Hematology/Oncology compensation: why the big inequality?

[yg1786]

So according to the Career in Medicine website, Oncologists make $267,643 at the 25% percentile and $688,578 at the 75th percentile. What gives with the big range? Are 25% of hem/onc working 35 hours and the others 80 hours a week? What makes some of these practices so lucrative? I was just surprised that anyone could make close 700K in hem/onc, let alone 25% of the speciality

Thanks

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[gutonc]

So according to the Career in Medicine website, Oncologists make $267,643 at the 25% percentile and $688,578 at the 75th percentile. What gives with the big range? Are 25% of hem/onc working 35 hours and the others 80 hours a week? What makes some of these practices so lucrative? I was just surprised that anyone could make close 700K in hem/onc, let alone 25% of the speciality

Thanks

The ones on the low-end are doing academics and working for HMOs. The ones on the high end are working 80-hr weeks, own their own infusion units and imaging centers and see 40 patients a day. There's a lot of room there in the middle.

 

[yg1786]

yeah i guess that makes sense, though I think this is a survey of private practioners. I think hem/onc had the biggest range of any speciality in terms of the 25%/75% income split so i was a little shocked. anyone else know if these numbers of the MGMA are misleading or not?

 

[texashemonc]

easy answer to this question.
the ones making the 75% are either extremely busy or are the ones "overtreating" patients with drugs, mostly supportive care ones such as aranesp and neulasta. In oncology, the more chemo you give, generally the more money one makes. It's sad when I see patients as a second opinion from other oncologists who have given dose-dense AC-T with neulasta support to a 70 yo women with T1N0 ER+PR+Her2- tumor following masectomy. or FOLFOX4 to a 75yo man with stage II colon cancer T3N0. This goes on and on.

Patients can't tell if they're being overtreated- their attitude is that more chemo, less risk of relapse and can easily be swayed by their docs.
Only other oncologists are the ones who can identify if the treatment plans are correct. I wish medicare could go after these corrupt docs. They have cut down on epo drugs already.

 

[docfromCN]

easy answer to this question.
the ones making the 75% are either extremely busy or are the ones "overtreating" patients with drugs, mostly supportive care ones such as aranesp and neulasta. In oncology, the more chemo you give, generally the more money one makes. It's sad when I see patients as a second opinion from other oncologists who have given dose-dense AC-T with neulasta support to a 70 yo women with T1N0 ER+PR+Her2- tumor following masectomy. or FOLFOX4 to a 75yo man with stage II colon cancer T3N0. This goes on and on.

Patients can't tell if they're being overtreated- their attitude is that more chemo, less risk of relapse and can easily be swayed by their docs.
Only other oncologists are the ones who can identify if the treatment plans are correct. I wish medicare could go after these corrupt docs. They have cut down on epo drugs already.

do these doctors need not to follow any guidelines?

 

[randombetch]

Isn't there some kind of oversight or someone at the top who can fire doctors who overtreat their patients? I feel like the department head of any hospital should have a responsibility to make sure none of his/her doctors are partaking in these immoral practicies.

 

[gutonc]

Isn't there some kind of oversight or someone at the top who can fire doctors who overtreat their patients? I feel like the department head of any hospital should have a responsibility to make sure none of his/her doctors are partaking in these immoral practicies.

You pre-meds are so cute. Anybody in a position to fire such a physician (assuming such treatment is in fact immoral which neither you nor I are in any position to judge) is also making money off of their practice. How many people are willing to kill the goose who lays the golden egg?

 

[randombetch]

You pre-meds are so cute. Anybody in a position to fire such a physician (assuming such treatment is in fact immoral which neither you nor I are in any position to judge) is also making money off of their practice. How many people are willing to kill the goose who lays the golden egg?

Well, it's quite unlawful for a physician to overtreat a patient, and I'm sure (or at least, I hope) those in the higher positions get some sort of backlash for allowing such behavior if caught (ie: if the physician gets sued for overtreating).

 

[AuroraK]

Well, it's quite unlawful for a physician to overtreat a patient, and I'm sure (or at least, I hope) those in the higher positions get some sort of backlash for allowing such behavior if caught (ie: if the physician gets sued for overtreating).

What exactly is overtreating in oncology? If a patient with 2 kids really really wants that 6th line chemo, and knows its dangerous, but wants that 1% chance to see her kids grow up, are you going to say no? Private insurers dont even have the cajones to say no in those situations usually (though they give you heck for it) because of the negative publicity. So unless you have Medicaid or Medicare, and the insurer will pay, and the patient wants it, what is overtreating?

And this is kinda the fundamental healthcare debate right now (and theres an article in NY Times about end of life care) that indirectly addresses this

 

[howelljolly]

Well, it's quite unlawful for a physician to overtreat a patient, and I'm sure (or at least, I hope) those in the higher positions get some sort of backlash for allowing such behavior if caught (ie: if the physician gets sued for overtreating).

Its not unlawful, and you probably don't understand what "overtreat" means.

One could simply replace "overtreat" with "treat aggressively".... giving full courses of chemo, as well as medically treating the side effects such as anemia, nausea, fatigue, etc. etc.

Theres nothing wrong with it, as long as the patient can handle it. Whether it really helps any more than a less aggressive treatment, we cant know since each patient responds differently

And no... the chair of the Heme/onc department, or the partners in a private heme/onc practice do not generally review the treatment plans of the individual attendings. Thats between the attending and the patient.

Nice job resurrecting a 2 year old thread.

 

[howelljolly]

Isn't there some kind of oversight or someone at the top who can fire doctors who overtreat their patients? I feel like the department head of any hospital should have a responsibility to make sure none of his/her doctors are partaking in these immoral practicies.

Its not immoral. You got a guy with a big lung mass. You put him on chemo. He tolerated it well, with minimal weight loss and other side effects. On followup scans, the tumor has gotten considerably smaller, but theres a small nodule left. What's immoral about giving another few weeks of chemo to blast that sucker away?

No top doctor anywhere should have to take "responsibility" for the way another doctor practices medicine.

Especially in oncology no department head should dictate how the individual attendings practice. There is an art to oncology, and each oncologist has their own style. It takes years of expereince for them to be able to gauge when it's better to push forward, and when to pull back. There isn't any sort of etched-in-stone treatment protocol that will tell you how to manage your individual patient. Oncologists should be valued for their individual expertise, and not be told what to do by the department chair.

Within the heme/onc practice that I rotated in, each oncologist had their own style, and own expertise. There was even a patient or two that switched oncologists within the practice because one or the other had more experience with and was more willing to give aggressive chemo (and treat the side effects), while one thought it wouldn't be safe. Same patient, two opinions. Who was correct, only time could tell. So, as always, it was up to the patient.


Imagine a patient going in for his monthly followup...

"Hi, Im here to see Dr Doe."

"Oh, we fired him, You'll see Dr. Smith instead."

"But Ive been seeing Dr Doe for a year, Hes treating my colon cancer."

"Yeah, we fired him because he gave Ms. Jones two additional rounds of chemo for her lung cancer."

"Oh, did Ms Jones die?"

"No."

"Oh, thats grand. Now, Im here to see Dr Doe he's been tailoring my treatment for a year now"

"Im sorry, you'll see Dr Smith. He has an appointment opening. His patient Mr. Baker died yesterday."

"Oh, Im sorry to hear that, I'd just talked to Mr Baker last month in the waiting room. Too much chemo, no doubt?"

"No, Mr Baker just got the usual course. Well, Dr Smith is ready for you. Best of luck now."

 

[randombetch]

You think treating more "aggressively" for the purpose of getting a higher paycheck isn't immoral?

You probably didn't understand what I meant by "over treat." A patient who wants an aggressive treatment is not overtreated by getting an aggressive treatment. A patient who wants a less aggressive treatment is overtreated by getting a more aggressive treatment than he or she would have liked.

Over treating, if interfering with the standard of care, is unlawful.

 

[gutonc]

You probably didn't understand what I meant by "over treat." A patient who wants an aggressive treatment is not overtreated by getting an aggressive treatment. A patient who wants a less aggressive treatment is overtreated by getting a more aggressive treatment than he or she would have liked.

The issue with this is that, these patients tend to be pretty vulnerable and open to any suggestion that Drug X will be the one to give them that extra time until little Jimmy's first birthday, or Tiffany's wedding or whatever. So while they may have initially been interested in less aggressive treatment (or none at all...something I always offer to my metastatic patients after describing other available options) they may be easily swayed to try a more aggressive/expensive therapy.

It's not as black and white as you lay it out to be. And I don't think anyone here is talking about not treating to standard of care. The thing about oncology is that, for the rarer cancers - and even for some relatively common ones like pancreatic, there's usually only one or 2 lines of "standard of care" therapy, after that you're flying by the seat of your pants, using phase II or case report data to treat.

 

[howelljolly]

You think treating more "aggressively" for the purpose of getting a higher paycheck isn't immoral?

You probably didn't understand what I meant by "over treat." A patient who wants an aggressive treatment is not overtreated by getting an aggressive treatment. A patient who wants a less aggressive treatment is overtreated by getting a more aggressive treatment than he or she would have liked.

Over treating, if interfering with the standard of care, is unlawful.

Whatever. Who are you? An oncologist who treats agressively for the purpose of getting a higher paycheck is insane because while their patient is giving them a purpose for treating them (i.e. Please Doc, I dont want to die), they're treating for the purpose of selling their chemo. Thats insane, and probably doesnt happen because the oncologist would have to be a sociopath.

Do you think that patients are forcibly overtreated? Do they strap the patient down for three hours and infuse them against their will? No. They bring themselves to the infusion center, roll up their sleeve, and sit there. They have a nurse infuse the chemo and stand there watching them for a reaction. If they get one, they stop the infusion. The oncologist takes said reaction into account for the next treatment.

C'mon. of course treating a patient against their will is assault. But your hypothetical of an oncologist choosing more expensive treatments, and subjecting patients to them against their will is absurd.

The issue with this is that, these patients tend to be pretty vulnerable and open to any suggestion that Drug X will be the one to give them that extra time until little Jimmy's first birthday, or Tiffany's wedding or whatever. So while they may have initially been interested in less aggressive treatment (or none at all...something I always offer to my metastatic patients after describing other available options) they may be easily swayed to try a more aggressive/expensive therapy.

It's not as black and white as you lay it out to be. And I don't think anyone here is talking about not treating to standard of care. The thing about oncology is that, for the rarer cancers - and even for some relatively common ones like pnacreatic, there's usually only one or 2 lines of "standard of care" therapy, after that you're flying by the seat of your pants, using phase II or case report data to treat.

Take that!

 

[texashemonc]

Unfortunately, even after commenting in this discussion 2 years ago, this is still a sore spot among oncologists. In private practice there is still a very real financial incentive to be pushing "aggressive" treatment regimens, just like any other medical specialty. When it comes to cancer patients though, it is unfortunate that many docs use this as an incentive to give chemo when the response rates are going to be very small and take advantage of their patients' lack of knowledge and fear of recurrence. I think that is most heavily abused in patients receiving adjuvant chemotherapy, such as in early breast or colon cancer.

What about patients given herceptin for a year for Her2 neu negative cancers? (at a cost of a few thousand a month). What about patients given aggressive chemotherapy for DCIS of the breast? It happens quite often in private practice. And no, the state boards won't do anything about it unless there has been actual harm to the patient from side effects of the chemotherapy.

And this happens in just about all practices, whether it be private or academic.

 

[howelljolly]

Unfortunately, even after commenting in this discussion 2 years ago, this is still a sore spot among oncologists. In private practice there is still a very real financial incentive to be pushing "aggressive" treatment regimens, just like any other medical specialty. When it comes to cancer patients though, it is unfortunate that many docs use this as an incentive to give chemo when the response rates are going to be very small and take advantage of their patients' lack of knowledge and fear of recurrence. I think that is most heavily abused in patients receiving adjuvant chemotherapy, such as in early breast or colon cancer.

What about patients given herceptin for a year for Her2 neu negative cancers? (at a cost of a few thousand a month). What about patients given aggressive chemotherapy for DCIS of the breast? It happens quite often in private practice. And no, the state boards won't do anything about it unless there has been actual harm to the patient from side effects of the chemotherapy.

And this happens in just about all practices, whether it be private or academic.

Fair enough.

 

[AuroraK]

Unfortunately, even after commenting in this discussion 2 years ago, this is still a sore spot among oncologists. In private practice there is still a very real financial incentive to be pushing "aggressive" treatment regimens, just like any other medical specialty. When it comes to cancer patients though, it is unfortunate that many docs use this as an incentive to give chemo when the response rates are going to be very small and take advantage of their patients' lack of knowledge and fear of recurrence. I think that is most heavily abused in patients receiving adjuvant chemotherapy, such as in early breast or colon cancer.

What about patients given herceptin for a year for Her2 neu negative cancers? (at a cost of a few thousand a month). What about patients given aggressive chemotherapy for DCIS of the breast? It happens quite often in private practice. And no, the state boards won't do anything about it unless there has been actual harm to the patient from side effects of the chemotherapy.

And this happens in just about all practices, whether it be private or academic.

Point taken, especially on the herceptin issue, which I had never heard before being given to HER2 neg patients. That said, I feel the opposite way at VA, where everything is so managed and restricted I cant even get the right antibiotics to appropriately cover our patients. But there is a balance somewhere in between thats for sure.

 

[loveoforganic]

Jfc, is top 75% really that high or is that inflated???? If not, where's all that money come from? Surely not salary, and heme/onc isn't really procedure-driven, is it? Is there a cut for the pricey prescriptions?

Edit: another link, that seems much more reasonable.. http://swz.salary.com/salarywizard/layouthtmls/swzl_compresult_national_HC07000054.html

 

[howelljolly]

Jfc, is top 75% really that high or is that inflated???? If not, where's all that money come from? Surely not salary, and heme/onc isn't really procedure-driven, is it? Is there a cut for the pricey prescriptions?

Edit: another link, that seems much more reasonable.. http://swz.salary.com/salarywizard/layouthtmls/swzl_compresult_national_HC07000054.html

Dispensary. The doc is making money off the chemo infusion center. Possibly.

 

[roswel]

Hematology Oncology as a speciality is changing from outpatient to inpatient, especially chemo infusion wise, because; out pt infusion reimbursement rates are going down. Now Physicians will get less reimbursment from medicare but Medicare will still pay more now for inpatient chemo to hospitals for each pt Chemo Rx. So now trend is that hospitals are highering hematologist oncologist so they make money via oncologist through in pt chemo. On happy side, starting sallary for hematology oncology ( away from big city ) is still 400k being offered by hospitals to keep oncologist as hospital employe.....In past these oncologist used to join independent groups with out pt infusion centers in past in the start of their career....

 

[staup]

Interesting... I haven't heard about this before. Hem/Onc will always make more money then primary care because chemo administration is somewhat complicated and a "semi procedure", and an attending can be responsible for many pts getting chemo at once. That being said, I'm sure it will change even more in the future, but for now, private practice partners are still making a ton in the right situation.

Money aside, it will always be a great specialty, ripe with research opportunities, great patient relationships, and a reasonable lifestyle (other than being in a one or two doc private practice).

Thanks for the info though.

 

[asprin81]

bump

 

[Socrates25]

Unfortunately, even after commenting in this discussion 2 years ago, this is still a sore spot among oncologists. In private practice there is still a very real financial incentive to be pushing "aggressive" treatment regimens, just like any other medical specialty. When it comes to cancer patients though, it is unfortunate that many docs use this as an incentive to give chemo when the response rates are going to be very small and take advantage of their patients' lack of knowledge and fear of recurrence. I think that is most heavily abused in patients receiving adjuvant chemotherapy, such as in early breast or colon cancer.

What about patients given herceptin for a year for Her2 neu negative cancers? (at a cost of a few thousand a month). What about patients given aggressive chemotherapy for DCIS of the breast? It happens quite often in private practice. And no, the state boards won't do anything about it unless there has been actual harm to the patient from side effects of the chemotherapy.

And this happens in just about all practices, whether it be private or academic.

I dont think the issue with heme/onc applies equally to all specialties. Heme/onc is one of only 2 or 3 specialties that get paid for how many drugs/infusions they give, which of course skews their incentives.

A pediatrician or an IM doc doesnt get paid extra money for handing out scripts for antibiotics. They have other incentives to do so (e.g. doc wants to see 50 patients per day and its easier to just write scripts rather than argue with parents) but its not a direct "money in my pocket" kind of issue.

 

[carrigallen]

In general, you get more for doing more. If I order a procrit shot at an infusion center, I get to charge for: 1) the visit 2) the drug 3) administering the shot. Compare that to answering a protracted telephone call for abdomen pain at 2 am, where I get to charge for: nothing.

CMMS adheres to the idea that "talk is cheap" in its reimbursement policies. It is savvier to order PET scans, labs, procrit, hyperfractionated xrt, etc, rather than have often time-consuming discussions with family. In some ways, families often want doctors who 'do things', especially if the interventions are fairly harmless. Patients who are treated unnecessarily are often the most appreciative, and the easiest to keep in your practice.

The ideal practice would be a sytem where the new patient swipes his insurance card, and then a robot charges him for visit, draws his CTCs, and gives him three separate IM injections of avastin, abraxane, neulasta. If patient has Heme diagnosis code, then the injections are rituxan + procrit. He is then continued on lifelong maintenance therapy. All questions or requests to speak to a doctor are referred to 911 dispatcher.
(being facetious here)

 

[interactmd]

Not only did they get rid of any markup on procrit, good luck getting paid for the injection, or the visit!

Procrit's been a loser since this 2007 NYT article, which pretty much killed the procrit gig. That was almost five years ago! I'm too young to ever have gotten much financial incentive from Procrit. It's easy to take the Procrit shot at us, but it doesn't reflect reality.

After the 2007 article, the FDA and CMS came out with a lot of new guidelines on Procrit, telling us when we could or couldn't use it, and putting a REMS program on it, making patients sign a paper saying they're aware they will die sooner if they take a Procrit shot.

I personally use very minimal Procrit in my practice for people on chemo, and limited amounts on people with anemia of chronic renal insufficiency, MDS, and other indications. I hope that's ok with everyone.

Mike