Perspective$ in Oncology

[scarbrtj]

CMS Part B spending is about $1.5 billion a year for rad onc and about $7 billion a year for hem/onc. (The highest rad onc spending ever: 2011, about $1.85 billion.)

Keytruda sales alone are now ~$19 billion a year.

I made a graph:

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[taserlaser]

All I can say is, yikes.

 

[medgator]

I think circa 2006-2008, someone at ASTRO presented that cms spending on RO was equal to spending on epo/procrit for that year.

Hypo-fractionation cost savings will be more than eaten up by all the new immunotherapy and targeted agents in the market ...

 

[DebtRising]

Good thing former pharma exec Scott Azar is targeting rad onc for mandatory bundling.

 

[scarbrtj]

I think circa 2006-2008, someone at ASTRO presented that cms spending on RO was equal to spending on epo/procrit for that year.

Hypo-fractionation cost savings will be more than eaten up by all the new immunotherapy and targeted agents in the market ...

Now Procrit sells about $700 million a year in the US. But the sales for Zytiga (~$3.4 billion) are twice what CMS spends for rad onc. (Of course those drug sales from J&J's report include Medicare and private insurance.)

 

[Irradi8or]

Rad Onc % costs as a total cost of cancer care is only about 2.5-4%, whereas Part B drugs are close to 25% and hospitalizations are close to 25%. Rad Onc is not a source of large cost savings for our healthcare system and arguably delivers a lot of value for how much we spend on it.

 

[Haybrant]

Love when the academic med oncs get all huffy and on their high horse about radiation expense. These fools are the ones bankrupting the medical system doing the bidding of pharma and often getting little to nothing in return

 

[Krukenberg]

Sadly I think protons have an outsize influence on the perception of high cost in radiation oncology. Also, the adoption and Medicare cost of IMRT rose nearly exponentially after it came out, which Medicare noticed. I think there was a high profile publication about it

 

[medgator]

Sadly I think protons have an outsize influence on the perception of high cost in radiation oncology. Also, the adoption and Medicare cost of IMRT rose nearly exponentially after it came out, which Medicare noticed. I think there was a high profile publication about it

As I've heard it, RO became a line item on a congressional budget once we reached a billion in charges for that service.

Protons has only added fuel to the fire

 

[PRAD_ONC]

not surprising when keytruda costs "4000X its weight in gold. "

Treating with Checkpoint Inhibitors—Figure $1 Million per Patient

 

[ganglia777]

does this mean rad onc salaries will decrease to $250K and it will be easier to match into rad onc in 5 years?

 

[deleted947887]

does this mean rad onc salaries will decrease to $250K and it will be easier to match into rad onc in 5 years?

5 years? LOL
More like 5 days.

 

[ganglia777]

5 years? LOL
More like 5 days.

Can you apply to heme/onc fellowship after being boarded in rad onc? Or are we screwed

 

[deleted947887]

Can you apply to heme/onc fellowship after being boarded in rad onc? Or are we screwed

I'd just stay at my intern program, claim I fell in love with IM, complete IM then do Heme Onc. Easy to get out of rad onc, no one can force you to do a residency you dont want to do (despite what people will tell you).

Regardless, RadOnc is now pathology. Do not believe the hype coming from academics and their residents. Academics want the highest quality free labor they can get. Their residents think they can move up in the field by selling medical students BS. The field is dead. I'd go as far as saying junior faculty are also becoming free labor (think about this for a second, academic salaries have not increased over the last 5 years despite inflation, no more 20/80 scientist positions, heck no more 60/40-I'm talking about Harvard PhD super stars; still dont believe me? Let's see how many American grads go into fellowship this year).

 

[RO2019]

Let's see how many American grads go into fellowship this year).

Yeah let's. I'll be waiting to hear that one. May be waiting for a while.

You're such an obvious troll, but I appreciate a good troll.

The funny thing is that most people don't realize it. You got the mods fooled.

 

[deleted947887]

Why am I a troll? Why are you angry? Why is it you get offended at any of this? I'm not insulting you or anyone. I'm just telling the truth. I took a career to help people. Why would I mislead medical students and tell them to pursue a career towards a dead end. Where they will be limited geographically, financially, and will spend much of their time studying physics and biology? Why should they do that when there are better alternatives out there? Look, I'm not happy I made a mistake, but I'm not gonna fool medical students into making the same mistake. That's just evil. I have absolutely nothing to gain. Do you think if no American medical grads apply to rad onc, that will improve my situation? No, sadly it won't because PDs will hire FMGs. They just want a pulse to write notes. You, my friend, are the troll.

Yeah let's. I'll be waiting to hear that one. May be waiting for a while.

You're such an obvious troll, but I appreciate a good troll.

The funny thing is that most people don't realize it. You got the mods fooled.

 

[medgator]

Yeah let's. I'll be waiting to hear that one. May be waiting for a while.

You're such an obvious troll, but I appreciate a good troll.

The funny thing is that most people don't realize it. You got the mods fooled.

Sounds like someone needs a history lesson from the 70s and 80s (even early 90s) about who got into RO residencies, let alone non-ACGME accredited fellowships.

 

[RO2019]

My comment was specifically about him saying 'lets see how many American grads do a fellowship this year'

Despite people on here constantly bleating about fellowships, American grads are not having to do fellowships. The same ones keeps being posted again and again on the astro site because they are not filling, and the ones that are, are as usual, being filled by foreign grads coming for extra training

It's an idiotic scare tactic to try to claim that there are so few jobs that US grads are having to do fellowships. not happening.

Perhaps that will change in the future, but right now? This year? No, that's not a thing.

 

[deleted947887]

Who am I scaring? And why? I have absolutely nothing to gain from scaring anyone. I think you're scared because you're realizing this is true. Radiation oncology is an academic sham. Come into radiation oncology if you want to waste your life.

Medical students, RO2019 will be you in 3 years if you match into rad onc.

My comment was specifically about him saying 'lets see how many American grads do a fellowship this year'

Despite people on here constantly bleating about fellowships, American grads are not having to do fellowships. The same ones keeps being posted again and again on the astro site because they are not filling, and the ones that are, are as usual, being filled by foreign grads coming for extra training

It's an idiotic scare tactic to try to claim that there are so few jobs that US grads are having to do fellowships. not happening.

Perhaps that will change in the future, but right now? This year? No, that's not a thing.

 

[evilbooyaa]

Let's stay on topic here @sphinx2019 (and in reply @RO2019 ). There are multiple posts about the job market and it has been discussed ad nauseum on this forum, and that has nothing directly to do with the fact that Rad Onc gets paid one small fraction of what med-onc gets paid. You are presenting your opinion and RO2019 is presenting his/her's about the state of the field. Neither of you are posting any new information. I encourage you to continue your discussion in PM or start a new thread if so inclined.

That being said, I'd be interested in knowing the average payout per physician, given that there are so many more med oncs nationwide than there are rad oncs. And are they differentiating med-onc and hematology payments?

 

[yahyamer25]

Love when the academic med oncs get all huffy and on their high horse about radiation expense. These fools are the ones bankrupting the medical system doing the bidding of pharma and often getting little to nothing in return

Referring to Oncologists as "fools" is absurd. Retract it.

 

[Phantom1]

Who am I scaring? And why? I have absolutely nothing to gain from scaring anyone. I think you're scared because you're realizing this is true. Radiation oncology is an academic sham. Come into radiation oncology if you want to waste your life.

Medical students, RO2019 will be you in 3 years if you match into rad onc.

Sphinx2019 your obviously very angry and upset about your career choice, but you need to stop hijacking these threads, venting your frustration here, and making overexagerated claims. It sounds like you might be overworked or depressed. Honestly, you really should go seek professional help and talk to a therapist. If your not happy with Rad Onc then retrain in a different field, doctors do it all the time. I dont want to hear your excuses about why you can’t do that or whatever. Point is take it somewhere else and go get some help from a therapist.

 

[Phantom1]

CMS Part B spending is about $1.5 billion a year for rad onc and about $7 billion a year for hem/onc. (The highest rad onc spending ever: 2011, about $1.85 billion.)

Keytruda sales alone are now ~$19 billion a year.

I made a graph:

Scarbrtj, this is really interesting and a great graph which would be great to publish and promote at meetings to highlight how little rad onc costs compared to the significant benefit and long term control rates we generate for many disease sites.

Would be interesting to estimate the cost per patient year of survival or QALY gained? I think that would be even more striking. Also if CMS negoatiated a keytruda drug cost reduction, what percentage would pay for the entire rad onc field? Also so I assume that this 1.5B does not include techincal fees or does it??

 

[scarbrtj]

Scarbrtj, this is really interesting and a great graph which would be great to publish and promote at meetings to highlight how little rad onc costs compared to the significant benefit and long term control rates we generate for many disease sites.

Would be interesting to estimate the cost per patient year of survival or QALY gained? I think that would be even more striking. Also if CMS negoatiated a keytruda drug cost reduction, what percentage would pay for the entire rad onc field? Also so I assume that this 1.5B does not include techincal fees or does it??

I do not believe so. For example in this table, radiology accounts for about $4 billion but we know there is much more CMS imaging spending than that. So it must just be professional. Even so, let's say worst case total rad onc spending across all payors in America is $15 billion. Total healthcare spending is $3.5 trillion. Radiation oncology would therefore account for less than one half of one percent of all healthcare spending in America. Very cost effective. Since rad oncs make up less than one half of one percent of all doctors in America this is probably a pretty reasonable chunk of spending and ratio.

 

[domestique]

Rad Onc % costs as a total cost of cancer care is only about 2.5-4%, whereas Part B drugs are close to 25% and hospitalizations are close to 25%. Rad Onc is not a source of large cost savings for our healthcare system and arguably delivers a lot of value for how much we spend on it.

Is anyone aware of a source for this? I keep hearing exactly this over and over that rad onc is ~ 3% of total Medicare spending for oncology (I assume this is derived by looking at the total figure Medicare pays across all "parts" A thru D for all patients with ICD diagnosis code of a cancer. But, I've never seen a source demonstrating this clearly. This exact thing came up at Astro Advocacy Day but Astro staff said they can't back this up. Specifically it was said "this is tough to know". They did say rad onc was about 2 - 3% of all Medicare Part B spending though. When I heard this "tough to know" response I thought, sure it's tough to know but we are paying you to know it, so figure it out or pay a consultant to figure it out. Thanks in advance.

 

[PossibleEMapplicant]

Let's stay on topic here @sphinx2019 (and in reply @RO2019 ). There are multiple posts about the job market and it has been discussed ad nauseum on this forum, and that has nothing directly to do with the fact that Rad Onc gets paid one small fraction of what med-onc gets paid. You are presenting your opinion and RO2019 is presenting his/her's about the state of the field. Neither of you are posting any new information. I encourage you to continue your discussion in PM or start a new thread if so inclined.

That being said, I'd be interested in knowing the average payout per physician, given that there are so many more med oncs nationwide than there are rad oncs. And are they differentiating med-onc and hematology payments?

Is that really true about rad onc's making more than heme/onc doctors? According to the last MGMA salary review that I saw put rad onc way higher than heme/onc.

 

[scarbrtj]

Is that really true about rad onc's making more than heme/onc doctors? According to the last MGMA salary review that I saw put rad onc way higher than heme/onc.

I don't really know what in hell rad oncs "make" anymore. It may be like asking: what does an NFL player make? There are way more NFL players than rad onc respondents in salary surveys. There's about 5000 rad oncs in the US. The usual number replying on these surveys is less than 100. One year I saw MGMA give national salary data for rad onc based on 35 rad oncs nationwide. Suspect. But let's assume $1.5B for rad onc spread among 5000 rad oncs: $300K per rad onc. And let's assume $7B spread among 15000 hem oncs nationwide: $450K per hem onc. Hidden in this is the technical reimbursement data which I don't think is included in the $1.5B. Getting technical reimbursement for a rad onc (at least starting out) may be like an NCAA player wanting to make it to the NFL... to carry on with the prior analogy. But I think it is safe to say hem oncs are higher reimbursed per MD by Medicare than rad oncs are.

 

[Irradi8or]

Is anyone aware of a source for this? I keep hearing exactly this over and over that rad onc is ~ 3% of total Medicare spending for oncology (I assume this is derived by looking at the total figure Medicare pays across all "parts" A thru D for all patients with ICD diagnosis code of a cancer. But, I've never seen a source demonstrating this clearly. This exact thing came up at Astro Advocacy Day but Astro staff said they can't back this up. Specifically it was said "this is tough to know". They did say rad onc was about 2 - 3% of all Medicare Part B spending though. When I heard this "tough to know" response I thought, sure it's tough to know but we are paying you to know it, so figure it out or pay a consultant to figure it out. Thanks in advance.

Hi domestique,

There are actually several sources for this, most of which have parsed the same (or a subset of the same) data set. Some of the older analyses that take the data from the 2000's-early 2010's into account I think will have a slightly higher % of radiation therapy costs as a component of the total cost of care (~4%), while the more recent data in the last 5 years or so may have a lower % of costs attributed to radiation (~2.5-3%), as the cost of Medicare Part B drugs and other cost drivers have increased.

http://www.milliman.com/uploadedFiles/insight/2016/trends-in-cancer-care.pdf

 

[scarbrtj]

Hi domestique,

There are actually several sources for this, most of which have parsed the same (or a subset of the same) data set. Some of the older analyses that take the data from the 2000's-early 2010's into account I think will have a slightly higher % of radiation therapy costs as a component of the total cost of care (~4%), while the more recent data in the last 5 years or so may have a lower % of costs attributed to radiation (~2.5-3%), as the cost of Medicare Part B drugs and other cost drivers have increased.

http://www.milliman.com/uploadedFiles/insight/2016/trends-in-cancer-care.pdf

View attachment 261500

So what this graph is saying is that rad onc's share is down ~33% (from 6% to 4%) 2004->2014.
And med onc's share (cytotoxic+biologic) is up 77% (7%+2% to 9%+7%) from 2004->2014.
Quite the swing.
I imagine this trend has only accelerated since 2014.

 

[Irradi8or]

So what this graph is saying is that rad onc's share is down ~33% (from 6% to 4%) 2004->2014.
And med onc's share (cytotoxic+biologic) is up 77% (7%+2% to 9%+7%) from 2004->2014.
Quite the swing.
I imagine this trend has only accelerated since 2014.

Actually, I think you are looking at "Other Chemo and Cancer drugs" instead of the "Radiation Oncology". Medicare TCOC (total cost of care) of RT actually increased for Medicare 1% to 3% during this 2004 to 2014 timeframe, while TCOC for RT was stable at 4% during this period for commerical.

I do think that in the last 5 years we will indeed see a decreasing TCOC for RT, especially given trends in higher cost of newer biologics/immunotherapies and increasing hypofx and decreasing indications for XRT.

 

[medgator]

I do think that in the last 5 years we will indeed see a decreasing TCOC for RT, especially given trends in higher cost of newer biologics/immunotherapies and increasing hypofx and decreasing indications for XRT.

Good thing RO academia addressed that issue by expanding residency slots

 

[scarbrtj]

Actually, I think you are looking at "Other Chemo and Cancer drugs" instead of the "Radiation Oncology". Medicare TCOC (total cost of care) of RT actually increased for Medicare 1% to 3% during this 2004 to 2014 timeframe, while TCOC for RT was stable at 4% during this period for commerical.

I do think that in the last 5 years we will indeed see a decreasing TCOC for RT, especially given trends in higher cost of newer biologics/immunotherapies and increasing hypofx and decreasing indications for XRT.

Ah OK I see it now (bad colors lol). Let's do something (questionable) like just adding it all up...

........................medicare............................commercial
.....................2004........2014......................2004..........2014
Rad onc....1%............3%.........................4%..............4%
Chemo...
...cytox.......6%...........5%........................7%................9%
...biologic.3%...........9%........................2%.................7%

Rad onc total increased 1%+4%-->3%+4% from 2004 to 2014, a 40% increase (5%->7%).
Chemo side increased (6%+3%+7%+2%)-->(5%+9%+9%+7%) from 2004 to 2014, a 67% increase (18%-->30%).

I don't know what to make of other categories like "professional services" and how they would break out across specialties, if at all.

 

[domestique]

Actually, I think you are looking at "Other Chemo and Cancer drugs" instead of the "Radiation Oncology". Medicare TCOC (total cost of care) of RT actually increased for Medicare 1% to 3% during this 2004 to 2014 timeframe, while TCOC for RT was stable at 4% during this period for commerical.

Thanks for sharing this. Someone had sent me a pdf of these data before advocacy day with some caveats so I wasn't sure if it could be fully trusted. But just to see what would happen, I quoted these data anyway to every person I met with from the house member and senate offices in which I had meetings. I said we are about 3 percent of TCOC for onc patients and we treat about 50-60% of this cohort in one manner or another (curative or palliative intent), so by definition, on net balance, we are cost effective. Every single person found this data interesting and I received a range of comments back that were all variations of "tell me again why CMS is busting your *****?" This is why I grew irritated with the "this is tough to know" response.

 

[deleted941485]

Thanks for sharing this. Someone had sent me a pdf of these data before advocacy day with some caveats so I wasn't sure if it could be fully trusted. But just to see what would happen, I quoted these data anyway to every person I met with from the house member and senate offices in which I had meetings. I said we are about 3 percent of TCOC for onc patients and we treat about 50-60% of this cohort in one manner or another (curative or palliative intent), so by definition, on net balance, we are cost effective. Every single person found this data interesting and I received a range of comments back that were all variations of "tell me again why CMS is busting your *****?" This is why I grew irritated with the "this is tough to know" response.

This is probably a partially attributed of to pharma. I mean really there are 6 figure drugs out there and people are starting to complain about cost. So what’s a former pharma worker turned HHS overload to do? Cut the **** out of everything else so you can spend a higher proportion of it on said drugs medicare spending doesn’t change. Hail it as a victory for cost effective care. Rinse and repeat.

 

[scarbrtj]

Epilogue I. Evolving Perspectives.

From Vinay Prasad...
If you add all these numbers up (y axis is $billions), it's about $950B/30y. Rad onc is costing society about $5-7B/y* now (my own private estimate and data; $1.5B/y for Medicare). I think it'd be reasonable to assume the avg would be $1.5B/y for last 30y. Likely an overestimate, but let's assume. Thus it seems cancer drugs cost 20 times or more what radiation has cost society over the last 30y. Now add in all the ever-appearing immunologics etc...

It would not be unreasonable to assume therefore that for every dollar spent for rad onc care, we are spending $50... or $100?... for "chemo" care. Astounding. Whether it's 20x or 50x or 100x, or more, though, there's much perspective to be gained... positive and negative and existential... for the radiation oncologist from this mental exercise IMHO. At least monetarily, med onc is lapping rad onc hard.

* The smart people out there will realize this works out to about $1-1.4m per rad onc. The really really smart will realize this works out to about an avg salary of $300-360K per rad onc. The really really really avg intelligence people already realize the numerator is shrinking and the denominator is growing.

 

[scarbrtj]

Sounds like someone needs a history lesson from the 70s and 80s (even early 90s) about who got into RO residencies, let alone non-ACGME accredited fellowships.

Epilogue II. A History Lesson.

 

[radiation]

Epilogue I. Evolving Perspectives.

From Vinay Prasad...
If you add all these numbers up (y axis is $billions), it's about $950B/30y. Rad onc is costing society about $5-7B/y* now (my own private estimate and data; $1.5B/y for Medicare). I think it'd be reasonable to assume the avg would be $1.5B/y for last 30y. Likely an overestimate, but let's assume. Thus it seems cancer drugs cost 20 times or more what radiation has cost society over the last 30y. Now add in all the ever-appearing immunologics etc...

It would not be unreasonable to assume therefore that for every dollar spent for rad onc care, we are spending $50... or $100?... for "chemo" care. Astounding. Whether it's 20x or 50x or 100x, or more, though, there's much perspective to be gained... positive and negative and existential... for the radiation oncologist from this mental exercise IMHO. At least monetarily, med onc is lapping rad onc hard.

* The smart people out there will realize this works out to about $1-1.4m per rad onc. The really really smart will realize this works out to about an avg salary of $300-360K per rad onc. The really really really avg intelligence people already realize the numerator is shrinking and the denominator is growing.

I think med onc is rapidly heading towards unsustainable territory. At some point the costs of drugs will be too much for society to bear and the political pendulum will start coming down hard on drug company reimbursement. I don't know when that time will come, but I would rather be a radiation oncologist when it happens

 

[medgator]

I think med onc is rapidly heading towards unsustainable territory. At some point the costs of drugs will be too much for society to bear and the political pendulum will start coming down hard on drug company reimbursement. I don't know when that time will come, but I would rather be a radiation oncologist when it happens

Even in the best of reimbursement times (outside of perhaps particle therapy), our drug has always been cost effective

 

[scarbrtj]

I think med onc is rapidly heading towards unsustainable territory. At some point the costs of drugs will be too much for society to bear and the political pendulum will start coming down hard on drug company reimbursement. I don't know when that time will come, but I would rather be a radiation oncologist when it happens

Would have to disallow pharm companies remaining wildly profitable. "Pharma runs America"... and I'm no tinfoil hatter. If it's a hammer it'll be a velvet hammer, designed for show and to assuage. Think of the industry... the people... the R&D... the financiers... the govt lobbyists... the TV commercials!... propping it all up. So even if a hammer, look closely and be skeptical. (And it won't have held a monetary candle to radiation's hypofractionation/indication hammer.)