Protons are blowing Rad Onc's boat out the CMS water

[OTN]

I certainly agree vis a vis fraction shaming and the high-handed nonsense. I am not sure I share your concern with "butterfly effects". Don't get me wrong, there are definitely folks at CMS who are out to destroy us. I am just of the mindset that we should do the studies first, and THEN decide if the benefit is worth the expense.

Many think our speciality is paid more than it is worth. We have put a lot of effort into trying to find ways to be more efficient by decreasing costs. However, I also think we should be investing in research on the other side of the equation as well by seeing if we can provide more valuable treatments -that could MAYBE justify a higher pricetag.

"Many think our specialty is paid more than it is worth" - there's good data showing RT consistently does very well in terms of QALY cost. It's a shame our profession's leaders don't spend more time espousing this info, rather than consistently trying to shame members of our own specialty who may not practice identically to how they do.

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Members don't see this ad.

 

[deleted1111261]

"Many think our specialty is paid more than it is worth" - there's good data showing RT consistently does very well in terms of QALY cost. It's a shame our profession's leaders don't spend more time espousing this info, rather than consistently trying to shame members of our own specialty who may not practice identically to how they do.

This!

 

[Gfunk6]

In our field, there is very little expansion of what we do. This is why we have such pathos and academic careers disproportionately studying value based care, de-escalation and equity (mostly a political and not academic issue).

The big centers are not dumb however. They know (or suspect) that aggregate utilization will go down inexorably. Their goal is just to increase market share by any means necessary in this brave new world. Forget being a center of excellence for New Yorkers, MSKCC will be a regional center with sites throughout the north east. PENN is putting protons in Lancaster.

The goal will be high cost, single fraction XRT for everyone, only given at large prestigious centers. That is until all regional competition is eliminated.

The academic radonc is just the useful idiot in this system.

And the beauty of it all is that they can charge their insane rates regardless of location. Therefore SBRT in midtown Manhattan will cost the same whether you do it in the mothership or rural Delaware.

 

[Ray D. Ayshun]

Parking fees are zero in my one linac town

 

[medgator]

Parking fees are zero in my one linac town

And a quick stroll into the office!

 

[RadOncDoc21]

And a quick stroll into the office!

My keurig coffee selection is top notch!

 

[Mandelin Rain]

My keurig coffee selection is top notch!

Do you even EKG, bro?

 

[RadOncDoc21]

Do you even EKG, bro?

You’re too fancy… I’m one step above instant coffee and the powder cream, especially since Starbucks wants to charge 10 dollars a cup. I’m sure MSKCC probably has a Mr. Coffee maker or something. Times are hard these days.

 

[medgator]

You’re too fancy… I’m one step above instant coffee and the powder cream, especially since Starbucks wants to charge 10 dollars a cup. I’m sure MSKCC probably has a Mr. Coffee maker or something. Times are hard these days.

They probably have an overpriced Starbucks on the way to dept I'm guessing

 

[deleted1111261]

Miele !!

 

[metallica81788]

And a quick stroll into the office!

One of the best perks of satellite or small department life!

I would say you can't put a price on it, but surely the admins have worked that into the $/RVU/compensation package for future negotiations

 

[thesauce]

Do you even EKG, bro?

This has my vote for post of the year

 

[evilbooyaa]

This has my vote for post of the year

?!
It's only JANUARY

 

[Mandelin Rain]

?!
It's only JANUARY

 

[deleted1111261]

?!
It's only JANUARY

Keep a note of this and at December end we can have best post ceremony

 

[RickyScott]

 

[SneakyBooger]

View attachment 348986

Thanks. Enlightening.

 

[Mandelin Rain]

View attachment 348986

 

[communitydoc13]

I'd like the @RickyScott take.

My take:

Medicare reimburses 175% for protons over IMRT. These places bill way way way over this (5-10x typically?) and per prior discussion may use ridiculous rates negotiated with private payors to cover the difference. This means that cost to society and remuneration to these places for a medicare patient is often 10x per fraction of IMRT given at a place that collects only what Medicare pays.

Billed rates for private payors for IMRT are not included in this graph and would be nice to see.

PENN has an outlier private payor somewhere.

Oh snap!!! And because PENN has an outlier Payor, they set their charge to medicare at a ridiculous rate (thus why these places charge what they do) so they can maximize reimbursement for patients with this ridiculous plan.

 

[Tsigolonco noitaidar]

I'd like the @RickyScott take.

My take:

Medicare reimburses 175% for protons over IMRT. These places bill way way way over this (5-10x typically?) and per prior discussion may use ridiculous rates negotiated with private payors to cover the difference. This means that cost to society and remuneration to these places for a medicare patient is often 10x per fraction of IMRT given at a place that collects only what Medicare pays.

Billed rates for private payors for IMRT are not included in this graph and would be nice to see.

PENN has an outlier private payor somewhere.

Oh snap!!! And because PENN has an outlier Payor, they set their charge to medicare at a ridiculous rate (thus why these places charge what they do) so they can maximize reimbursement for patients with this ridiculous plan.

thanks for the explanation. So a dumb question: does Medicare pay different rates at different institutions depending on what rate each institution sets? And this is based on the rate being set for private payors at that institution?

 

[BobbyHeenan]

thanks for the explanation. So a dumb question: does Medicare pay different rates at different institutions depending on what rate each institution sets? And this is based on the rate being set for private payors at that institution?

This doesn't answer your question but there are different medicare "multipliers" based upon what geographic location you're in. Reimbursement in Appalachia is wildly different than many coastal metros.

 

[deleted941485]

View attachment 348986

I'd like the @RickyScott take.

My take:

Medicare reimburses 175% for protons over IMRT. These places bill way way way over this (5-10x typically?) and per prior discussion may use ridiculous rates negotiated with private payors to cover the difference. This means that cost to society and remuneration to these places for a medicare patient is often 10x per fraction of IMRT given at a place that collects only what Medicare pays.

Billed rates for private payors for IMRT are not included in this graph and would be nice to see.

PENN has an outlier private payor somewhere.

Oh snap!!! And because PENN has an outlier Payor, they set their charge to medicare at a ridiculous rate (thus why these places charge what they do) so they can maximize reimbursement for patients with this ridiculous plan.

In the setting of less fx and less indications…literally the only thing left is $/fx.

 

[communitydoc13]

does Medicare pay different rates at different institutions depending on what rate each institution sets?

I don't think this is the way it works. I don't think the institution leverages medicare, and if there is a difference in payment, it's down in the weeds compared to the difference in charges.

What's clear to me now is how institutions set their fee schedule. They charge very close to the highest amount they can get from a private payor. This of course lets them may the most money they can for private insurance folks as well as those with secondary insurance in addition to medicare.

Those institutions offering protons and with a favorable payor mix are rich as hell from a radonc perspective. Interestingly, many of these places pay docs particularly poorly.

 

[deleted941485]

I don't think this is the way it works. I don't think the institution leverages medicare, and if there is a difference in payment, it's down in the weeds compared to the difference in charges.

What's clear to me now is how institutions set their fee schedule. They charge very close to the highest amount they can get from a private payor. This of course lets them may the most money they can for private insurance folks as well as those with secondary insurance in addition to medicare.

Those institutions offering protons and with a favorable payor mix are rich as hell from a radonc perspective. Interestingly, many of these places pay docs particularly poorly.

Best of both worlds. Great reimbursement and rock bottom salaries for the docs.

I know a dude who used to work them. Saw a **** ton of patients and took a medical directorship. Worked for 3 years and never made more than 350K. When he asked for more, he was given the corporate line about how this is the market rate. I guess it’s true when you basically ARE the market.

 

[maxxor]

thanks for the explanation. So a dumb question: does Medicare pay different rates at different institutions depending on what rate each institution sets? And this is based on the rate being set for private payors at that institution?

No. CMS pays what CMS pays. They do not negotiate. However, if your fee schedule is less than the current CMS rate, they want to pay the lesser amount.

What others have alluded to is that Medicare Advantage plan administrators somehow have to pay the higher rates that private payers to make up the difference between what CMS pays.

 

[RickyScott]

Thanks. Enlightening.

I'd like the @RickyScott take.

My take:

Medicare reimburses 175% for protons over IMRT. These places bill way way way over this (5-10x typically?) and per prior discussion may use ridiculous rates negotiated with private payors to cover the difference. This means that cost to society and remuneration to these places for a medicare patient is often 10x per fraction of IMRT given at a place that collects only what Medicare pays.

Billed rates for private payors for IMRT are not included in this graph and would be nice to see.

PENN has an outlier private payor somewhere.

Oh snap!!! And because PENN has an outlier Payor, they set their charge to medicare at a ridiculous rate (thus why these places charge what they do) so they can maximize reimbursement for patients with this ridiculous plan.

Agreed. Just another data point that protons are a disproportionately large direct contributor to overall radonc costs because of inflated negotiated prices (wouldn’t surprise me if they were 3% or less of treatment but 15-20% of costs). Indirectly, the halo effect of protons by luring patients to high cost systems, is likely to be just as significant.

 

[IonsAreOurFuture]

Don't forget Peoria! Looks like they're getting a multi-room setup.

OSF Breaks Ground On New $237 Million Cancer Institute

OSF HealthCare's Cancer Institute will offer proton beam therapy cancer treatment.

www.wcbu.org

Before a groundbreaking ceremony on Tuesday, the bishop for the Catholic Diocese of Peoria, Louis Tylka, led OSF workers in prayer. He encircled a mound of dirt in front of a Caterpillar excavator and blessed the land, flicking holy water at the ground.

Maybe ASTRO should bring on the Bishop as a lobbyist?

Here is another new proton center announcement, this one for San Antonio, due to open in 2024. That's a pretty rapid build - just 2 years. It looks like a single-room center; that's usually what Proton International does.

FIRST LOOK: San Antonio Proton Therapy Center - HCD Magazine

 

[thecarbonionangle]

Here is another new proton center announcement, this one for San Antonio, due to open in 2024. That's a pretty rapid build - just 2 years. It looks like a single-room center; that's usually what Proton International does.

FIRST LOOK: San Antonio Proton Therapy Center - HCD Magazine

Is this separate from the UTSA one?

 

[IonsAreOurFuture]

Is this separate from the UTSA one?

UT Health San Antonio, Proton International partner for new advanced cancer therapy facility - UT Health San Antonio

UT Health San Antonio contact: Steven Lee, 210-450-3823, [email protected] Proton International contact: Kristen Chandler Powers, 502-939-3323, [email protected] SAN ANTONIO – The University of Texas Health Science Center at San Antonio, also known as UT Health San Antonio, and Proton...

news.uthscsa.edu

It looks like this facility will be staffed by UT San Antonio doctors. The exact ownership breakdown, I'm not sure.

 

[OTN]

Is this separate from the UTSA one?

no

 

[TheWallnerus]

Just imagine if around 2005 there had been a company helping put in radiotherapy centers called “IMRT International.” I know of some people that might have had a stroke. But “Proton International?” No problem.

 

[deleted941485]

Just imagine if around 2005 there had been a company helping put in radiotherapy centers called “IMRT International.” I know of some people that might have had a stroke. But “Proton International?” No problem.

Just get on the bandwagon. Cause there’s no other wagon to get on.

 

[OTN]

Just imagine if around 2005 there had been a company helping put in radiotherapy centers called “IMRT International.” I know of some people that might have had a stroke. But “Proton International?” No problem.

If IMRT required the amount of capital to get off the ground that protons do, no doubt those companies would have existed.

 

[radiation]

Just imagine if around 2005 there had been a company helping put in radiotherapy centers called “IMRT International.” I know of some people that might have had a stroke. But “Proton International?” No problem.

D3 RADIATION PLANNING, INC. :: Massachusetts (US) :: OpenCorporates

Free and open company data on Massachusetts (US) company D3 RADIATION PLANNING, INC. (company number 000980682), 5750 CENTRE AVE., SUITE 500, PITTSBURGH, PA, 15206

opencorporates.com

A form of that actually existed and was run by Dwight Heron. If somebody did a deep dive on that company, you might be surprised how deep that rabbit hole went

 

[TheWallnerus]

If IMRT required the amount of capital to get off the ground that protons do, no doubt those companies would have existed.

The remuneration of IMRT never trumped protons, but the profit margin (in relative terms) sure did. Could have allowed for some nice graft in the same vein as Proton International. I am not a graduate of the Wharton School of Business, but all these things boil down to one thing: there must be a profit margin that lets some people (or businesses, which always consist of people) that don’t actually participate medically to make some cash.

 

[deleted941485]

D3 RADIATION PLANNING, INC. :: Massachusetts (US) :: OpenCorporates

Free and open company data on Massachusetts (US) company D3 RADIATION PLANNING, INC. (company number 000980682), 5750 CENTRE AVE., SUITE 500, PITTSBURGH, PA, 15206

opencorporates.com

A form of that actually existed and was run by Dwight Heron. If somebody did a deep dive on that company, you might be surprised how deep that rabbit hole went

3D solutions I think was the name.

 

[radiation]

3D solutions I think was the name.

that company may or may not be the reason you see this when you google his name...

 

[BobbyHeenan]

that company may or may not be the reason you see this when you google his name...
View attachment 349306

I respect the hustle.

I wonder though if you do red light therapy before the beam turns on if you can bill hyperthermia codes?

Former UPMC cancer doctor trades medical practice for private enterprise

‘It was a tough decision, but it was the right decision.’

www.post-gazette.com

 

[Gfunk6]

Dr. Heron with his 50th anniversary Lambo Aventador

#radoncrocks

 

[RickyScott]

3D solutions I think was the name.

D3 was sold to varian and was well respected. They were used widely for imrt remote planning (at a time when imrt planning was too difficult for some community practices) as well as to get an imrt program up and running. They were also widely used to commission linacs

 

[Lamount]

Dr. Heron with his 50th anniversary Lambo Aventador

View attachment 349308

#radoncrocks

I would never buy a lambo, even if I was a billionare. Don't get me wrong... they are awesome. I just feel like every time I got out, people would be expecting Bruce Wayne or a celebrety... and then it would just be me.

 

[IonsAreOurFuture]

I would never buy a lambo, even if I was a billionare. Don't get me wrong... they are awesome. I just feel like every time I got out, people would be expecting Bruce Wayne or a celebrety... and then it would just be me.

You're a rock star in my book Lamount.

 

[deleted1111261]

D3 was sold to varian and was well respected. They were used widely for imrt remote planning (at a time when imrt planning was too difficult for some community practices) as well as to get an imrt program up and running. They were also widely used to commission linacs

We did a rotation at D3 when I was a resident. It’s like a dosimetry sweatshop! But with middle aged white people instead of 11 years old boys.

 

[medgator]

I would never buy a lambo, even if I was a billionare. Don't get me wrong... they are awesome. I just feel like every time I got out, people would be expecting Bruce Wayne or a celebrety... and then it would just be me.

Just super impractical for me... Would rather just stick with a Model S plaid and its understated exterior, way more space/functionality and lower maintenance/fuel costsm... Not to mention the ability to smoke the Lambo at a stoplight at a fraction of the price

 

[OTN]

Just super impractical for me... Would rather just stick with a model s plaid and its understated exterior and lower maintenance/fuel costs and the ability to smoke the Lambo at a stoplight at the fraction of the price

As a motorhead I'm going to have to weigh in here, on the "protons and CMS" discussion: Model S plaid is a one-trick acceleration pony and the aventador would destroy it on a racetrack, despite the 0.8ish second gap from 0-60 the Model S would hold. Having said THAT, a Porsche GT3 would wreck both of them, and the McLaren Senna GTR would demolish them all. Thank you for coming to my TED talk.

 

[medgator]

As a motorhead I'm going to have to weigh in here, on the "protons and CMS" discussion: Model S plaid is a one-trick acceleration pony and the aventador would destroy it on a racetrack, despite the 0.8ish second gap from 0-60 the Model S would hold. Having said THAT, a Porsche GT3 would wreck both of them, and the McLaren Senna GTR would demolish them all. Thank you for coming to my TED talk.

For sure.... But with the difference in money you'd save between the two, you could basically buy a loaded weekend warrior GT2/3 i think and still have 5-6 figures left for gas and maintenance

 

[thecarbonionangle]

With the cancer moonshot 2.0 relaunch announced, i see a lot of MDACC in pics with Biden. I wonder if some proton grift is in the works. Never count Biden or the Chinese out folks!

 

[deleted941485]

With the cancer moonshot 2.0 relaunch announced, i see a lot of MDACC in pics with Biden. I wonder if some proton grift is in the works. Never count Biden or the Chinese out folks!

Proton exemption?

 

[thecarbonionangle]

Proton exemption?

If its what you say, I love it!

 

[deleted941485]

If its what you say, I love it!

As I have said earlier, I have given up pretty much any hope of being anything more than a proton shill and you know what as long as the paychecks are rolling in I’m ok with that.