k. My RVU rate is exactly the same ($70). That would be $90 now. A $90 rate is unheard of. My guess is many are stuck at pre-pandemic rates and mindset in terms of thinking about these numbers and collectively we need to try and claw back some of what has been lost when changing jobs and re-negotiating contracts. Again, another reason you don't want to be billing and collecting professional fees from medicare on your own these days. A hospital will have greater flexibility to fund your RVU rate well beyond what you could collect on your own.

7. 77014 (cone beam CT review) is nearly 25% of my income and this code is going away next year. Nobody knows how or if it will be replaced (will there be a professional component in the new code and what will it be?) This is a big deal and something to think about in the context of all of the above.
 
alwaysbeIMRTing said:
A couple thoughts in response to multiple posts above:

1. OP seems primarily focused on money. This is not going to end well. I took the highest paying job I could out of residency (650k with 125k signing bonus) in a very rural area. It was one of the biggest mistakes of my life. I would have been better off taking a lower paying job upfront and working on building up my income later as I gained experience and value to employers. Remember that you are touching the top marginal tax bracket at these income levels. An extra 100k sounds like a fortune to a resident. After 40-50% to the tax man, it's not going to meaningfully move the needle on your lifestyle. Don't move to the middle of nowhere because they are offering you an extra 100k base or signing bonus. Big luxury houses in the middle of nowhere? Not likely. Housing options will not be anything you are interested in (think the entire town being small 1960s ranch houses with zero rental options), and if you do decide to build a fancy doctor house, good luck selling it for anywhere near what it cost to build.

2. Yes, employed positions can earn > 1M. You can check this at Marithealth.com. Someone recently posted a 1.6M employed income in west Virginia. Of course, this is all coming from productivity and this person is probably working 12 hours days 5 days a week plus catch up on the weekends. Nobody is going to base you at 7 figures (the highest I've ever heard of is low 800s). It is critical for employed positions that your contract pays you a flat rate per RVU (eat what you kill) without a limit. Unless you are in a low volume clinic, this is the most important number in your negotiations. Ideally your RVU numbers will be paid out on a monthly basis.

3. I believe employed positions are often the most bang for your buck these days. If you are in a rural area, your RVU rate will likely be paying you out of technical collections. Add in benefits and a medical director stipend, and you are basically accessing a decent portion of the technical without any buy-in. The downside is of course you aren't a partner and there is no buy-out. You can be let go at any time.

4. Technical codes do not contribute to wRVUs. When I did these calculations in the past, of all RVUs produced, 21.5% of mine were wRVUs (or put another way 21.5% of global collections were professional collections).

5. Agree with <5 day workweek for employed positions. Employers are coming around on this and not chaining solo docs to the machine anymore. At this point in my career, there is no way I would ever consider a 5 day a week position only for the purpose of direct supervision (if they are so busy 5 days of consults are needed and I am paid per RVU, that's a different story).

6. Please don't hide all of this info in the private forum. It's important for graduating residents to understand. I wish I did. The paranoia from some about trying to hide subspecialist income is a little extreme. We have recently experienced pretty wild inflation. The $650k salary I had 6 years ago when I started would now be equivalent to $828k. My RVU rate is exactly the same ($70). That would be $90 now. A $90 rate is unheard of. My guess is many are stuck at pre-pandemic rates and mindset in terms of thinking about these numbers and collectively we need to try and claw back some of what has been lost when changing jobs and re-negotiating contracts. Again, another reason you don't want to be billing and collecting professional fees from medicare on your own these days. A hospital will have greater flexibility to fund your RVU rate well beyond what you could collect on your own.

7. 77014 (cone beam CT review) is nearly 25% of my income and this code is going away next year. Nobody knows how or if it will be replaced (will there be a professional component in the new code and what will it be?) This is a big deal and something to think about in the context of all of the above.
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Thank you for such a great and thorough response. I’m not primarily focused on money but I do have an expensive taste (sports cars, swiss watch, lake house and boats excite me alot) and I hope after many years of hard work I’d be able to afford at least some of those. The difference betweem a rural area and a nice city a significant. Making $650k in rural west virgina where you can buy a 4-5 bedroom house for $300k vs. making $350k in Manhattan where you probably won’t even be able to buy a house. I also enjoy radiation oncology alot so I absolutely wouldn’t mind working 10-12 hours 5 days a week as long as it reflects in my compensation, that was the reason I ask this question
 
DrProtonX said:
Thank you for such a great and thorough response. I’m not primarily focused on money but I do have an expensive taste (sports cars, swiss watch, lake house and boats excite me alot) and I hope after many years of hard work I’d be able to afford at least some of those. The difference betweem a rural area and a nice city a significant. Making $650k in rural west virgina where you can buy a 4-5 bedroom house for $300k vs. making $350k in Manhattan where you probably won’t even be able to buy a house. I also enjoy radiation oncology alot so I absolutely wouldn’t mind working 10-12 hours 5 days a week as long as it reflects in my compensation, that was the reason I ask this question
Click to expand...

Lot of places between those two ends of the spectrum. As pointed out there may not be a house worth buying above 200k in many of these towns, so you may have money, but have to find ways to spend it in ways that don't excite you when the houses, restaurants, social life, etc have little appeal to you.

Find yourself a nice suburb of a mid-sized city in the midwest or south. Pay may not be quite as good as the middle of now-where jobs, but life's too short to hate where you live.
 
alwaysbeIMRTing said:
7. 77014 (cone beam CT review) is nearly 25% of my income and this code is going away next year. Nobody knows how or if it will be replaced (will there be a professional component in the new code and what will it be?) This is a big deal and something to think about in the context of all of the above.
Click to expand...

I wish this was openly discussed earlier and we had an opportunity to comment. I literally found out about this via a random LinkedIn post that discussed it in passing.
 
NotMattSpraker said:
I wish this was openly discussed earlier and we had an opportunity to comment. I literally found out about this via a random LinkedIn post that discussed it in passing.
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Yup. Just randomly showed up in some ASTRO post for me.

I assume they are going to bundle all these IGRT codes (like the surface guided, orthogonals, CBCT's) into one code (hopefully). Though you know the reimbursement is about to be cut too. From what I gathered it likely be be disappearing, but you can bet another cut is coming...and that is a HUGE chunk of RVU's or pro fees.
 
Not to beat to death supply and demand, but if cms cut radiologists, rvus by 25%, I doubt it would affect their salaries. They would just get 25% more per rvu.
 
RickyScott said:
Not to beat to death supply and demand, but if cms cut radiologists, rvus by 25%, I doubt it would affect their salaries. They would just get 25% more per rvu.
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It would in the end. Maybe the current generation would have similar comp but admin will ask questions/restructure comp if you aren't making enough for them
 
udrag14 said:
It would in the end. Maybe the current generation would have similar comp but admin will ask questions/restructure comp if you aren't making enough for them
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even if cms totally eliminates all proffessional reimbursement, radonc and radiology will still bring in a huge amount for the hospital, which are bilking society with 5-10x cms technical rates through private payors.

Salaries like every other good and service in the economy is priced by supply and demand. We do not defy gravity.
 
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