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medgator said:
It did but it was generally 2/3, not 0-1/3
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yeah I mean read any of the threads that show up at the bottom sometimes for 'similar threads'

fun to look at threads from 2003, 2013 etc

the story has always been the same - job market is tight in RO. that was always the rub on rad onc. it's just that its worse now when it doesnt need to be.
 
Unfortunately measures like number of offers don't quantify the job market very well. Uro is felt to have a great job market. Most Urologists I know didn't get more then 2 or maybe 3 firm job offers. It's not that they couldn't have gotten more, its just that as you go through the process (maybe you reach out to X number of places, interview at Y), you drop out of or withdraw from most places as you focus on the ones you're truly interested in.

The ratio of jobs contacted to jobs offered or on-site interviews offered probably provide a better sense, more so then the total number of offers. It is the old "money, location, job description, pick 2". The better the job market, the more likely that you can pick 2 or all 3. In a worse market you might get 1 or none.
 
I'm actually not surprised the breast cancer trial was negative. I treat a ton of SBRT for oligomets and have been able to get most of our medoncs to buy in. I haven't treated that many breast cancer patients, however. Seems to me they tend to progress in a non-oligometastatic pattern, developing multiple areas of disease at once rather than slow progression.

On a positive note, the 8 year COMET results look great.
 
SubserviantToABR said:


Strong work by NRG Oncology and Dr. Chmura for doing this study...but I am not holding out for oligomets to save radiation oncology.
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Fisher remains undefeated.

We will have to find other diseases where *true* oligomet states exist. And hope they truly exist...

Or, it's possible that the "oligometastasis" paradigm doesn't have any thoroughly solid grounding in reality and was just based on the not entirely fulsome and long ago observations/wild-ass guesses re: breast cancer outcomes by two dudes.

OTN said:
I haven't treated that many breast cancer patients, however. Seems to me they tend to progress in a non-oligometastatic pattern, developing multiple areas of disease at once rather than slow progression.
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Sam Hellman from 1995 just called and is holding for you on line one.

MEdXJ73.png
 
TheWallnerus said:
Fisher remains undefeated.

We will have to find other diseases where *true* oligomet states exist. And hope they truly exist...

Or, it's possible that the "oligometastasis" paradigm doesn't have any thoroughly solid grounding in reality and was just based on the not entirely fulsome and long ago observations/wild-ass guesses re: breast cancer outcomes by two dudes.



Sam Hellman from 1995 just called and is holding for you on line one.

MEdXJ73.png
Click to expand...
Personally, I have always felt like the indication for treating oligoprogressive disease is much more compelling than oligometastatic disease.

When treating oligoprogressive disease, you are selecting for metastatic patients with indolent biology and/or receiving highly effective drugs, and focusing only on areas that show resistance to systemic therapy.
 
Lamount said:
Personally, I have always felt like the indication for treating oligoprogressive disease is much more compelling than oligometastatic disease.
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ascopost.com

Can SBRT to Selected Sites of Limited Progression or Oligoprogression Extend Progression-Free Survival in Advanced Lung Cancer but Not Breast Cancer?

Stereotactic body radiation therapy (SBRT) lengthens progression-free survival for patients with advanced lung cancer who have oligoprogression (ie, tumors that have not been fully responsive to syste...
ascopost.com

Figured the CURB trial might be up your alley. Tiny numbers in all these trials. Very dangerous design. Interesting that oligopogressive lung demonstrated benefit whereas breast did not.
 
RickyScott said:
Good time to keep in mind sabr-comet is randomized phase 2 trial. In oncology, such trials are confirmed by the subsequent randomized phase 3 around 45% of the time.
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SABR-COMET may be a chimera. Pre-trial OS positivity was set at p<0.2; initial results showed p=0.09 better OS at ~2y and the trial was declared positive although I recall everyone at the time saying: "Positive, with caution; not practice-changing." With 8y followup, the p-value went to 0.008; ~1 out of 5 SABR patients had >5y survival without recurrence. It's unusual, especially in metastatic cancer patients (who tend to die in followup), for insignificant survival curves to separate more widely and become significant at distant time periods. I can't think of another example right this second. SABR-COMET started accruing in 2012 and through 2016. How we treat metastatic lung cancer has changed a lot since then; SABRing has not.

Confirmation around 45% of the time is valid for initial p-values from previous studies in the 0.05 to 0.02 range, roughly. Was SABR-COMET positive at p=0.09 (rather unlikely to be confirmed in phIII) or p=0.008 (pretty likely to be confirmed)? Take your pick!
 
TheWallnerus said:
SABR-COMET may be a chimera. Pre-trial OS positivity was set at p<0.2; initial results showed p=0.09 better OS at ~2y and the trial was declared positive although I recall everyone at the time saying: "Positive, with caution; not practice-changing." With 8y followup, the p-value went to 0.008; ~1 out of 5 SABR patients had >5y survival without recurrence. It's unusual, especially in metastatic cancer patients (who tend to die in followup), for insignificant survival curves to separate more widely and become significant at distant time periods. I can't think of another example right this second. SABR-COMET started accruing in 2012 and through 2016. How we treat metastatic lung cancer has changed a lot since then; SABRing has not.

Confirmation around 45% of the time is valid for initial p-values from previous studies in the 0.05 to 0.02 range, roughly. Was SABR-COMET positive at p=0.09 (rather unlikely to be confirmed in phIII) or p=0.008 (pretty likely to be confirmed)? Take your pick!
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I mean… it passes the smell test. I have quite a few patients that I have been treating on TKI or IO with multiple courses of SBRT alive >1 year out. They really don’t have great systemic alternatives. Would they be alive if not for my game of wack-o-mole? Who knows. But how do you NOT blast a growing tumor when you know nothing else can stop it?
 
Interesting -

1653661294999.png


Drilling down - here's the abstract:

1653661353521.png


1653661528130.png


The "NCI-PPS" center is obviously Sloan. The highlighted part in the last image is key - yes, there's a HUGE variation in what was charged...but reimbursements were "similar across centers" and ranged $6k-$9k. This is what makes this type of work so difficult, because what is charged doesn't reflect what is paid, even though the charges grab headlines.

Per this abstract, Sloan is 61% of pembro claims in NYC and gobbled up 65% of total payments last year.

Reading this abstract:

Sloan charges $20,000 and 48% of that is reimbursed by Medicare in 2021:
1653661894727.png

Which is $9,600.

This hospital charging $155,000 only gets 5% reimbursed:
1653661971588.png

Which is $7,750.

Obviously this is just an abstract and not a full paper, so these methods are confusing and I could be doing that math wrong. Please correct me if I'm off!

But the take home point for me is that Sloan is reimbursed almost $2,000 more than this "outrageous" hospital charging $155,000 - and Sloan also is 65% of total payments in NEW YORK CITY, which has a tremendous number of hospitals and providers.

End. PPS-exempt. Centers. Now.
 
elementaryschooleconomics said:
Interesting -

View attachment 355418

Drilling down - here's the abstract:

View attachment 355419

View attachment 355421

The "NCI-PPS" center is obviously Sloan. The highlighted part in the last image is key - yes, there's a HUGE variation in what was charged...but reimbursements were "similar across centers" and ranged $6k-$9k. This is what makes this type of work so difficult, because what is charged doesn't reflect what is paid, even though the charges grab headlines.

Per this abstract, Sloan is 61% of pembro claims in NYC and gobbled up 61% of total payments last year.

Reading this abstract:

Sloan charges $20,000 and 48% of that is reimbursed by Medicare in 2021:
View attachment 355422
Which is $9,600.

This hospital charging $155,000 only gets 5% reimbursed:
View attachment 355423
Which is $7,750.

Obviously this is just an abstract and not a full paper, so these methods are confusing and I could be doing that math wrong. Please correct me if I'm off!

But the take home point for me is that Sloan is reimbursed almost $2,000 more than this "outrageous" hospital charging $155,000 - and Sloan also is 61% of total payments in NEW YORK CITY, which has a tremendous number of hospitals and providers.

End. PPS-exempt. Centers. Now.
Click to expand...
Yes.
 
elementaryschooleconomics said:
End. PPS-exempt. Centers. Now.
Click to expand...
Agree totally.

We reviewed in another thread that the charges mean very little for the average patient or payor (including medicare). They represent something close to the highest negotiated payment for a given service or drug (This highest negotiated rate may represent a tiny number of execs with a gold plated plan willing to pay more to make more).
 
elementaryschooleconomics said:
Interesting -

View attachment 355418

Drilling down - here's the abstract:

View attachment 355419

View attachment 355421

The "NCI-PPS" center is obviously Sloan. The highlighted part in the last image is key - yes, there's a HUGE variation in what was charged...but reimbursements were "similar across centers" and ranged $6k-$9k. This is what makes this type of work so difficult, because what is charged doesn't reflect what is paid, even though the charges grab headlines.

Per this abstract, Sloan is 61% of pembro claims in NYC and gobbled up 65% of total payments last year.

Reading this abstract:

Sloan charges $20,000 and 48% of that is reimbursed by Medicare in 2021:
View attachment 355422
Which is $9,600.

This hospital charging $155,000 only gets 5% reimbursed:
View attachment 355423
Which is $7,750.

Obviously this is just an abstract and not a full paper, so these methods are confusing and I could be doing that math wrong. Please correct me if I'm off!

But the take home point for me is that Sloan is reimbursed almost $2,000 more than this "outrageous" hospital charging $155,000 - and Sloan also is 65% of total payments in NEW YORK CITY, which has a tremendous number of hospitals and providers.

End. PPS-exempt. Centers. Now.
Click to expand...
The interpretation is correct; MSKCC charges less but gets a far greater proportion reimbursed. What doesn’t make sense to me is why the reimbursements from CMS different at all across the non PPS exempt hospitals?

I thought that drug falls under ASP+6%.
 
elementaryschooleconomics said:
but reimbursements were "similar across centers" and ranged $6k-$9k
Click to expand...
Reimbursement amounts per...

Patient?
Cycle?
Year?

Anybody talking "charges" in medicine can't be taken seriously. It's like a guy saying he's got a ten foot schlong. Where it's at is reimbursement. All of us in medicine and in the media need to let "overcharging" go. It's a non-issue (for the most part).

Medicare reimburses ~$2.7B/year for Keytruda across about 50,000 patients (for comparison, about 250-350K Medicare patients per year get RT) per year at about $50K per patient per year.

EySvrao.jpg


klCF9L6.jpg
 
communitydoc13 said:
Agree totally.

We reviewed in another thread that the charges mean very little for the average patient or payor (including medicare). They represent something close to the highest negotiated payment for a given service or drug (This highest negotiated rate may represent a tiny number of execs with a gold plated plan willing to pay more to make more).
Click to expand...
Charges are what a hospital asks for. Prices/paid/reimbursement is what they get. That’s why price transparency for prices paid is so important. From the upenn data, some insurances were actually paying 5-10x cms rates for xrt. If they are delivering 60% of keytruda, why would you exempt these centers from the apm?
 
Last edited:
elementaryschooleconomics said:
Interesting -

View attachment 355418

Drilling down - here's the abstract:

View attachment 355419

View attachment 355421

The "NCI-PPS" center is obviously Sloan. The highlighted part in the last image is key - yes, there's a HUGE variation in what was charged...but reimbursements were "similar across centers" and ranged $6k-$9k. This is what makes this type of work so difficult, because what is charged doesn't reflect what is paid, even though the charges grab headlines.

Per this abstract, Sloan is 61% of pembro claims in NYC and gobbled up 65% of total payments last year.

Reading this abstract:

Sloan charges $20,000 and 48% of that is reimbursed by Medicare in 2021:
View attachment 355422
Which is $9,600.

This hospital charging $155,000 only gets 5% reimbursed:
View attachment 355423
Which is $7,750.

Obviously this is just an abstract and not a full paper, so these methods are confusing and I could be doing that math wrong. Please correct me if I'm off!

But the take home point for me is that Sloan is reimbursed almost $2,000 more than this "outrageous" hospital charging $155,000 - and Sloan also is 65% of total payments in NEW YORK CITY, which has a tremendous number of hospitals and providers.

End. PPS-exempt. Centers. Now.
Click to expand...
Similar? Sloan gets ~20% more taxpayer money for the same. exact. service. That's the story line a serious health care cost researcher would run with. I'm not open to the idea that MSK infusion nurses are somehow better inserting IVs or dripping in pembro than at the non-PPS exempt NCI centers. Just incredibly disingenuous research.
 
Last edited:
Mandelin Rain said:
Similar? Sloan gets ~20% more taxpayer money for the same. exact. service. That's the story line a serious health care cost researcher would run with. I'm not open to the idea that MSK infusion nurses are somehow better inserting IVs or dripping in pembro than at the non-PPS exempt NCI centers. Just incredibly disingenuous research.
Click to expand...
I will admit up front I am not sure if this applies to outpatient drug infusion.

However, what’s the variation in DRG reimbursement attributable to a given change in Case Mix Index? Could mskcc actually have a higher CMI? A lower CMI? Is the PPS exemption worth more or less than their CMI would earn them relative to say Cornell or NYU?

Some hospitals have surprisingly high CMI and others are low. I’m not sure where in the DRG payment formula the CMI is applied.

Could this explain why there are different CMS payments in that abstract?
 
maxxor said:
I will admit up front I am not sure if this applies to outpatient drug infusion.

However, what’s the variation in DRG reimbursement attributable to a given change in Case Mix Index? Could mskcc actually have a higher CMI? A lower CMI? Is the PPS exemption worth more or less than their CMI would earn them relative to say Cornell or NYU?

Some hospitals have surprisingly high CMI and others are low. I’m not sure where in the DRG payment formula the CMI is applied.

Could this explain why there are different CMS payments in that abstract?
Click to expand...
Would have been a great question for the authors to explore.
 
elementaryschooleconomics said:
View attachment 355424



Dear Rahul:

The quality of the residents has been in decline for the past 20 years. Didn't you know that? You and your residents are to blame.

View attachment 355425
Click to expand...

For what it’s worth, I’m a PGY5 with a weird score report. Scored in the 1st to 16th percentile with 12-36% of questions correct. The last two years, I scored in the 60th-95th percentile across various sections. I studied much harder this year (due to written boards) than in years past.

Prior score report: Total Qs / % correct / percentile based on PGY year (had not taken peds, did not bother reading the Qs before selecting an answer).
1653679824686.png


Moreover, PDs were able to review questions and answers with residents this year. I took advantage since we were forced to take the ACR in-service despite not receiving our scores until post-boards (waste of time). Left the review confident for ABR clinical writtens. Probably answered at least 65-75% of questions correctly, though I have no proof of that now.

None of this is important. I think that you were simply being facetious. But this ineptitude is on the ACR.

Or I had a terrible test.
 
cmw021 said:
For what it’s worth, I’m a PGY5 with a weird score report. Scored in the 1st to 16th percentile with 12-36% of questions correct. The last two years, I scored in the 60th-95th percentile across various sections. I studied much harder this year (due to written boards) than in years past.

Prior score report: Total Qs / % correct / percentile based on PGY year (had not taken peds, did not bother reading the Qs before selecting an answer).
View attachment 355438

Moreover, PDs were able to review questions and answers with residents this year. I took advantage since we were forced to take the ACR in-service despite not receiving our scores until post-boards (waste of time). Left the review confident for ABR clinical writtens. Probably answered at least 65-75% of questions correctly, though I have no proof of that now.

None of this is important. I think that you were simply being facetious. But this ineptitude is on the ACR.

Or I had a terrible test.
Click to expand...
Haha. I forget how many possible answers there were per question, but presumably 5 or 6. So a 16-20% would be expected of a monkey. Sounds like acr fd something up. If nothing else, perhaps good evidence that instead of doing this each year, we could instead just let the residents hang out at home.
 
cmw021 said:
For what it’s worth, I’m a PGY5 with a weird score report. Scored in the 1st to 16th percentile with 12-36% of questions correct. The last two years, I scored in the 60th-95th percentile across various sections. I studied much harder this year (due to written boards) than in years past.

Prior score report: Total Qs / % correct / percentile based on PGY year (had not taken peds, did not bother reading the Qs before selecting an answer).
View attachment 355438

Moreover, PDs were able to review questions and answers with residents this year. I took advantage since we were forced to take the ACR in-service despite not receiving our scores until post-boards (waste of time). Left the review confident for ABR clinical writtens. Probably answered at least 65-75% of questions correctly, though I have no proof of that now.

None of this is important. I think that you were simply being facetious. But this ineptitude is on the ACR.

Or I had a terrible test.
Click to expand...
Oh yeah I am ABSOLUTELY joking, to be very clear. I don't consider test scores on ANY exam to be a reflection of skills/intelligence/etc of the physician taking it, especially the exams we take in RadOnc.

The in-service exam in Radiation Oncology was the lowest quality exam I have taken in my entire medical career by a wide margin.

I do strongly suspect something went wrong on the technical end somewhere. But...oh my God is this a funny Tweet coming from a PD after the 2018 ABR Fiasco and response.
 
Ray D. Ayshun said:
Haha. I forget how many possible answers there were per question, but presumably 5 or 6. So a 16-20% would be expected of a monkey. Sounds like acr fd something up. If nothing else, perhaps good evidence that instead of doing this each year, we could instead just let the residents hang out at home.
Click to expand...
Most commonly four, but I think was 5-6 for some. Disappointed, but not surprised they aren't even bothering to look into it...

Just wanted to post my experience in case there were any other residents perusing and concerned about their scores. Carry on!
 
cmw021 said:
Most commonly four, but I think was 5-6 for some. Disappointed, but not surprised they aren't even bothering to look into it...

Just wanted to post my experience in case there were any other residents perusing and concerned about their scores. Carry on!
Click to expand...
Thanks for posting.
 
elementaryschooleconomics said:
Oh yeah I am ABSOLUTELY joking, to be very clear. I don't consider test scores on ANY exam to be a reflection of skills/intelligence/etc of the physician taking it, especially the exams we take in RadOnc.

The in-service exam in Radiation Oncology was the lowest quality exam I have taken in my entire medical career by a wide margin.

I do strongly suspect something went wrong on the technical end somewhere. But...oh my God is this a funny Tweet coming from a PD after the 2018 ABR Fiasco and response.
Click to expand...
A few comments about the ACR In-Service from an old timer, former PD

1) Departments pay $ for this test (not sure what the 2022 costs)
2) The test has never been validated against other measures of competence (ABR writtens, orals, etc)
3) Years ago I tried to convince ABR and ACR to (confidentially) determine whether there was any correlation between the two
4) Both refused..."we don't have the time or money to do that"
5) I offered to do the work gratis...no dice
6) In the past when I was PD I would get an extra copy and man were the questions horrible...MCQs can be done well but not on this test
7) I asked whether we could just stop taking the test (since its value has not been demonstrated) and save the department $ but the RESIDENTS said they wanted to continue to take the test so they could figure out "where they were" in relationship to others

The ACR dues are $900/year. Much higher than ASTRO/ASCO/ACRO/ABS

The test itself is worth than worthless in my view yet many continue to pay for it
 
Chartreuse Wombat said:
7) I asked whether we could just stop taking the test (since its value has not been demonstrated) and save the department $ but the RESIDENTS said they wanted to continue to take the test so they could figure out "where they were" in relationship to others
Click to expand...
I'm not surprised at all by this, even though at first glance it seems outlandish.

To make it that far in the crucible of medical education in America, you have to mold yourself into this grotesque avatar of elite focus, dedication, and subservience.

I'm certain your residents at the time couldn't fathom not having some sort of "standardized" measure of themselves because in the modern era that is all physicians - especially physicians in training - know.

It's this crushing system that has created a workforce of highly educated doctors ruled by C-suite MBAs, and left RadOnc under the leadership of a man who graduated medical school in 1979 because we're too busy waiting for our phone call from eviCore to beg for a chance to practice a version of medicine.
 
elementaryschooleconomics said:
I'm not surprised at all by this, even though at first glance it seems outlandish.

To make it that far in the crucible of medical education in America, you have to mold yourself into this grotesque avatar of elite focus, dedication, and subservience.

I'm certain your residents at the time couldn't fathom not having some sort of "standardized" measure of themselves because in the modern era that is all physicians - especially physicians in training - know.

It's this crushing system that has created a workforce of highly educated doctors ruled by C-suite MBAs, and left RadOnc under the leadership of a man who graduated medical school in 1979 because we're too busy waiting for our phone call from eviCore to beg for a chance to practice a version of medicine.
Click to expand...
I laughed and had a nervous poop
 
elementaryschooleconomics said:
I'm not surprised at all by this, even though at first glance it seems outlandish.

To make it that far in the crucible of medical education in America, you have to mold yourself into this grotesque avatar of elite focus, dedication, and subservience.

I'm certain your residents at the time couldn't fathom not having some sort of "standardized" measure of themselves because in the modern era that is all physicians - especially physicians in training - know.

It's this crushing system that has created a workforce of highly educated doctors ruled by C-suite MBAs, and left RadOnc under the leadership of a man who graduated medical school in 1979 because we're too busy waiting for our phone call from eviCore to beg for a chance to practice a version of medicine.
Click to expand...

Residents wanted extra tests?

What is wrong with people…
 
OTN said:
He woke up today and chose violence
Click to expand...
Ralph's version of violence is the kind where I feel the need to ask his nurse to open the curtains in the morning to let sunlight in, put his chair in the hallway so he can see everyone, and make sure his hearing aids are in place and working properly.
 
elementaryschooleconomics said:
Ralph's version of violence is the kind where I feel the need to ask his nurse to open the curtains in the morning to let sunlight in, put his chair in the hallway so he can see everyone, and make sure his hearing aids are in place and working properly.
Click to expand...
Don't forget the nighttime chamomile tea and occasional melatonin gummie. Familiarity/routine is paramount
 
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