Private practice from scratch

[DrProtonX]

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Is it possible for new grads to start a private practice from scratch? Do you need big connections to get approve for a loan to build a freestanding radiation center? Is it even worth it as opposed to joining an already established practice?

 

[medgator]

The deck has been stacked against PP/freestanding centers for years. Annual reimbursement cuts continue unabated while labor pressures keep rising. I wouldn't want to in this environment.

Are there even any places left where this is feasible in a reasonable sized metro?

 

[Gfunk6]

It is possible, but very, very challening even for someone who knows what they ae doing. Here is task list:

1. You need to be a non-CON state. If you are in a CON state, you have to convince state authorities that there is a need to build a center in the area that you are proposing. Most members of this council will have vested interest in NOT approving your application because they own/profit from the centers in other parts of the state.

2. You need to identify a source of referrals. Realistically you need at least a couple of medical oncologists with a healthy sprinkling of surgical specialists (Neurosurgery, ENT, Gyn Onc, Urology) and even PCPs that can direct new breast, prostate, and lung cancer patients to you. If you have a competitor in town it will be a severe uphill battle unless the existing referring physicians are asking for an alternative.

3. You need to convince the bank to front you a loan for a linac, vault, and office facilities. Even in the best case scenario, I can't imagine this costing less than $5M. The linac will be the hardest component as you have minimial negotiating power. Large academic networks or private practice aggregators (like US Oncology) can demand lower prices because they buy in high volume. You will need a detailed proforma out to at least 10 years.

4. You need to get a long-term maintnenace service contract on your linac; I believe the first year or so is included in the initial purchase. Never ever run a linac without this in place.

5. You need a minimum of two RTTs and one Dosi (can be remote) and one Physics (can be remote). The salary and comp will vary wildly depending on where you are in the country. You will also need a front desk person who can probably also function as your office manager.

6. If you can somehow work out everything above, you will be in a nearly peerless working environment with full autonomy (with all the pluses and minues that come with it). To quote the lyrics of Fort Minor:

This is ten percent luck
Twenty percent skill
Fifteen percent concentrated power of will
Five percent pleasure
Fifty percent pain

 

[DrProtonX]

It is possible, but very, very challening even for someone who knows what they ae doing. Here is task list:

1. You need to be a non-CON state. If you are in a CON state, you have to convince state authorities that there is a need to build a center in the area that you are proposing. Most members of this council will have vested interest in NOT approving your application because they own/profit from the centers in other parts of the state.

2. You need to identify a source of referrals. Realistically you need at least a couple of medical oncologists with a healthy sprinkling of surgical specialists (Neurosurgery, ENT, Gyn Onc, Urology) and even PCPs that can direct new breast, prostate, and lung cancer patients to you. If you have a competitor in town it will be a severe uphill battle unless the existing referring physicians are asking for an alternative.

3. You need to convince the bank to front you a loan for a linac, vault, and office facilities. Even in the best case scenario, I can't imagine this costing less than $5M. The linac will be the hardest component as you have minimial negotiating power. Large academic networks or private practice aggregators (like US Oncology) can demand lower prices because they buy in high volume. You will need a detailed proforma out to at least 10 years.

4. You need to get a long-term maintnenace service contract on your linac; I believe the first year or so is included in the initial purchase. Never ever run a linac without this in place.

5. You need a minimum of two RTTs and one Dosi (can be remote) and one Physics (can be remote). The salary and comp will vary wildly depending on where you are in the country. You will also need a front desk person who can probably also function as your office manager.

6. If you can somehow work out everything above, you will be in a nearly peerless working environment with full autonomy (with all the pluses and minues that come with it). To quote the lyrics of Fort Minor:

This is ten percent luck
Twenty percent skill
Fifteen percent concentrated power of will
Five percent pleasure
Fifty percent pain

Thank you for a thorough response. It’s such a shame it’s almost impossible to start your own practice after residency in our specialty. As an alternative, have you ever heard of any rad onc partners with a community hospital and get a part of the technical fee?

 

[OTN]

It is possible, but very, very challening even for someone who knows what they ae doing. Here is task list:

1. You need to be a non-CON state. If you are in a CON state, you have to convince state authorities that there is a need to build a center in the area that you are proposing. Most members of this council will have vested interest in NOT approving your application because they own/profit from the centers in other parts of the state.

2. You need to identify a source of referrals. Realistically you need at least a couple of medical oncologists with a healthy sprinkling of surgical specialists (Neurosurgery, ENT, Gyn Onc, Urology) and even PCPs that can direct new breast, prostate, and lung cancer patients to you. If you have a competitor in town it will be a severe uphill battle unless the existing referring physicians are asking for an alternative.

3. You need to convince the bank to front you a loan for a linac, vault, and office facilities. Even in the best case scenario, I can't imagine this costing less than $5M. The linac will be the hardest component as you have minimial negotiating power. Large academic networks or private practice aggregators (like US Oncology) can demand lower prices because they buy in high volume. You will need a detailed proforma out to at least 10 years.

4. You need to get a long-term maintnenace service contract on your linac; I believe the first year or so is included in the initial purchase. Never ever run a linac without this in place.

5. You need a minimum of two RTTs and one Dosi (can be remote) and one Physics (can be remote). The salary and comp will vary wildly depending on where you are in the country. You will also need a front desk person who can probably also function as your office manager.

6. If you can somehow work out everything above, you will be in a nearly peerless working environment with full autonomy (with all the pluses and minues that come with it). To quote the lyrics of Fort Minor:

This is ten percent luck
Twenty percent skill
Fifteen percent concentrated power of will
Five percent pleasure
Fifty percent pain

You'll need 10% down in cash as well, which would be several hundred thousand. I don't think hanging a shingle is possible for a radonc in 2025.

 

[medgator]

All of the above.

thankfully, in 2025, ASTRO still hasn't gotten its way either or this thread would be an entirely moot point.

 

[xrt123]

"This is ten percent luck
Twenty percent skill
Fifteen percent concentrated power of will
Five percent pleasure
Fifty percent pain"

10/10 reference!

 

[BobbyHeenan]

Thank you for a thorough response. It’s such a shame it’s almost impossible to start your own practice after residency in our specialty. As an alternative, have you ever heard of any rad onc partners with a community hospital and get a part of the technical fee?

Yes, this happens.

Though it's not always termed as X% of technical to the rad onc. It may be a "medical director" stipend or some other money thrown their way or a very high $/RVU contract.

Either way it is money that is above and beyond what their pro fees generate that comes from the hospital.

In my experience those other strategies for whatever reason are more appetizing to admin than a % of technical...I have theories on that but certainly a reluctance to have full transparency would be seen as important to many admins.

 

[Gfunk6]

As an alternative, have you ever heard of any rad onc partners with a community hospital and get a part of the technical fee?

Heard of it? Sure. But most of these are probably legacy sweetheart deals that no longer apply to new Rad Oncs joining the practice after the fact. A regional hospital in my area gave a Rad Onc this awesome techinical share a few decades ago. The hospital admins were counting down the days until he retired and the new group got a straight pro fee only deal.

 

[BobbyHeenan]

Heard of it? Sure. But most of these are probably legacy sweetheart deals that no longer apply to new Rad Oncs joining the practice after the fact. A regional hospital in my era gave a Rad Onc this awesome techinical share a few decades ago. The hospital admins were counting down the days until he retired and the new group got a straight pro fee only deal.

This has been my experience as well.

There is room to negotiate more on top of pro fees in these rural places, but there is now a distaste for a flat % of technical type of arrangement like I had seen in generations past.

 

[TheWallnerus]

Is it possible for new grads to start a private practice from scratch? Do you need big connections to get approve for a loan to build a freestanding radiation center? Is it even worth it as opposed to joining an already established practice?

New grad: impossible. Unless you’re the umpteenth child of Elon Musk.