Physical Presence; you mean like I have to be there?

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Another settlement, so there won't be definitive case law established. It would be interesting to see if they were counting someone (ie med onc or mid level) as the supervisor while the rad oncs were out of the office or if they just didn't have anyone there designated as the covering provider.

However, this is just another one in the trend of therapists making big time money telling on groups that may play in that "gray area" of direct supervision. It's one of the reasons I would ideally like to cover some rural clinics (not super rural like medicare exempt), but can't send a NP some days as coverage because I"m not willing to play around with all of these cases.

When I go to the floor to see consults we still call that physical presence so we treat, surely that is OK, right? My department is attached to the hospital. Obviously, I'm at the linac for HDR, CT sims, verification, SBRT, etc.
 
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Another settlement, so there won't be definitive case law established. It would be interesting to see if they were counting someone (ie med onc or mid level) as the supervisor while the rad oncs were out of the office or if they just didn't have anyone there designated as the covering provider.

However, this is just another one in the trend of therapists making big time money telling on groups that may play in that "gray area" of direct supervision. It's one of the reasons I would ideally like to cover some rural clinics (not super rural like medicare exempt), but can't send a NP some days as coverage because I"m not willing to play around with all of these cases.

When I go to the floor to see consults we still call that physical presence so we treat, surely that is OK, right? My department is attached to the hospital. Obviously, I'm at the linac for HDR, CT sims, verification, SBRT, etc.

Rumor on street is a certain whistleblower mentioned may have turned in ANOTHER site.
 
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Rumor on street is a certain whistleblower mentioned may have turned in ANOTHER site.

Yeah, these suits are coming more and more often.

You better keep your therapists happy if you're doing anything in a gray area.
 
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Daily Practice - Reimbursement - Practice Management Resources - Supervision - American Society for Radiation Oncology (ASTRO)

Previous thread for reference: Treatment with Mid Level Providers

I await Florida jokes from the peanut gallery, but it seems like these shenanigans happen in many places.

You're probably safer in a hospital based situation than freestanding, but either way, the requirements state that the individual providing supervision has to be able to furnish assistance at any time with igrt. How many med oncs/ob gyns/FPs can line up a CBCT or check a hazy port film?
 
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Daily Practice - Reimbursement - Practice Management Resources - Supervision - American Society for Radiation Oncology (ASTRO)

I await Florida jokes from the peanut gallery, but it seems like these shenanigans happen in many places.

You're probably safer in a hospital based situation than freestanding, but either way, the requirements state that the individual providing supervision has to be able to furnish assistance at any time with igrt. How many med oncs/ob gyns/FPs can line up a CBCT?

The IGRT is where the issue is. Completely agree with you.

I go over IGRT goals of alignment at verification with therapists; depending on the case sometimes I physically am at the linac for all pre-treatment CBCT (ie bladder boost or complex case), but for things where they are confident/good at alignment like a prostate or prostate bed CBCT I'm not always there physically at the linac...so they certainly have treated patients when I'm upstairs on the floor while they beam on a CBCT case. This was normal in my residency as well.
 
The IGRT is where the issue is. Completely agree with you.

I go over IGRT goals of alignment at verification with therapists; depending on the case sometimes I physically am at the linac for all pre-treatment CBCT (ie bladder boost or complex case), but for things where they are confident/good at alignment like a prostate or prostate bed CBCT I'm not always there physically at the linac...so they certainly have treated patients when I'm upstairs on the floor while they beam on a CBCT case. This was normal in my residency as well.

I think you have more cover in an attached hospital based department, but technically they still should be able to make you come down from the floor and check an igrt if need be, per Medicare supervision guidelines, although "immediate" availability might be brought up as an issue.

In the freestanding setting, I wouldn't push the envelope at all. Too many whistleblower settlements already on the books...
 
so are these 2 cases concerned with IGRT or simply the fact of beam being on without MD "in Department"?
 
so are these 2 cases concerned with IGRT or simply the fact of beam being on without MD "in Department"?

It's going to be hard to figure that out since these cases settle. I'm not aware of any cases like this that have gone completely through trial with a final judgement - that's where you get the details and the case law. However, just about every IMRT case has some form of IGRT most of the time I'd imagine (at least orthogonal x-ray -cpt G6002 or CBCT -cpt 77014-26), so separating out "beam on" vs. IGRT is challenging.

*Most* of these cases are pretty egregious things, like doing CT sims without doctor present or even one case had an ENT as the supervising physician on the gamma knife radioactive materials license. However, there were instances of beam on with the urologist and not the rad onc serving as the supervising physician at a urorad center that brought about charges, but the urorad center at least argued well enough that no settlement ever came to fruition, though surely mounted major legal fees. They argued successfully that there was enough ambiguity in the law that while it "may be best" to have a rad onc there, there was enough wiggle room that the urologist could oversee treatments instead. As nice as it may be to have that particular position as a rad onc there, I think we can agree as a specialty that this is really not good practice and if you want your training valued you can't just stand by and let other specialties serve as appropriate oversight.
 
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It's going to be hard to figure that out since these cases settle. I'm not aware of any cases like this that have gone completely through trial with a final judgement - that's where you get the details and the case law.

No one in their right mind would ever let a case like that go to court and risk potential triple/treble damages, which is what Medicare allows in these whistleblower cases for a maximum potential payout (I.e. $5 million in fraudulent charges would turn into a $15 million penalty).

I've posted examples in the other thread I linked of both hospital and freestanding centers getting nailed. The safest thing to do is be there during igrt cases (pretty much any 3D or IMRT pt these days).

The other option is to treat but not charge when you can't have a physician there, as Medicare/Medicaid/Tricare can't really claw back no charges (3 x $0 = $0) :eek:
 
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No one in their right mind would ever let a case like that to go court and risk potential triple/treble damages, which is what Medicare allows in these whistleblower cases for a maximum potential payout (I.e. $5 million in fraudulent charges would turn into a $15 million penalty)

Right.

I think that's part of the deal here...don't give anyone any reason to whistle blow. Keep your therapists happy...because the feds know they have the time, resources, and ability to just flex muscle and make you settle because you don't want to deal with any of it.
 
so are these 2 cases concerned with IGRT or simply the fact of beam being on without MD "in Department"?

In the case I quoted it was accusation of no MDs in department. The hospital strongly objected, saying this was untrue and that MDs were physically present. However proving this to the Feds was an onerous, expensive process. In the end, was cheaper to settle.


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In the case I quoted it was accusation of no MDs in department. The hospital strongly objected, saying this was untrue and that MDs were physically present. However proving this to the Feds was an onerous, expensive process. In the end, was cheaper to settle.


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I've always wondered how this could be established, outside of interviewing witnesses like therapists/dosimetrists, etc. We have electronic schedules in our group with ARIA that clearly show patients scheduled in clinic, but for those days where nothing is on the schedule except daily treatment patient's, it's something I've wondered about, especially as witness testimony gets unreliable the further back you go to examine a time period.
 
This discussion always revolves around medicare/medicaid oversight as that is where all the settlements/penalties arise from. Do commercial insurance companies care and is there any precedent of them coming after groups/hospitals for lack of supervision?
 
My department is physically located on the large hospital grounds. However, I do a lot of inpatient rounds during the day and go to OR for seed implants. Do you think therapists may potentially raise the issue of lack of physician supervision?


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This discussion always revolves around medicare/medicaid oversight as that is where all the settlements/penalties arise from. Do commercial insurance companies care and is there any precedent of them coming after groups/hospitals for lack of supervision?
Not that I've seen. It almost always revolves around CMS and Tricare patients.
 
Not that I've seen. It almost always revolves around CMS and Tricare patients.

I've wondered about this too. At some point it's going to happen. I think for now the attorney's fees, etc would cut into your "profit" from taking it to court, but if that number gets high enough I don't see why a private payer wouldn't come calling for their piece back.
 
My department is physically located on the large hospital grounds. However, I do a lot of inpatient rounds during the day and go to OR for seed implants. Do you think therapists may potentially raise the issue of lack of physician supervision?


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I'm in the same boat. I'm not hospital employed though for what that's worth.

Given all of these issues our staff sat down with risk mgmt and the hospital to review our policies. Our policy is that for rounds as inpatient I am readily available to walk downstairs or across campus and help with a CBCT, so we still treat then.

For procedures I notify the department when I am scrubbed in and we turn off the machines then. They treat up until the time I scrub then stop. It's really annoying and probably overkill but you can see in this thread the issues at play. THe therapists actually dislike it and would rather treat, but it is what it is and they understand the issues at play. Again, just keep them happy.
 
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I'm in the same boat. I'm not hospital employed though for what that's worth.

Given all of these issues our staff sat down with risk mgmt and the hospital to review our policies. Our policy is that for rounds as inpatient I am readily available to walk downstairs or across campus and help with a CBCT, so we still treat then.

For procedures I notify the department when I am scrubbed in and we turn off the machines then. They treat up until the time I scrub then stop. It's really annoying and probably overkill but you can see in this thread the issues at play. THe therapists actually dislike it and would rather treat, but it is what it is and they understand the issues at play. Again, just keep them happy.

This is exactly what I do and my rationale is the same. I even go as far as to avoid walking 100 yards to the sub shop across the street (and instead walk 2-3 times farther to the hospital cafeteria since although I'm farther I'm technically still on campus).

I have worked in several of those rural 10-15 patients per day centers in exempt locations and there is no way to staff with a full time MD but I was very comfortable with an NP baby sitting/managing side effects while I was available remotely to check IGRT even before treatment. I've also worked at an academic center were an 84 year old radiation oncologist would "cover" vacations but he generally just napped or read the newspaper while the therapists and PA ran the show but it was ok since he was (great)grandfathered and didn't have to recertify (the dude was covering a sim on a prone breast patient and he literally thought the axial slice through the breast was an image of a skull/brain ... the scarier part was that he was apparently in the CT sim room and the woman was on sim table topless right in front of him but he still couldn't put it together!)
 
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In his heyday, he never had to worry about supervision of Medicare patients.

This is exactly what I do and my rationale is the same. I even go as far as to avoid walking 100 yards to the sub shop across the street (and instead walk 2-3 times farther to the hospital cafeteria since although I'm farther I'm technically still on campus).

I have worked in several of those rural 10-15 patients per day centers in exempt locations and there is no way to staff with a full time MD but I was very comfortable with an NP baby sitting/managing side effects while I was available remotely to check IGRT even before treatment. I've also worked at an academic center were an 84 year old radiation oncologist would "cover" vacations but he generally just napped or read the newspaper while the therapists and PA ran the show but it was ok since he was (great)grandfathered and didn't have to recertify (the dude was covering a sim on a prone breast patient and he literally thought the axial slice through the breast was an image of a skull/brain ... the scarier part was that he was apparently in the CT sim room and the woman was on sim table topless right in front of him but he still couldn't put it together!)
 
I have worked in several of those rural 10-15 patients per day centers in exempt locations and there is no way to staff with a full time MD but I was very comfortable with an NP baby sitting/managing side effects while I was available remotely to check IGRT even before treatment.

I think this is where the rub on all this is for a lot of practices. There are a lot of these 10-15 patient rural-ish centers that don't qualify for medicare exempt status, but really can't justify a 5-day a week rad onc. So if you have someone off site looking at the imaging is it OK then if you have a well trained NP or med onc there there physically in the building?

I'm not willing to risk that anymore, but I know for a fact that goes on in a number of places, including academic satellites (or at least it did about 4-5 years ago when i was looking at jobs).
 
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we all know its BS. I agree someone should check SBRT bc its high dose but everything else is BS. And if it is SBRT just don't treat that day, doesn't have to be consecutive treatments. We are not gods, any monkey can be trained to look at a film. Make the hospital admins come down to check it, they are the ones that benefit from the $$ flowing in. Oh wait, they have meetings to be at and powerpoints to present
 
we all know its BS. I agree someone should check SBRT bc its high dose but everything else is BS. And if it is SBRT just don't treat that day, doesn't have to be consecutive treatments. We are not gods, any monkey can be trained to look at a film. Make the hospital admins come down to check it, they are the ones that benefit from the $$ flowing in. Oh wait, they have meetings to be at and powerpoints to present

It's also bs that med onc is the go to referral source for many solid malignancies, but that is something you can change in practice.

as for igrt, whether it's bs or not is irrelevant. Remember, it's ultimately your license on the line legally, not theirs, so if the therapist has any doubts, they should feel comfortable enough to get ahold of you at any time. Moreover, CMS has made the rules and the settlements prove it's not worth testing them.

When cms tells you to jump, your response should be "how high?" This is where dentists and oral surgeons have really got it made, no insurance, cash only
 
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Hate to revive the issue on this topic as it's painful, what do you guys do in your practice at present to make this work in the situation that one physician has daily am childcare responsibilities if your practice is a 2 or 3 person setup? Is it reasonable to have a policy of taking turns as the early physician. Would you consider just starting patients at a later time if you're not a super high volume clinic. Thanks
 
Hate to revive the issue on this topic as it's painful, what do you guys do in your practice at present to make this work in the situation that one physician has daily am childcare responsibilities if your practice is a 2 or 3 person setup? Is it reasonable to have a policy of taking turns as the early physician. Would you consider just starting patients at a later time if you're not a super high volume clinic. Thanks
One option is to not bill, not very palatable IMO. Beyond that, you shift the schedule around. If you have more than one person to cover the linac, then I would just rotate, like you suggested.
 
you can also not treat medicare pts in the morning- the presence rules only apply to pts medicare/or medicare advantage?
 
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so to get it straight, medicare requires it but insurance does not? Whats with this discrepancy? Also, is anyone ACR certified center, they require it apparently which is causing some headaches
 
I hate to bother you all with my European views, but:

The problem is that in the US you are able to sustain operation of a LINAC even when it's running with 10-15 patients. This is because radiation oncology actually pays off pretty well in the US, so you earn enough per individual patient to pay off the costs associated with operating a LINAC and even make profit even you treat so few patients.
In Europe, you won't find a place where a LINAC would be running with 10-15 patients. :)
30-40 patients is a must and I know places with 60 patients on one LINAC.
 
I hate to bother you all with my European views, but:

The problem is that in the US you are able to sustain operation of a LINAC even when it's running with 10-15 patients. This is because radiation oncology actually pays off pretty well in the US, so you earn enough per individual patient to pay off the costs associated with operating a LINAC and even make profit even you treat so few patients.
In Europe, you won't find a place where a LINAC would be running with 10-15 patients. :)
30-40 patients is a must and I know places with 60 patients on one LINAC.

And in usa, docs can have patient loads of 10-15 patients! , so one aspect of fragmentation is that it artificially creates the need for more docs. Unfortunately, our professional society has not spoken up while residency slots doubled on top of this - so you have a "bubble" of oversupply that will pop if there is payment reform/ consolidation of health care systems, change in presence rules. It would be interesting to know how our numbers of radoncs compare to richer countries with higher GDP/capita like Germany, Switzerland, Norway

Patient census is unique to radonc among specialties in the sense that I dont think a German primary care sees more patients per day than an American, but for radonc .......
 
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I hate to bother you all with my European views, but:

The problem is that in the US you are able to sustain operation of a LINAC even when it's running with 10-15 patients. This is because radiation oncology actually pays off pretty well in the US, so you earn enough per individual patient to pay off the costs associated with operating a LINAC and even make profit even you treat so few patients.
In Europe, you won't find a place where a LINAC would be running with 10-15 patients. :)
30-40 patients is a must and I know places with 60 patients on one LINAC.
I don't consider this to be a "problem" in the US. Our country is much more spread out and rural than Germany in many places, so it would be difficult for large segments of our population to travel for care. I like that we can be profitable with 10-15 patients on treatment and continue to serve these communities. I would consider Europe's situation to be the "problem."
 
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Agree with OTN - Look at the geographical size of the US versus any country in Europe (excluding Russia). Either some places have Linacs treating 10-15 patients, or those patients likely don't end up getting radiation like in 3rd world countries.
 
if you look at major metropolitan areas -where vast most of the population resides-, it is likely that within/near/outskirts those dense areas you have many single vault linacs treating 10-15 patients. I know of 3 within 5 miles of my hospital. I bet you the vast majority of linacs treating 10-15 pts are not in the rural setting, and that they are treating 10-15 patients because of competition not geography.
 
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if you look at major metropolitan areas -where most of the population resides-, it is likely that within those dense areas you have many single vault linacs treating 10-15 patients. I know of 3 within 5 miles of my hospital. I bet you the vast majority of linacs treating 10-15 pts are not in the rural setting, and that they are treating 10-15 patients because of competition not geography.

So what? Unless we dramatically change reimbursement based on geographic region, that's going to happen. Also, at least in my dense major metropolitan area, that's demonstrably false. We have 75 patients on tx between 2 linacs right now, and all of our centers have between 20-40 patients on tx per linac at any time. You're more accurate when it comes to academic centers, which in my experience have 1/2 to 1/3 the workload per machine compared to non-academic practices.
 
At my institution our work horse linacs treat 30 - 40 a day.

I think you can make the argument that physicians in academics may have 10 - 15 on treatment, but the linacs are pretty much never that empty.
 
So what? Unless we dramatically change reimbursement based on geographic region, that's going to happen. Also, at least in my dense major metropolitan area, that's demonstrably false. We have 75 patients on tx between 2 linacs right now, and all of our centers have between 20-40 patients on tx per linac at any time. You're more accurate when it comes to academic centers, which in my experience have 1/2 to 1/3 the workload per machine compared to non-academic practices.

There has to be a balance and it is my understanding the proliferation of linacs treating 10-15 patients corresponded to the increased reimbursement/advent from IMRT. The point is favorable reimbursement encouraged an oversupply of centers, and that there may be a contraction if changes are made to reimbursement/bundled payments.
 
There has to be a balance and it is my understanding the proliferation of linacs treating 10-15 patients corresponded to increased reimbursement from IMRT. The point is favorable reimbursement encouraged an oversupply of centers, and that there may be a contraction if changes are made to reimbursement/bundled payments.
And I would say we do not have an oversupply, but rather a good geographic distribution which allows treatment of patients in their own community.
 
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At my institution our work horse linacs treat 30 - 40 a day.

I think you can make the argument that physicians in academics may have 10 - 15 on treatment, but the linacs are pretty much never that empty.
That's pretty good compared with the departments I've seen. Never made sense to me why some places throw away so much money buying two machines/vaults when one would have sufficed.
 
The entire USA is in dire need of CON laws on LINACs.
 
The entire USA is in dire need of CON laws on LINACs.

example: Philadelphia area has 4 Gamma knives within several miles of each other: cooper, TJU,pense,temple
 
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The entire USA is in dire need of CON laws on LINACs.
I wouldn't disagree with that. Would still allow for rural centers. Would NOT help the current job market, though.
 
if you look at major metropolitan areas -where vast most of the population resides-, it is likely that within/near/outskirts those dense areas you have many single vault linacs treating 10-15 patients. I know of 3 within 5 miles of my hospital. I bet you the vast majority of linacs treating 10-15 pts are not in the rural setting, and that they are treating 10-15 patients because of competition not geography.

So what? Unless we dramatically change reimbursement based on geographic region, that's going to happen. Also, at least in my dense major metropolitan area, that's demonstrably false. We have 75 patients on tx between 2 linacs right now, and all of our centers have between 20-40 patients on tx per linac at any time. You're more accurate when it comes to academic centers, which in my experience have 1/2 to 1/3 the workload per machine compared to non-academic practices.

I think the question is.... what is a reasonable drive and expectation for patients? At one of the satellites I treat at, we average 15-25 depending on season. Is it reasonable to make those patients drive anywhere from 25-35 mins each way daily to get radiation?

Agree with OTN - Look at the geographical size of the US versus any country in Europe (excluding Russia). Either some places have Linacs treating 10-15 patients, or those patients likely don't end up getting radiation like in 3rd world countries.
And that's why when some of these really rural places can't find a rad onc, they can sometimes still treat Medicare patients without direct rad onc supervision, secondary to that CAH (Critical access hospital) designation.

I wouldn't disagree with that. Would still allow for rural centers. Would NOT help the current job market, though.

It would probably help it by cratering the market a la early-to-mid 90s, and basically scare away the good talent.
 
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I think the question is.... what is a reasonable drive and expectation for patients? At one of the satellites I treat at, we average 15-25 depending on season. Is it reasonable to make those patients drive anywhere from 25-35 mins each way daily to get radiation?
I have patients that drive 1 hour to get their radiation therapy one way.
30 min is pretty normal.
And lots of patients come to radiation using public transportation. I have patients who spend 3 hours on the road between trams, buses and trains to get to us and back home.
Why is that such a big issue?

And in the end why not treat patients as in-patients or in a hotel-like setting?
When Lona Linda was the sole spot treating prostate cancer with protons hundreds of patients traveled from all over the US and anroad and slept in hotels around the treatment center for weeks.

It's all a matter of how you spend public money and what's more prudent to do. Sustain non-profitable Linacs treating tiny amounts of patients by paying big bucks per treatment or covering costs of travelling and sleeping away from home during treatment for patients who are fit enough to do so?

One could also make the argument that fewer large-volume centers probably provide better care than tiny centers and enhance clinical research.
 
I have patients that drive 1 hour to get their radiation therapy one way.
30 min is pretty normal.
And lots of patients come to radiation using public transportation. I have patients who spend 3 hours on the road between trams, buses and trains to get to us and back home.
Why is that such a big issue?

And in the end why not treat patients as in-patients or in a hotel-like setting?
When Lona Linda was the sole spot treating prostate cancer with protons hundreds of patients traveled from all over the US and anroad and slept in hotels around the treatment center for weeks.

It's all a matter of how you spend public money and what's more prudent to do. Sustain non-profitable Linacs treating tiny amounts of patients by paying big bucks per treatment or covering costs of travelling and sleeping away from home during treatment for patients who are fit enough to do so?

One could also make the argument that fewer large-volume centers probably provide better care than tiny centers and enhance clinical research.
Fair points and I don't pretend to the know the answer.

The flip side of that is the psychosocial aspect of delivering care to patients who are hours away from home and their support network, who are now unable to work in some cases because they spend weeks away from their home base. A good chunk of my patients continue to work through treatment (teachers, construction, consulting, engineers etc).

We all know what depression can do to the immune system (and how the immune system can impact cancer control).

Personally, I wouldn't want to be treated in the ivory tower academic factory of 12 linacs, 4 simulators, 3 HDR units and a proton center, but that's just me

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If I ever need radiation I plan to work as much as I can during the time I get radiation. Those are the patients who seem to have the mildest side effects.

1 hours transport each way is routine? You're treating people who have to take public transport 3 hours every day? It's seems like a big deal to me because the way we sell radiation is that it's just another errand for patients to run, daily, for a few weeks. It's not 'just' a daily errand when you literally spend the better part of a regular work day just doing the treatment and commuting.

We had one patient who wanted to do that (take a bus and a train over 3 hours to come to us for breast treatment) and we actively tried to convince her to go a facility closer to her home. It's not as good of treatment, because if she isn't 100% reliable and misses a train or something she's not coming in for the day. Patients shouldn't have to travel for 2 or more hours round trip for a daily treatment if there are options that are comparable closer to home.

We DO have ways to allow patients to stay Mon-Fri on a hospital subsidized rate, but that's just for convenience and for the rare stuff that we push to treat here.
 
Lot's of my patients keep working during treatment. Even if the are away for 3-4 hours, they usually work part-time for example in the afternoon. There are tons of jobs where you can do that, some of course are not possible. But we do keep the linacs running up until 18:00, so we have some patients who come for treatment after work.
Some others come at sharp 08:00 and then travel to work. Many office workers start here at 09:00-09:30.


Now, speaking of workforce, here's a survey for Europe:
Radiotherapy staffing in the European countries: Final results from the ESTRO-HERO survey - ScienceDirect

No data on Germany.

RO-docs per million people:
Switzerland: 13.9
Norway: 27.3
The Netherlands: 15.3
Denmark: 30.9

US data???


Like you said, it's a trade-off.
If you don't want your patients to be travelling long, then you are going to need more small-volume units.
The bottom line is money.
In Switzerland you get around 25.000 dollars for a 8 week prostate treatment. Vor a VMAT, all costs included (consultations, ct, planning, sim, treatment). I think the price tag in the US is significantly higher (care to comment?).

Please bear in mind that hypofractionation is going to hit those small units even harder. If half of the patients are prostate cancer patients, hypofractionation is going to free up 25% of the capacity of these linacs, once people start switching from 40 to 20 fractions.
Ultra-hypofractionated schedules, IORT and brachytherapy for breast are also going to have a similar effect.
 
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If I am understanding the above comments, pts are "travelling a long time" because they are using public transportation in most cases. If i had to take public transportation to my work 10 miles a way- it would also take me 2-3 hours. Insurance/regulations should permit reimbursing them for uber as it is relatively small cost in relation to IMRT. Putting radiation centers 3-5 miles from a patient rather than 7-10 is not the answer. There are lots of urban areas where there are multiple single vault centers within several miles of each other. this is not about North Dakota. There are plenty of locations in the northeast where the poulation density is higher than Western Europe like the state of new jersey.
 
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