Rad Onc Twitter

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TheWallnerus said:
Wonder if FLC ever realized it was MSKCC that had the significantly higher costs, not the 340B hospitals. The tweet needed to be labeled misinformation by Twitter.
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Mind numbing.

You should probably let her know.

Edit: Oh. You did. As did others.

But her research is apparently and suddenly in to “prices” rather than “cost”, even while she actively (and perhaps purposely) mistakes prices for cost.

Unserious research by an unserious researcher.
 
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Mandelin Rain said:
Mind numbing.

You should probably let her know.

Edit: Oh. You did. As did others.

But her research is apparently and suddenly in to “prices” rather than “cost”, even while she actively (and perhaps purposely) mistakes prices for cost.

Unserious research by an unserious researcher.
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My problem with her research is the focus on the out of pocket expense of the patient, not the actual price paid by the insurer/employer. It is a way to avoid raising the monopolistic price gouging of large academic centers. Some Cadillac plans (large unions) etc have almost no out of pocket expenses. So what. Some sh-t insurances also have almost no out of pocket (but very limited networks)
 
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My problem is that in the medical literature, words like “similar” have an implied meaning.

That meaning doesn’t include “statistically significantly different”.

If MSK could produce data that they had 20% better outcomes compared to these same hospitals, would that be referred to as “similar”?

It’s simply ridiculous.
 
RickyScott said:
My problem with her research is the focus on the out of pocket expense of the patient, not the actual price paid by the insurer/employer. It is a way to avoid raising the monopolistic price gouging of large academic centers. Some Cadillac plans (large unions) etc have almost no out of pocket expenses. So what. Some sh-t insurances also have almost no out of pocket (but very limited networks)
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Full disclosure, I consider Dr. Chino a friend. Her research has always been about patients’ out of pocket expenses because of her experience of being financially crippled by her late husbands medical expenses for years after he died from cancer. It’s personal for her. That aside, “financial toxicity” is a big topic with many angles. Of course it matters what insurance is paying for drug X from center Y vs center Z, but this is VERY hard to know… and it matters only in the macroscopic sense of the health care system. Patients’ out of pocket expenses are more knowable and more individually relevant… so why not focus on the low hanging fruit?
 
Lamount said:
Full disclosure, I consider Dr. Chino a friend. Her research has always been about patients’ out of pocket expenses because of her experience of being financially crippled by her late husbands medical expenses for years after he died from cancer. It’s personal for her. That aside, “financial toxicity” is a big topic with many angles. Of course it matters what insurance is paying for drug X from center Y vs center Z, but this is VERY hard to know… and it matters only in the macroscopic sense of the health care system. Patients’ out of pocket expenses are more knowable and more individually relevant… so why not focus on the low hanging fruit?
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out of pocket expense is often ultimately determined by the employer who is fitting the bill and deciding what plans/arrangements to offer their employees. For many, it is basically a job benefit/essentially part of your compensation package. Employers have the option of selecting plans with almost no out of pocket expenses.
This type of research often implies that insurance companies are leading millions of Americans into bankruptcy, when the issue is the hospitals/pharm companies. It ignores the true nature of the most common insurance relationship wherein the insurer is just basically taking a commission on health care transactions that they manage with the employer paying the bill.
 
Lamount said:
it matters only in the macroscopic sense of the health care system. Patients’ out of pocket expenses are more knowable and more individually relevant… so why not focus on the low hanging fruit?
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Except macro is probably the biggest problem of all considering it is reflected in higher premiums for all of us/society. You're really talking about change in the couch cushions when we are discussing the rent increasing astronomically
 
medgator said:
Except macro is probably the biggest problem of all considering it is reflected in higher premiums for all of us/society. You're really talking about change in the couch cushions when we are discussing the rent increasing astronomically
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Yip, when nyc pays for a school teacher to have breast protons at 200k, it has to mean less money available for the homeless etc
 
RickyScott said:
Yip, when nyc pays for a school teacher to have breast protons at 200k, it has to mean less money available for the homeless etc
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yep same as when someone does 45 fractions for prostate cancer or bills VMAT for a 15 fraction palliative bone met case.

this is a slippery slope.
 
jondunn said:
yep same as when someone does 45 fractions for prostate cancer.

this is a slippery slope.
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There goes Jon Dunn fraction shaming from his high cost academic satellite again. Choosing wisely, as always.

Do you even know what you charge/collect for 5-28, bruh? Is it less than your 45 fx competition? More acute and financial toxicity?
 
medgator said:
There goes Jon Dunn fraction shaming from his high cost academic satellite again. Choosing wisely, as always.

Do you even know what you charge/collect for 5-28, bruh? Is it less than your 45 fx competition? More acute and financial toxicity?
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way to completely miss the point.
 
RickyScott said:
out of pocket expense is often ultimately determined by the employer who is fitting the bill and deciding what plans/arrangements to offer their employees. For many, it is basically a job benefit/essentially part of your compensation package. Employers have the option of selecting plans with almost no out of pocket expenses.
This type of research often implies that insurance companies are leading millions of Americans into bankruptcy, when the issue is the hospitals/pharm companies. It ignores the true nature of the most common insurance relationship wherein the insurer is just basically taking a commission on health care transactions that they manage with the employer paying the bill.
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I don’t think it “ignores” the true nature of insurance. It simply presents a patient-specific metric. Sure, there are parts of out of pocket expenses that have nothing to do with the hospital, but some parts do (%of amount amount billed, who is in-network vs out etc…) From a patient’s perspective, isn’t this all that matters? Frankly, I think it is a little out-of-touch for us to argue that it DOESN’T matter.
 
Lamount said:
I don’t think it “ignores” the true nature of insurance. It simply presents a patient-specific metric. Sure, there are parts of out of pocket expenses that have nothing to do with the hospital, but some parts do (%of amount amount billed, who is in-network vs out etc…) From a patient’s perspective, isn’t this all that matters? Frankly, I think it is a little out-of-touch for us to argue that it DOESN’T matter.
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You don't think patients care about the amount of their monthly premiums? That's an out of pocket cost too even if it isn't a copay or deductible
 
Lamount said:
I don’t think it “ignores” the true nature of insurance. It simply presents a patient-specific metric. Sure, there are parts of out of pocket expenses that have nothing to do with the hospital, but some parts do (%of amount amount billed, who is in-network vs out etc…) From a patient’s perspective, isn’t this all that matters? Frankly, I think it is a little out-of-touch for us to argue that it DOESN’T matter.
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Out of pocket expense is largely controlled by the pts employer and the coverage they provide. If it is inadequate, it is because health care is too expensive (3x that of other countries which also have better life expectancy) because the mskcc and UPenn’s are price gouging.
 
medgator said:
Except macro is probably the biggest problem of all considering it is reflected in higher premiums for all of us/society. You're really talking about change in the couch cushions when we are discussing the rent increasing astronomically
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Sure… it is important to folks like you, me, doctors and healthcare economists, but it is understandably less important to the patients who are trying to figure out if they can afford treatment and pay next month’s rent.

It’s like when vaccines were first available to folks over 65. I knew, from a systemic perspective, there were many ailing elderly that should be prioritized, but I still waited on hold to get my relatively-healthy parents the first available appointment.

Both the macro and the micro matter
 
medgator said:
You don't think patients care about the amount of their monthly premiums? That's an out of pocket cost too even if it isn't a copay or deductible
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That’s a next year problem, whereas out-of-pocket expenses is a next month problem
 
Lamount said:
Sure… it is important to folks like you, me, doctors and healthcare economists, but it is understandably less important to the patients who are trying to figure out if they can afford treatment and pay next month’s rent.

It’s like when vaccines were first available to folks over 65. I knew, from a systemic perspective, there were many ailing elderly that should be prioritized, but I still waited on hold to get my relatively-healthy parents the first available appointment.

Both the macro and the micro matter
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But on micro level, it’s between the patient and their employer? Overwhelming out of pocket expense: All one can conclude is that employers should pay more/provide better benefits?
 
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RickyScott said:
But on micro level, it’s between the patient and their employer? All one can conclude is that employers should pay more/provide better benefits?
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I think that is part of it, but not the whole thing. Things like deductibles and out-of-pocket maxes are obviously really important… but negotiated rates factor in to the percentage of the bill paid by the patient, which is also impacted by which hospitals are included in which networks
 
Lamount said:
I think that is part of it, but not the whole thing. Things like deductibles and out-of-pocket maxes are obviously really important… but negotiated rates factor in to the percentage of the bill paid by the patient, which is also impacted by which hospitals are included in which networks
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Employers are free to include highly expensive price gouging networks at no deductible. (If mskcc is dispensing more than half the keytruda in nyc, any decent employer will be forced to cover them on mskcc terms).
I have close family who worked for government. Everything/everywhere is included with very little copay.

I really don’t understand the case she is making here. My best guess is that employers should lower salaries and put that money to providing better health care coverage so that employees are not hit with life destroying debt when they go to a upenn, mdacc or mskcc?
Basically, you really can’t disentangle the macro from the micro.
 
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I think it's important to talk about all aspects of "financial toxicity", and I'm glad people are doing work in this space.

To give her and the other authors the benefit of the doubt: perhaps they didn't intend to imply what was implied. We are, of course, contextualizing this research in the setting of everything else she has done and where she is currently employed. I don't know who wrote what in this abstract, because it actually does a decent job of not editorializing, and we all know word limits on these abstracts are a nightmare. Maybe she had nothing to do with the wording and the first author did everything? I don't know.

What "triggered" me (haha, couldn't resist) was both in her Tweet and the abstract, it was specifically highlighted that the "NCI-PPS" had "the lowest" charge:

"Conclusions:
There is significant variability in charges for pembrolizumab in Medicare claims with price increases outpacing the annual rate of inflation. Within NYC, the highest charges were from a 340B hospital; NCI-PPS had higher volume and total payments but consistently lower charged prices each year. Our study highlights extreme price variability, and has policy implications for price transparency requirements and uniform rate setting to establish payment levels and control rate of annual growth."

If only they hadn't included the "but..." part of that sentence, because if you look, most of the charges are in a similar range:

1653860599772.png


I do think the $155k charge is extreme, and an outlier. However, I am ABSOLUTELY NOT impressed with Sloan's low "charge" when they garner the highest percent reimbursement from that charge, and take >60% of reimbursement for the whole city.

If you're going to spin this abstract, there's really only two ways to go:

1) A single hospital is charging significantly more than the other hospitals (though not collecting much on that charge)
2) Sloan Kettering is collecting significantly more than the other hospitals (despite the optics of having the lower charge)

Using the "but" statement, and specifically mentioning how low the charge is in the Tweet, smells of agenda. I could be wrong, I guess.

Anyway - though how this data was presented was flawed, I'm glad we're having this discussion. Doctors are kept in the dark about this, intentionally, by the manipulative C-suite folks. We should be arguing and disagreeing about this, because it means we're talking about it.

As always, I will continue to cheer Fumiko and her colleagues on, even if I don't agree with what they're presenting. More! More! More! This is what we need, not another goofy NCDB study on correlational BS in pancreas data from 10 years ago.
 
elementaryschooleconomics said:
I do think the $155k charge is extreme
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So I don't know where the charge comes from, and I know I'm belaboring the point, but I'm pretty sure these places aren't allowed to "charge" different rates for different payors (please correct me if I'm wrong), even though they receive different "payments" from different payors.

This is a peculiarity of our effed-up health care system, where payments are negotiated, and as @RickyScott has mentioned many a time, insurance companies are not incentivized to pay less (although the gvt is).

This crazy $155k charge, much like PENNs crazy charge, likely represented the highest negotiated rate, which also likely impacts bottom lines very little at the Hospital. The idea behind charging this is that you can't get more than you ask for.

Now, given that "charges" are entering into public conversation, I wouldn't put it past the MSKCCs of the world to consciously avoid outlier charges. They really aren't driving profitability (or whatever you call it in the non-profit world) and can be viewed as a proxy of financial toxicity (whereas we know that financial toxicity has all sorts of sources). The smart bean counters at a place like MSKCC will have a more savvy way of calculating "charge".

As an aside, I'm pretty sure the folks with the plans paying $155k are doing fine and are not suffering a whole lot of "next month" problems regarding health care expenses. I may be wrong, but I would need some data to suggest that there are plans out there paying exorbitant negotiated rates, while providing bad coverage and leaving lots of out of pocket costs. (Those plans should be first to go)
 
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communitydoc13 said:
So I don't know where the charge comes from, and I know I'm belaboring the point, but I'm pretty sure these places aren't allowed to "charge" different rates for different payors (please correct me if I'm wrong), even though they receive different "payments" from different payors.

This is a peculiarity of our effed-up health care system, where payments are negotiated, and as @RickyScott has mentioned many a time, insurance companies are not incentivized to pay less (although the gvt is).

This crazy $155k charge, much like PENNs crazy charge, likely represented the highest negotiated rate, which also likely impacts bottom lines very little at the Hospital. The idea behind charging this is that you can't get more than you ask for.

Now, given that "charges" are entering into public conversation, I wouldn't put it past the MSKCCs of the world to consciously avoid outlier charges. They really aren't driving profitability (or whatever you call it in the non-profit world) and can be viewed as a proxy of financial toxicity (whereas we know that financial toxicity has all sorts of sources). The smart bean counters at a place like MSKCC will have a more savvy way of calculating "charge".

As an aside, I'm pretty sure the folks with the plans paying $155k are doing fine and are not suffering a whole lot of "next month" problems regarding health care expenses. I may be wrong, but I would need some data to suggest that there are plans out there paying exorbitant negotiated rates, while providing bad coverage and leaving lots of out of pocket costs. (Those plans should be first to go)
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I believe there is a legal cap on the percentage profit health insurance can make 10-20% ?which is why they (along with the hospital)have such a vested in interest in making the size of the pizza bigger.
 
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RickyScott said:
I believe there is a legal cap on the percentage profit health insurance can make 10-20% ?which is why they (along with the hospital)have such a vested in interest in making the size of the pizza bigger.
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I can imagine a niche plan where average person insured is upper middle class and in their 40 or 50s. Operating costs of all insurance companies should be low. These are circumstances where insurance companies are looking for opportunities to spend money.
 
TheWallnerus said:
Keep your "trials," I have experience

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I mean, to be fair, just because a treatment doesn't help a heterogeneous admixture of patients, doesn't mean it won't help an individual patient who has a specific need.

Inversely, a positive trial does not mean that every single person who meets the inclusion criteria would stand to benefit from the treatment being tested.

I think of clinical trials as telling us which way the wind is blowing (and to some extent, how fast it is blowing). I don't think it tells us where an individual parachuter will land.
 
Lamount said:
I don't think it tells us where an individual parachuter will land.
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I think this is fair.

Also, regardless of PFS survival benefit, if you had a de-novo metastatic breast with good KPS, limited mets, prognosis that exceeds years and a significant spine lesion, SBRT for durability of local control not unreasonable for that reason alone.

I would not counsel the patient that I'm making them live longer however.
 
communitydoc13 said:
I think this is fair.

Also, regardless of PFS survival benefit, if you had a de-novo metastatic breast with good KPS, limited mets, prognosis that exceeds years and a significant spine lesion, SBRT for durability of local control not unreasonable for that reason alone.

I would not counsel the patient that I'm making them live longer however.
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If you prevent a cord compression though?
 
Lamount said:
I mean, to be fair, just because a treatment doesn't help a heterogeneous admixture of patients, doesn't mean it won't help an individual patient who has a specific need.

Inversely, a positive trial does not mean that every single person who meets the inclusion criteria would stand to benefit from the treatment being tested.

I think of clinical trials as telling us which way the wind is blowing (and to some extent, how fast it is blowing). I don't think it tells us where an individual parachuter will land.
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Yes, but it will tell us whether Evicore will allow us to give them a parachute
 
communitydoc13 said:
I think this is fair.

Also, regardless of PFS survival benefit, if you had a de-novo metastatic breast with good KPS, limited mets, prognosis that exceeds years and a significant spine lesion, SBRT for durability of local control not unreasonable for that reason alone.

I would not counsel the patient that I'm making them live longer however.
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I think there is QoL value to potentially delaying systemic therapy by 3, 6, or whatever months.
 
OTN said:
Yes, but it will tell us whether Evicore will allow us to give them a parachute
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I heard through the grapevine years ago (and I'm probably misremembering) that a well respected faculty member at Baylor had given conjoined talks titled something like, "The miracle of the phase III randomized trial" and "The tyranny of the phase III randomized trial".

...probably just misremembering.
 
TheWallnerus said:
Being led by a rad onc. I can't figure the "rad" angle yet.



www.medicaldevice-network.com

MD Anderson develops ultrasound-guided microbubbles cancer treatment

The University of Texas MD Anderson Cancer Center researchers have developed the MUSIC platform to improve antitumour immune responses.
www.medicaldevice-network.com www.medicaldevice-network.com
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Ds-dna detected in the cytoplasm leads to inflammation and cell death (as a defense against viruses). radiation also activates this pathway when dna ends up outside the nucleus. Supposedly, it is involved in the abscopal effect.
 
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