Is going private practice a bad decision given the upcoming payment model changes?

Jul 24, 2019
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Hello everyone, I don't post much but was curious about everyone's thoughts about the practice realm given the impending payment model changes. I have two job offers in an ideal area for me with an academic satellite or a private practice standalone (with multiple centers). The compensation with the private group is far more in addition to potential partnership in a few years but I worry about how the payment model will ultimately impact small groups versus a bigger center. If it wasn't for the payment model changes I think I would take the private practice job in a heart beat.

For those in the job market, did the potentially changing payment model factor in to your decisions? Would you turn down a good private practice job given these potential changes?
 

Gfunk6

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Speaking as a private practice partner whose practice extensively hypofractionates (both moderate and extreme) I can tell you that our Medicare payments would stay neutral/slightly improve with proposed CMS capitated payments. Furthermore, implementation of the RO APM would (presumably) mitigate the burden of meticulously billing all charges as we currently do.

We look forward to it and were somewhat disappointed at the delay.
 
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Thanks for sharing that. I had no idea. Admittedly, I don't know enough about Radiation Oncology billing and just assumed the worst. Is it safe to say most stable private practices won't be significantly impacted? Any good resources on billing and the new APM?
 
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scarbrtj

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I saw a couple interesting items in the Red Journal the last few months...
1) At Mayo Clinic e.g., if I'm reading it right, their average RO patient tx costs are ~$50K per Medicare patient. I am in PP and our avg is about $12500/pt. We do OK. I would think we would be facing a big drop in the RO APM if we got reimbursed $50K per patient though.
2) That said, you'd think academics would hypofx more than PP. Maybe they don't. Again, citing Mayo Clinic data, they foresee a 9% drop in revenue overall with RO APM. I think a drop like that is livable, but not palatable obviously.
3) IMHO you'll always come out ahead in the money game in PP, on avg making millions more in a lifetime. If that's high on your list...
 
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Wish money wasn't a factor but with student loans it's unfortunately near the top of my list. Thanks for the article
 
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For the foreseeable future, it will always be more financially rewarding to be a partner in a private practice, unless your hospital gives the group or you a good deal.
 
Aug 25, 2018
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Hello everyone, I don't post much but was curious about everyone's thoughts about the practice realm given the impending payment model changes. I have two job offers in an ideal area for me with an academic satellite or a private practice standalone (with multiple centers). The compensation with the private group is far more in addition to potential partnership in a few years but I worry about how the payment model will ultimately impact small groups versus a bigger center. If it wasn't for the payment model changes I think I would take the private practice job in a heart beat.

For those in the job market, did the potentially changing payment model factor in to your decisions? Would you turn down a good private practice job given these potential changes?
I actually turned down the opportunity to buy an entire practice because of these changes. The practice is being priced based on the current model and I'm fearful of "buying high, selling low." If you end up getting stuck paying off the practice in 10, 15 or even 20 years its probably ok if you know for certain you wouldn't mind living there.... but it was very rural and very cold... and I just wasn't sure I could do it.

There were two other factors contributing to me getting cold feet. One was that there was no certificate of need program. If the hospital across the street wants a linac... then they can just plop one down. Also... the general surgeon and ENT had just become employed and they were a huge referral stream for that practice. If that hospital does open their own linac... then that's half the current business that would evaporate.

On the bright side... if APM causes major layoffs of hospital employed docs... you can rest easy knowing you aren't going to fire yourself. So if you can see yourself living in the area of that private practice for life... I would take it.

And if I owned a center right now and was near the end of my career... you bet I would be trying to off load it!
 
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CaesarRO

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Do your calculations on the impact of APM differ if your looking at a PSA PP vs one that owns the machines?

Sent from my Pixel 2 XL using Tapatalk
 
Jul 30, 2018
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Since all the PP groups where I am have folded last one in 2014, It’s really a moot point. The most likely thing to happen to most rads who are employed in some kind of corporate practice at this point is this. Everyone will take a hit on APM and you’ll make less and you’ll put up with it because you have no other options in most major markets.

If you want to do
Private go right ahead just know it probably won’t be around by the time you make partner if they even offer that to you.
 

RadOncDoc21

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Would 21st century be considered private or corporate? I would definitely consider them corporate but pretend to be private.
 
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RadOncDoc21

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Yeah only the patients would consider 21C it it’s latest handler a “mom and pop” cancer clinic
You’ll be surprised, a lot of the referring docs don’t know the difference either or know about other types of practices, facilities they own.
 

RadRadRad

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I’d still probably go private over academic if the group has history of following through with partnership plan and if there is enough volume to justify your position. The second point is valid for all jobs but probably more important for pp. A good job needs a defined role and patient group for the new hire. I would be wary of taking any job where you don’t see a path to having 15-20 on treat (minimum). A retiring doc or a new facility to staff Rather than a group just looking to cut down on their workload.
 
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I think the decision is sort of irrelevant nowadays. In The last 10 years you either were employed or in the process of becoming employed (aka private).

In the next 10 years, I think everyone will basically operate with an academic title and most patients will be going to major centers for cancer care.

It’s large centralized and easier to control costs and practice patterns aka like via oncology.
 

Pointless

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I think the decision is sort of irrelevant nowadays. In The last 10 years you either were employed or in the process of becoming employed (aka private).

In the next 10 years, I think everyone will basically operate with an academic title and most patients will be going to major centers for cancer care.

It’s large centralized and easier to control costs and practice patterns aka like via oncology.
Damn, so most of my patients are going to drive 1 1/2 hours every day back and forth for treatment to get to the nearest "major" center? That's too bad. Thanks for the heads up though, I'll let them know.
 

Pointless

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Hello everyone, I don't post much but was curious about everyone's thoughts about the practice realm given the impending payment model changes. I have two job offers in an ideal area for me with an academic satellite or a private practice standalone (with multiple centers). The compensation with the private group is far more in addition to potential partnership in a few years but I worry about how the payment model will ultimately impact small groups versus a bigger center. If it wasn't for the payment model changes I think I would take the private practice job in a heart beat.

For those in the job market, did the potentially changing payment model factor in to your decisions? Would you turn down a good private practice job given these potential changes?
For the love of God, take the private position :)

APM will hit the practices that haven't embraced hypofrac for breast and prostate much harder than it will for those who have already adopted and taken that hit. In fact, as Gfunk noted above, those practices that have fully embraced hypofrac and cost savings already may even see a bump in revenue. So, I guess it pays to know how any practice that you are joining treats their patients. 60/30 for all breasts and 79.2/39 for prostates? Or 40/15 for breast and 70/28 for prostate?
 
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Damn, so most of my patients are going to drive 1 1/2 hours every day back and forth for treatment to get to the nearest "major" center? That's too bad. Thanks for the heads up though, I'll let them know.
I’m sure they’ll set up lodging for them otherwise SOL.
 
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scarbrtj

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Damn, so most of my patients are going to drive 1 1/2 hours every day back and forth for treatment to get to the nearest "major" center? That's too bad. Thanks for the heads up though, I'll let them know.
If we can cut ALL treatments down to 5 fractions or less (and get level 5 autonomy!) 90 minute drives during a course of RT will be no sweat.

Much shorter radiation treatment found to be safe, effective for people with soft tissue sarcoma: Study shows radiation therapy can be cut from 5 weeks to 5 days
Ultrahypofractionated/SBRT is becoming a standard of care option for low- to intermediate-risk prostate cancer
 
Jul 30, 2018
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For the love of God, take the private position :)

APM will hit the practices that haven't embraced hypofrac for breast and prostate much harder than it will for those who have already adopted and taken that hit. In fact, as Gfunk noted above, those practices that have fully embraced hypofrac and cost savings already may even see a bump in revenue. So, I guess it pays to know how any practice that you are joining treats their patients. 60/30 for all breasts and 79.2/39 for prostates? Or 40/15 for breast and 70/28 for prostate?
I forget who published it but there was a paper that looked at APM impact on a satellite for a major Med ctr.

In the APM, You basically lose on every disease site except breast. It wasn’t like 5-10% loss per site. It was like 20-30% loss in revenue for any head and neck pt that walks in the door or 25% for any lung ca pt. Prostate same thing.

People under this delusion that the early adopters will be rewarded by CMS are kidding themselves. Just look at how MIPS turned out for the average GP.
 
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Precisely. We’re basically cutting out like 85% of current treatment fractions for most disease sites and expecting everything will be ok from a revenue side.

I mean if your recommended treatment is always 5 x 5 for almost everything. Not really seeing us being big don the list of respectable specialities for very long.
 
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medgator

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Is Bernie Sanders a socialist?
You really don't want to go down this road.... Should we look at the current administrations farmer bailout? Or the AG discussing the treasury purchasing a stake in Ericsson to counteract huawei. Or the bipartisan decision to bailout GM and Chrysler etc.

The op should look at the practices history in terms of who has become partner/track record of the practice not screwing new hires etc, whether there is a real position that will be created in terms of anticipated volume etc

PP will always exist in some form. Pretty sure topa, sero etc aren't selling out to a hospital, nor are those vantage, McKesson/uson practices

If site neutrality ever comes to pass, the pendulum may actually swing back towards pp
 
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You really don't want to go down this road.... Should we look at the current administrations farmer bailout? Or the AG discussing the treasury purchasing a stake in Ericsson to counteract huawei. Or the bipartisan decision to bailout GM and Chrysler etc.

The op should look at the practices history in terms of who has become partner/track record of the practice not screwing new hires etc, whether there is a real position that will be created in terms of anticipated volume etc

PP will always exist in some form. Pretty sure topa, sero etc aren't selling out to a hospital, nor are those vantage, McKesson/uson practices

If site neutrality ever comes to pass, the pendulum may actually swing back towards pp
Pretty sure topa and sero won’t be worth the paper they’re written on in an M4A setting so good luck selling them. It wouldn’t be worth the extra effort of running a bussiness when all your patients have been placed in what amounts to the largest HMO backed up by guns and ammo ever created.

If there’s no PP in an area and all big centers then what can you compare payments to? An entity that’s doing a vanishing act?

Bernie Sanders embraces the term socialist and his health care advisor loves the NHS more than the welfare of his own family. In Europe maybe he’s just a garden variety centrist
 
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medgator

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Pretty sure topa and sero won’t be worth the paper they’re written on in an M4A setting so good luck selling them.
Hint: those centers are doing just fine taking care of a significant chunk of "M" patients as a % of their revenue.

Radiation is a volume business. Even Medicaid works financially if you run a lean (non hospital) practice. The only people refusing to take care of Medicare patients at this point are the Mayo's of the world.

Bernie Sanders embraces the term socialist and his health care advisor loves the NHS more than the welfare of his own family. In Europe maybe he’s just a garden variety centrist
Nobody listened to the centrists here regarding the ACA, and the other side basically punted the issue for 8 years so here we are
 
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Hint: those centers are doing just fine taking care of a significant chunk of "M" patients as a % of their revenue.

Radiation is a volume business. Even Medicaid works financially if you run a lean practice
Sounds like a meat mill

Multiply any number by 0 and it’s still zero man.

Commercial payers are the name of the game. The bussiness managers at my generic greedy academic practice who have been chronically understaffing for years would say. Govt patients are basically a known loss and unless you have traditional Medicare to break even on your enterprise isn’t going anywhere fast.

The more govt payers you have good luck getting the money needed to make improvement update machines pay for a new sim. Or a new afterloader, oh wait brachy went to complete **** years ago. Hell even pay the staff before paying yourself. It’s a joke.
 

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Agree with medgator
It’s a numbers game. From a profee side, this is obvious. The not orients you see the more you make. Commercial pays more than Medicare/Medicaid but you’re getting paid something as long as patient insured

in technical side this is even more true. Depending on payor mix and negotiated rates, the break even point may vary. It at some point all your fixed costs are covered and profit goes up pretty fast once you get above that threshold.
 

OTN

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Pretty sure topa and sero won’t be worth the paper they’re written on in an M4A setting so good luck selling them. It wouldn’t be worth the extra effort of running a bussiness when all your patients have been placed in what amounts to the largest HMO backed up by guns and ammo ever created.

If there’s no PP in an area and all big centers then what can you compare payments to? An entity that’s doing a vanishing act?

Bernie Sanders embraces the term socialist and his health care advisor loves the NHS more than the welfare of his own family. In Europe maybe he’s just a garden variety centrist
M4A is not going to happen, so it’s not worth discussing on this board.
 

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Hint: those centers are doing just fine taking care of a significant chunk of "M" patients as a % of their revenue.
well said

I wonder if there is anyone here who has less than 50% of their patients as medicare patients. Hard to imagine unless all you see is Peds/HPV-positive head and neck/cervix
 

Bequerel

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Would anyone make a 7 figure buy into a successful and secure private practice (if that actually existed) given current economic uncertainty? I would be inclined to do so, as I think I would come out ahead having a chunk of the technical fees. These opportunities don’t likely exist much anymore, but it seems that it would be away to avoid the inevitable downward pressure hospital admins are going to have on our salaries.
 

RadRadRad

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Would anyone make a 7 figure buy into a successful and secure private practice (if that actually existed) given current economic uncertainty? I would be inclined to do so, as I think I would come out ahead having a chunk of the technical fees. These opportunities don’t likely exist much anymore, but it seems that it would be away to avoid the inevitable downward pressure hospital admins are going to have on our salaries.
yes. If con state and returns from buy in could pay off buy in within 3-5 years
 

OTN

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Would anyone make a 7 figure buy into a successful and secure private practice (if that actually existed) given current economic uncertainty? I would be inclined to do so, as I think I would come out ahead having a chunk of the technical fees. These opportunities don’t likely exist much anymore, but it seems that it would be away to avoid the inevitable downward pressure hospital admins are going to have on our salaries.
7 figure buy-in? Not without real estate as a part of it.
 
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7 digits ranges from $1000000 to $9999999... so, having ownership of a linac for a mil or two... you’d do just fine with 12 on treatment. Might be good. Not as good for 8-9 mil
 

Reaganite

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1. What does 7 digits mean? Buy-in is often based on a multiple (I've seen 4-6) of average yearly ebitda over some historical period. This is the best-case scenario for the partners since it's based on historical collections. Given the uncertainty of radiation reimbursement (i.e. likely declines), I personally will not buy a practice for this amount unless I have an intimate understanding of the payors and referral dynamics in the community and also see larger scale benefit for our group. (e.g. the practice fills some hole in our geographic coverage or puts the hurt on a competitor).
2. Initial post says "potential" partnership. What does "potential" mean? Like, "yeah, bro, we're gonna make you a partner in a few years" or is it very clearly delineated in a contract?
3. Who refers to the practice and who are the main payors? How stable are those referrals going to be over the next few years? I once had a guy try to scam me into a big buy-out knowing full well half of his referring docs were about to sell to a local academic center. Any rumblings about a urorads center opening or the med oncs opening their own vault? Any chance the major insurers have plans to develop "limited" networks that suddenly and completely exclud certain provider groups?
4. To determine the impact of APM, look at their payor mix and practice patterns. If it's all Medicare and every prostate gets 45 tx, bone mets get 20 tx, etc. then yeah, your revenue is going to decrease.
5. Every market is different, and there are geographies where PP will continue to flourish. In non-monopolistic markets, payors are fighting back against expensive hospitals and academic centers and are aggressively diverting their business to freestanding centers and community hospitals. Alternatively, it's going to be tough to survive in PP in areas where health systems have near monopolistic control of all providers. (e.g. Sutter).
 

scarbrtj

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Precisely. We’re basically cutting out like 85% of current treatment fractions for most disease sites and expecting everything will be ok from a revenue side.

I mean if your recommended treatment is always 5 x 5 for almost everything. Not really seeing us being big don the list of respectable specialities for very long.
Just (late)saw this today, thought about you!

 
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