Rad Onc Procedures and RVUs

[Barcelona PSG]

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I do a lot of procedures as part of academic settings. GYN Brachytherapy, prostate brachytherapy, Prostate fiducials and occasional spacers in only certain scenarios. While these generate a lot of technical RVUs, the professional RVUs are relatively less to the amount of work and complexity involved. Does anyone have a contract where you get a particular dime per procedure? Is it reasonable to negotiate? Appreciate inputs

 

[thesauce]

I do a lot of procedures as part of academic settings. GYN Brachytherapy, prostate brachytherapy, Prostate fiducials and occasional spacers in only certain scenarios. While these generate a lot of technical RVUs, the professional RVUs are relatively less to the amount of work and complexity involved. Does anyone have a contract where you get a particular dime per procedure? Is it reasonable to negotiate? Appreciate inputs

It’s worth an ask, but in an academic setting, I think it would be a very uphill battle. Has to go through 10 layers of bureaucracy and you would have to convince them to carve out a deal for you and not for others.

 

[TheWallnerus]

I do a lot of procedures as part of academic settings. GYN Brachytherapy, prostate brachytherapy, Prostate fiducials and occasional spacers in only certain scenarios. While these generate a lot of technical RVUs, the professional RVUs are relatively less to the amount of work and complexity involved. Does anyone have a contract where you get a particular dime per procedure? Is it reasonable to negotiate? Appreciate inputs

A dime per procedure makes the hospital lawyers very nervous. And possibly a DOJ lawyer tumescent.

 

[ramsesthenice]

I do a lot of procedures as part of academic settings. GYN Brachytherapy, prostate brachytherapy, Prostate fiducials and occasional spacers in only certain scenarios. While these generate a lot of technical RVUs, the professional RVUs are relatively less to the amount of work and complexity involved. Does anyone have a contract where you get a particular dime per procedure? Is it reasonable to negotiate? Appreciate inputs

This would be very atypical for an academic contract. Much more common for total RVUs to go into a formula to determine bonus. But guaranteed payment per procedure…never heard of such a thing. I’ve run a high volume Brachy program for a while and the unfortunate reality is that it’s kind of a loser when it comes to RVUs and net revenue.

 

[medgator]

This would be very atypical for an academic contract. Much more common for total RVUs to go into a formula to determine bonus. But guaranteed payment per procedure…never heard of such a thing. I’ve run a high volume Brachy program for a while and the unfortunate reality is that it’s kind of a loser when it comes to RVUs and net revenue.

💯

Hospital may make up some of it on outside imaging and OR time but as far as RO reimbursement, peds and brachy are really low reimbursement areas in the Dept but are still important/necessary services to offer in that setting.

It should surprise no one that brachy usage has declined precipitously in this country overall given the reimbursement climate, logistics and manpower needed

 

[RSAOaky]

I do a lot of procedures as part of academic settings. GYN Brachytherapy, prostate brachytherapy, Prostate fiducials and occasional spacers in only certain scenarios. While these generate a lot of technical RVUs, the professional RVUs are relatively less to the amount of work and complexity involved. Does anyone have a contract where you get a particular dime per procedure? Is it reasonable to negotiate? Appreciate inputs

Hard to give advice without knowing details of your comp structure tbh. Is your bonus or comp RVU based?

 

[BobbyHeenan]

Agree with what has been said.

I'm not in academics but in the private world one way sometimes to bump up the pay would be to give you a title like "Medical Director of Brachytherapy" that came with a stipend. Our system has what I perceive to be a very strict /conservative compliance dept and across multiple specialties they use this tactic to bump up pay for employed docs. Of course we're not talking insane dollars, but it's not unusual to see stipends of $100K for director positions - though these are typically overall directors and not just directors of sub-departments.

 

[ramsesthenice]

💯

Hospital may make up some of it on outside imaging and OR time but as far as RO reimbursement, peds and brachy are really low reimbursement areas in the Dept but are still important/necessary services to offer in that setting.

It should surprise no one that brachy usage has declined precipitously in this country overall given the reimbursement climate, logistics and manpower needed

I think prostate Brachy is a great treatment but SBRT will eventually give the knock out blow. Especially with good SBRT boost data. Pays a lot more. Technically much easer, a lot less laborious, and can be done in the vast majority of centers.

 

[ramsesthenice]

Agree with what has been said.

I'm not in academics but in the private world one way sometimes to bump up the pay would be to give you a title like "Medical Director of Brachytherapy" that came with a stipend.

This can happen in academics too. Not pay per procedure but can often negotiate a small leadership bump. Typically these are no more than 10-15K per year.

 

[Lamount]

May be hard to get compensated per procedure, but you may be able to leverage some sort of yearly bonus and/or decreased RVU targets for a given salary bracket to "allow you the flexibility offer highly specialized procedures, befitting of an academic medical center" (or some nonsense like that haha)

 

[randomname2018]

This can happen in academics too. Not pay per procedure but can often negotiate a small leadership bump. Typically these are no more than 10-15K per year.

This is fairly standard in academics.

As a disclaimer, academic leadership rarely agrees to anything that isn't heavily one-sided in their favor. Generally, these agreements are loosely defined and rarely associated with an actual job description—approach with a heavy dose of caution. While you get a couple hundred extra per check, you also happily place a noose on your neck for any problem they can associate with your service line.

 

[DoctwoB]

I think prostate Brachy is a great treatment but SBRT will eventually give the knock out blow. Especially with good SBRT boost data. Pays a lot more. Technically much easer, a lot less laborious, and can be done in the vast majority of centers.

I disagree and think it will remain regional. As a urologist i'm pretty unimpressed by outcomes in my SBRT patients, both symptomatically and oncologically. Conversely I'm in a spot with an extremely high volume brachy program and the outcomes are excellent. Docs here, both radonc, urologists, and referrings, are all on board and believers in brachy given our outcomes. Likewise reimbursement is highly dependent on the volume of your program. Doing the occasional brachy that takes 90 minutes isn't great. doing 12 in a day that take 15 min a pop in a low cost ASC makes beaucoup bucks on the facility side.

This is coming from someone who came in as a major brachy skeptic. Where I trained, brachy was slow, laborious, and had unimpressive outcomes. Hence the regional effect.

Also will depend heavily on reimbursement incentives moving forward. Many healthcare systems are moving towards risk-sharing/capitated payment models. Tough to beat brachy cost-effectiveness in that setting.

 

[medgator]

I disagree and think it will remain regional. As a urologist i'm pretty unimpressed by outcomes in my SBRT patients, both symptomatically and oncologically. Conversely I'm in a spot with an extremely high volume brachy program and the outcomes are excellent. Docs here, both radonc, urologists, and referrings, are all on board and believers in brachy given our outcomes. Likewise reimbursement is highly dependent on the volume of your program. Doing the occasional brachy that takes 90 minutes isn't great. doing 12 in a day that take 15 min a pop in a low cost ASC makes beaucoup bucks on the facility side.

This is coming from someone who came in as a major brachy skeptic. Where I trained, brachy was slow, laborious, and had unimpressive outcomes. Hence the regional effect.

Also will depend heavily on reimbursement incentives moving forward. Many healthcare systems are moving towards risk-sharing/capitated payment models. Tough to beat brachy cost-effectiveness in that setting.

Great points. I think brachy makes sense in the right setting but wherever it does end up getting done, needs to be a high volume place for it to make sense

 

[RadRadRad]

I do a lot of procedures as part of academic settings. GYN Brachytherapy, prostate brachytherapy, Prostate fiducials and occasional spacers in only certain scenarios. While these generate a lot of technical RVUs, the professional RVUs are relatively less to the amount of work and complexity involved. Does anyone have a contract where you get a particular dime per procedure? Is it reasonable to negotiate? Appreciate inputs

Ive seen other specialists with such arrangements. Like pulm with ebus, etc. Makes sense to ask
Probably more likely if they are doing something similar for other proceduralists at your hospital

 

[A_DeMichele]

brachy is essentially a community service. Yes, have to negotiate upfront and try to offset your losses somehow. Lower RVU target, extra protected time, etc

 

[OTN]

I disagree and think it will remain regional. As a urologist i'm pretty unimpressed by outcomes in my SBRT patients, both symptomatically and oncologically. Conversely I'm in a spot with an extremely high volume brachy program and the outcomes are excellent. Docs here, both radonc, urologists, and referrings, are all on board and believers in brachy given our outcomes. Likewise reimbursement is highly dependent on the volume of your program. Doing the occasional brachy that takes 90 minutes isn't great. doing 12 in a day that take 15 min a pop in a low cost ASC makes beaucoup bucks on the facility side.

This is coming from someone who came in as a major brachy skeptic. Where I trained, brachy was slow, laborious, and had unimpressive outcomes. Hence the regional effect.

Also will depend heavily on reimbursement incentives moving forward. Many healthcare systems are moving towards risk-sharing/capitated payment models. Tough to beat brachy cost-effectiveness in that setting.

I would think SBRT easily beats brachy in that setting - no OR time, no purchasing of needles/sources, no need for OR staff, just 5 more treatments on a machine which is a fixed asset. My SBRT experience has been the opposite of yours, again underscoring the regional variability of treatments, but we moved into prostate SBRT after already treating lung, hepatobiliary, etc, which is an order of magnitude more difficult.

 

[ultima]

I think prostate Brachy is a great treatment but SBRT will eventually give the knock out blow. Especially with good SBRT boost data. Pays a lot more. Technically much easer, a lot less laborious, and can be done in the vast majority of centers.

SBRT boost is not billable as SBRT per ASTRO.

 

[radiaterMike]

ASTRO model policy specifies: "SBRT is meant to represent a complete course of treatment and not be used as a boost following a conventionally fractionated course of treatment." So ASTRO is saying that an SBRT boost is not necessary as opposed to not billable (which I take to mean things we routinely do, but can't bill for - like simulations with IMRT, SBRT, etc)

 

[TheWallnerus]

SBRT boost is not billable as SBRT per ASTRO

IGRT is a "diagnostic test," per ASTRO. All diagnostic tests must show "evidence of intent (MD progress notes listing tests needed) and evidence of medical necessity (description of clinical conditions and treatment showing the need for the testing)."

So every IGRT event is not billable* per ASTRO without ordering it in the "progress notes," and a note as to why the image guidance "testing" is medically necessary.

*one infers

 

[medgator]

ASTRO says some dumb $&!t sometimes. They aren't CMS. Remember how much they hated imrt in breast cancer? CMS pays out plenty in IMRT charges for breast

 

[Gfunk6]

Agree with medgator. At times we use SBRT boost on prostate cancer, the same way one would use LDR/HDR as a boost. In other words 45-50.4 Gy to prostate + pelvic LNs --> 19 Gy/2 fx boost to prostate.

In order to bill this properly, you need for the IMRT course fo be completed and billed out. Wait 1-2 business days then submit auth for SBRT x 2 fractions - then re-simulate, re-plan and treat.

 

[macstjo15]

Has there been any trial comparing brachy vs. SBRT boost?

 

[Doctorer]

Has there been any trial comparing brachy vs. SBRT boost?

No.

 

[drowsy12]

Not every day that a rad onc gets to be CEO/Dean

 

[radiation]

Not every day that a rad onc gets to be CEO/Dean

Post from 2022 - now there is DeWeese and Kimmelman. Go get your monies from @TheWallnerus

This is essentially what Ed Halperin said in his editorial way back when… but then attempted to walk it back in the same editorial by optimistically predicting a hard working, industrious rad onc could get respect. And become a med school dean. LOLOL

If a rad onc gets appointed as a med school dean between now and 2030, the first person to DM me I will Venmo a hundred bucks.

DEFINE_ME

 

[TheWallnerus]

Post from 2022 - now there is DeWeese and Kimmelman. Go get your monies from @TheWallnerus

DM me….. nice

 

[Ray D. Ayshun]

Isn't being the CEO and Dean kinda like djt heading the Kennedy center?

 

[Neuronix]

Isn't being the CEO and Dean kinda like djt heading the Kennedy center?

The way I interpret it, especially in the context of the other NYU discussions, is that the dean/CEO position is there to generate revenue and crack the academics skulls if they get out of line.

It's a little weird to have the head of rad onc in that position with their physician-scientist basically in charge of dissolving their MD/PhD program.

Is this good news for radiation oncology?

 

[communitydoc13]

The way I interpret it, especially in the context of the other NYU discussions, is that the dean/CEO position is there to generate revenue and crack the academics skulls if they get out of line.

It's a little weird to have the head of rad onc in that position with their physician-scientist basically in charge of dissolving their MD/PhD program.

Is this good news for radiation oncology?

Deweese, Suntha (CEO), Kimmelman...all really within the past 5 years.

I think there is something about your department making lots of money that facilitates this.

Not a healthy aspiration for most serious academics IMO.

I view these folks as having "graduated" from radiation oncology. They will of course deny this.

 

[Ray D. Ayshun]

CEOs wash the blood off with Dean soap

 

[evilbooyaa]

Not every day that a rad onc gets to be CEO/Dean

Seems strange to have the same person be responsible for both CEO and Dean positions. Seems like a conflict of interest where whether he is actually being the best Dean he could be would be at odds with being the CEO, and vice-versa.

Who advocates for the medical students/residents? A person whose job is to simultaneously ensure the institution is making as much money as possible? Seems at odds. Not sure I would recommend that prospective students select a medical school where the Dean's right hand is slapped away by.... his own left hand since he's also the CEO of the medial enterprise. Even if tuition is free.

I'm not sure how one person can be expected to do BOTH tasks unless we accept that the day to day responsibilities of executives (whether they be in the C-suite or the ivory tower of medical school leadership) are not a full time job.... which then begs the question WTAF all other CEOs and Deans (who presumably have only one of those titles) are doing the other 50% of the time.

Additionally, if he's a PS, what happens to his lab? Dean/CEO are going to play part-time fiddle to basic scientist work? Or he's going to give up his lab?

NYU is a smart place that is heavily focused on public perception and maximizing their income. Hell they were the only cancer center with enough monies to shell out for a Super Bowl ad. If this is a bad idea (I'm not saying it is, it just calls into question ALL other CEO and Dean positions in academic medicine), they definitely have the money to hire two separate people to have those responsibilities.

 

[randomname2018]

I view these folks as having "graduated" from radiation oncology. They will of course deny this.

I would add Steve Hahn to this as well.

I have often found the career development path in Radiation Oncology to be rather strange. I never understood why such a focus was on the well worn ASTRO leadership and chairmanship pathways. Seems illogical.

 

[Neuronix]

Seems strange to have the same person be responsible for both CEO and Dean positions. Seems like a conflict of interest where whether he is actually being the best Dean he could be would be at odds with being the CEO, and vice-versa.

I've seen it done both ways. When there is a separate dean and CEO, the dean position ends up being powerless because the money and decisions are all controlled from the CEO side anyway.

I'm sure there are vice deans or whatever dealing with the usual day-to-day medical school, residency, and faculty affairs issues.

Additionally, if he's a PS, what happens to his lab? Dean/CEO are going to play part-time fiddle to basic scientist work? Or he's going to give up his lab?

These types usually pay a lot of money to others to run the lab and write the grants. That's part of the negotiations for the position.

 

[CurbYourExpectations]

Well if the deans/CEOs are anything like me, I know exactly what they're doing:

 

[evilbooyaa]

I've seen it done both ways. When there is a separate dean and CEO, the dean position ends up being powerless because the money and decisions are all controlled from the CEO side anyway.

I'm sure there are vice deans or whatever dealing with the usual day-to-day medical school, residency, and faculty affairs issues.



These types usually pay a lot of money to others to run the lab and write the grants. That's part of the negotiations for the position.

I mean OK, but seems weird for an institution to steer directly into that conception. It's like saying the quiet part out loud.

"Hey, Med students! Here's this guy, he's the Dean of you guys! He's here to support your careers! Although, he's also the CEO, so he will 100% prioritize the institution over you at ALL aspects and doens't actually haveyour back in any significant way. Best of luck in med school and getting a job that doesn't exploit you!"

 

[CurbYourExpectations]