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thecarbonionangle said:
The UPMC system is particularly bad in many ways. They have been buying up PPs and make everyone an employee. “Only 3-5 hours from this city” say their ads. Let’s just say they are not offering 700k+ For these hellpit locations (not even low quality biryani). These jobs used to offer that kind of money in rural areas now they have dried up. The biggest enemies are these academic systems which want everyone to work for them and monopolize cancer care. Choose wisely folks!!!
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At least Allegany hasn't been as ridiculous with the expansion. UPMC CEO was utterly tone deaf on that 60 minutes interview years ago
 
Upmc is not complying with price transparency although UPenn prices were listed here and gives you an idea of what upmc is charging.
 
1. Academic medical centers buy up private practices left and right, increasing the cost of care by x10 but with zero impact on quality.
2. Payors find that they suddenly have to pay out of their assess for the same services all of a sudden
3. Payors utilize third parties (e.g. EvilCore) to cost contain and limit treatment that is clinically "reasonable"
4. Radiation Oncologists are hired by EvilCore to perform the functions of #3
5. Academic chairs cry foul
 
Gfunk6 said:
1. Academic medical centers buy up private practices left and right, increasing the cost of care by x10 but with zero impact on quality.
2. Payors find that they suddenly have to pay out of their assess for the same services all of a sudden
3. Payors utilize third parties (e.g. EvilCore) to cost contain and limit treatment that is clinically "reasonable"
4. Radiation Oncologists are hired by EvilCore to perform the functions of #3
5. Academic chairs cry foul
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I can't tell when this forum is satire or trying to have honest discussion. Saying that academic medical centers is somehow the root cause for Evicore utilization is something someone says when they have already made up their mind about an issue and go looking for things that sound plausible to them
 
Evicore was founded in 1992.
Early ROBMs sprouted as a response to IMRT overutilization in the 2000s and the publication of the seminal NEJM note in early 2012

1623115689590.png

In many cases the overutilization was PP (back when a majority of RO was PP). Congress essentially concluded that overutilization was PP.
Academic departments eventually figured it out this led to consolidation with "rent seeking" which led to more ROBMs in the last decade
There is enough blame to go around to be sure.
Now we have the "random" RO APM that will penalize some and incentivize others based on zip codes. Oy
 
radiation said:
Saying that academic medical centers is somehow the root cause for Evicore utilization is something someone says
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Chartreuse Wombat said:
Evicore was founded in 1992
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Ensuring proper utilization of diagnostic radiology services seemed to be an early mandate (to be fair, my mother in law got annual PET scans for years as follow-up for her breast CA in the early 00s, that ish not flying nowadays).

Kaiser utilized them for therapeutic radiology services recently? (I think?). I hear Kaiser docs are pretty happy, is this true?

They must be providing good value to several stakeholders and their mandate is not evil.

Regarding docs working for Evicore? I'd do it if I had to and this is the sort of work that our kids are more likely to do than to actually directly provide a nuanced, decision based service (like non-surgical medicine or flying a plane not on autopilot). The tyranny of evidence based medicine means that the individual expert is valued less and less. That grey space where we make custom decisions (the most interesting part of my job) is viewed as a failure by people who design clinical trials, write regulations and pay for services.

The non-inferiority trial is perhaps the most tyrannical, well intentioned tool in terms of limiting our clinical decision making, especially since they are all really "not very-inferiority" trials. Of course this would never fly in an industry focused on safety. I'm waiting for the equivalent of a "mid-level" pilot.
 
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medgator said:
Pretty sure evilcore would have never had the oxygen to get started without the boomers giving 20+ fx Palliative and ongoing 33+ fx breast for everyone for years.

You aren't going to acknowledge the other side of that coin?
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Yes. I acknowledge it. Is that a gotcha that makes it ok to work for Evicore? I'm confused. Anything else besides my point you would like me to acknowledge?

1. Academic overexpansion had obvious collateral consequences we all agree on. I have said multiple times.
2. Fractionation fraud is bad. In my post yesterday I mentioned the case I saw of the boomer giving 50 cGy/day for prostate over something like 6 months. I don't know why you think I am trying to avoid acknowledging that.
3. The above don't negate the fact that Evicore's guidelines often result in denying of treatment to patients who need it. If/when I get in a position where I am in charging of staffing, anybody with Evicore in their employment history is getting promptly round filed without a second thought. I know I am not the only one who thinks this way. Something to think about before you decide to sell out and work for Evicore to pad your income or maintain your lifestyle in a pinch. Again, numerous other ways for an MD to bring in the cheese. Maybe not as easy as Evicore. But hey, a pill mill would probably be easier and bring in even more. Why not go all the way?

Yes, the number of inappropriate treatments that Evicore has prevented is certainly non-zero. Multiple things can be true at once, however.

Any more whataboutisms or strawmen you'd like to throw out instead of addressing what you find so objectionable about saying it's ok to profit from and support a company that harms patients? Do you disagree that they harm patients routinely?

Here, lets try this. For those pondering if it's ok to work for Evicore, which of the following is where you head is? Genuinely curious.
1. Working for Evicore is ok. I agree with their guidelines and don't believe they harm patients. They are overall good and prevent wasteful futile care.
2. Working for Evicore is ok because they good they do in preventing wasteful treatments at least balances the patients they harm and/or kill.
3. Working for Evicore is ok because if I do, it's not really me that's harming or killing patients. I admit by following the guidelines patients are getting harmed/killed, but I'm just a cog in a machine. It's the chairs' fault. If I didn't do it, someone else would.
4. Working for Evicore is ok because I believe I can manipulate the guidelines and find loopholes to approve all treatments I think are reasonable and do so under the radar without getting fired.
5. Working for Evicore is ok because it's not illegal and my priority is bringing in money the easiest way I possibly can without breaking the law.
6. Some version of "Muh family" justifies basically anything.
7. Wait, all of the above sound incredibly pathetic. I changed my mind and will not sell out under any circumstance.
 
Chartreuse Wombat said:
In many cases the overutilization was PP (back when a majority of RO was PP). Congress essentially concluded that overutilization was PP.
Click to expand...
"IMRT over-utilization." What is IMRT over-utilization. Was it doing IMRT before all the muckety-mucks said "OK, you can do IMRT for that now." The first randomized IMRT trial was in whole breast ~2005; trial showed IMRT superior. Nowadays "everyone" treats "all" lung cancers with IMRT (and few if any did around 2000-05... motion! gah!). IMRT is a Boo Radley boogeyman that actually is just a tired old man, sitting in his rocking chair, bothering no one, and he loves to help people. In my high-toned academic department we (not me per se) were treating 100% of all breast cases with IMRT and billing as such (and 100% prostate, and 100% rectal, and 100% sarcoma, and 100% H&N, etc etc) as early as 2001.

TL;DR There's a big difference between IMRT use and IMRT over-use, and essentially no one had the option for either in the 90's.
 
TheWallnerus said:
There's a big difference between IMRT use and IMRT over-use
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I'm a Dr. StrangeRad or: How I learned to stop worrying and love the IMRT.

Nearly all my clinical concerns were unwarranted: Modulating a beam around a moving target? Works fine. Low dose bath for esophagus and lung? Probably bogus and can be addressed with objectives. Lung outcomes are clearly better. 2nd malignancy risk? In my patients (65+) come-on.

The only concern left is some buzzing in my brain about lymphopenia. Who knows. Oh and in my hands, not usually the best option comprehensive nodal breast XRT.

The major problem with IMRT is how its billed. Pure and simple.
Turaco said:
CAT IIIB autoland ILS has been available for some time now.

en.wikipedia.org

Autoland - Wikipedia

en.wikipedia.org en.wikipedia.org

Plenty of cases of pilots crashing planes because they didn't trust the automatic systems.

en.wikipedia.org

Air Canada Flight 621 - Wikipedia

en.wikipedia.org en.wikipedia.org
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No doubt that pilot error is the major culprit now in terms of commercial air travel incidents. I'm just saying that this is how we are viewed by our own industry.
 
communitydoc13 said:
The major problem with IMRT is how its billed. Pure and simple.
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Exactly. Much of that has now been solved. 77295 reimbursing as much as 77301 now. Multiple beam complex devices went away. Everyone stopped many multiple 77301's along the course of treatment. Oh wait.

Turaco said:
Plenty of cases of pilots crashing planes because they didn't trust the automatic systems.
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Makes me remember that one of my best friends died because of an autopilot. RIP David Ashburn, one of the GOATs.
 
TheWallnerus said:
"IMRT over-utilization." What is IMRT over-utilization. Was it doing IMRT before all the muckety-mucks said "OK, you can do IMRT for that now." The first randomized IMRT trial was in whole breast ~2005; trial showed IMRT superior. Nowadays "everyone" treats "all" lung cancers with IMRT (and few if any did around 2000-05... motion! gah!). IMRT is a Boo Radley boogeyman that actually is just a tired old man, sitting in his rocking chair, bothering no one, and he loves to help people. In my high-toned academic department we (not me per se) were treating 100% of all breast cases with IMRT and billing as such (and 100% prostate, and 100% rectal, and 100% sarcoma, and 100% H&N, etc etc) as early as 2001.

TL;DR There's a big difference between IMRT use and IMRT over-use, and essentially no one had the option for either in the 90's.
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OK Dude but it really doesn't matter what you think it matters what the payors think. The payors are "guided" by CMS and CMS called the alarm a long time ago. You don't seem to understand that you can rant on SDN but it doesn't really matter
 
Chartreuse Wombat said:
OK Dude but it really doesn't matter what you think it matters what the payors think. The payors are "guided" by CMS and CMS called the alarm a long time ago. You don't seem to understand that you can rant on SDN but it doesn't really matter
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Yeah yeah I know. Even so, CMS spent ~1.5 billion on rad onc last year and ~1.9 billion 10 years ago (most ever). The kind of alarms Chicken Little is in to.
 
radiation said:
maybe someone can help me understand the math where academic rad onc has wildly proliferated and also costs 10x, yet CMS spending is down
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Sure.Because large hospital systems have more large leverage they can demand much higher than cms prices. That’s why healthcare spending outpaces inflation and is 10-15k per person. Just look at their negotiated rates that have been posted.
 
radiation said:
maybe someone can help me understand the math where academic rad onc has wildly proliferated and also costs 10x, yet CMS spending is down
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CMS spending /= Contracted Rates with Private Insurers /= Charged Rates

CMS spending is down because they've cut rates (dramatically over past decade) and we've decreased utilization (hypofractionation).
 
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RadOncDoc21 said:
I was just about to state this… the power of having a monopoly is ridiculously insane.
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Also having a monopoly on employment. Despite these insane reimbursements, a buddy of mine as a new grad interviewed there for a 100% clinical satellite job not long ago. Salary offer? $280k at full production, first year or two not expected to make even that. That position did fill, of course.
 
Mandelin Rain said:
CMS spending /= Contracted Rates with Private Insurers

CMS spending is down because they've cut rates (dramatically over past decade) and we've decreased utilization (hypofractionation).
Click to expand...
At end of the year, we should present an sdn “Oscars type award” for center with highest multiple of cms price in radonc.
 
Neuronix said:
Also having a monopoly on employment. Despite these insane reimbursements, a buddy of mine as a new grad interviewed there for a 100% clinical satellite job not long ago. Salary offer? $280k at full production, first year or two not expected to make even that. That position did fill, of course.
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Absolutely crazy that the cash cow that is UPenn rad onc is now offering a $280,000 salary. A place that is building community proton centers and purposed a certified palliative care network. Also note one of their vice chairs is also chair of the rad onc RRC.

In 10 years that offer is likely to be $225,000 if nothing changes.
 
fiji128 said:
Absolutely crazy that the cash cow that is UPenn rad onc is now offering a $280,000 salary. A place that is building community proton centers and purposed a certified palliative care network. Also note one of their vice chairs is also chair of the rad onc RRC.

In 10 years that offer is likely to be $225,000 if nothing changes.
Click to expand...

I heard similar as @Neuronix from colleague that said ~225K at Penn at less desirable satellite

@fiji128 - just heard starting salary has increased to 280K

EDITED with above info
 
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Chartreuse Wombat said:
Gotta save money for the expensive new life saving drugs
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It's great that IMRT and radiotherapy are being throttled for "cost control" aka padding the wallets of insurance company executives, whereas the FDA accelerated approval for a $56000/year Alzheimer's drug that might be as effective than dog piss.
 
RickyScott said:
Will repost prices of one player in case you weren’t aware:
Post in: 'Mandated Price Transparency: Should Those in Glass Houses Throw Stones?'

Mandated Price Transparency: Should Those in Glass Houses Throw Stones?
Click to expand...

The problem is that price transparency is still not transparent. List prices are still different than charged prices, which are also affected by collectables. At the end of the day private insurance is still by and large benchmarked to CMS

The narrative that is being suggested here is that academic centers are simultaneously the cause decreased rad onc utilization, increased rad onc costs, and decreased rad onc salaries. The story of rad onc's decline is much more complicated than "lets blame everything on academics". Being reductionist on the real issues of rad onc is never going to get more people to the table and actually do things that will help the field
 
fiji128 said:
Absolutely crazy that the cash cow that is UPenn rad onc is now offering a $280,000 salary. A place that is building community proton centers and purposed a certified palliative care network. Also note one of their vice chairs is also chair of the rad onc RRC.

In 10 years that offer is likely to be $225,000 if nothing changes.
Click to expand...
radiation said:
The problem is that price transparency is still not transparent. List prices are still different than charged prices, which are also affected by collectables. At the end of the day private insurance is still by and large benchmarked to CMS

The narrative that is being suggested here is that academic centers are simultaneously the cause decreased rad onc utilization, increased rad onc costs, and decreased rad onc salaries. The story of rad onc's decline is much more complicated than "lets blame everything on academics". Being reductionist on the real issues of rad onc is never going to get more people to the table and actually do things that will help the field
Click to expand...
You are dead wrong. These are not the List/ charge master prices. (Those are much higher and seperate) These are the Actual reimbursed negotiated rates with each insurance company! Kudos to UPenn and duke for complying but vast majority of hospitals choose to pay a fine rather than comply. You should contact Jordan Johnson (who even held a seminar on sdn) about the prices!

edit: would request sdn weighs in on your statement that these are chargemaster/list prices is completely false.
 
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radiation said:
The problem is that price transparency is still not transparent. List prices are still different than charged prices, which are also affected by collectables. At the end of the day private insurance is still by and large benchmarked to CMS

The narrative that is being suggested here is that academic centers are simultaneously the cause decreased rad onc utilization, increased rad onc costs, and decreased rad onc salaries. The story of rad onc's decline is much more complicated than "lets blame everything on academics". Being reductionist on the real issues of rad onc is never going to get more people to the table and actually do things that will help the field
Click to expand...

1. It is the job of academic centers to do the research to figure out how radiation can be used effectively, thus...increasing utilization. Why is some of the more interesting work re: low-dose RT for arthritis, for example, being done on this board, rather than in academia? Good work on the cardiac stuff for sure, and Chris Crane has done great work on unresectable upper GI cancers, but it is undeniable that the vast majority of trials published in the last 10 years have been unoriginal "non-inferiority" studies just looking at different fractionation schedules.

2. Costs of hospital-based and academic practices are higher than those in private practice. This is a fact which was confirmed by the APM "update" which stated that APM reimbursements will result in higher freestanding and lower hospital-based reimbursements...and that's without even bringing up the 11 exempt centers. Let's revisit this issue on September 1st when MDACC is going to be required to list their prices.

3. Decreased radonc salaries: Absolutely due to academia, full stop. No one else has the power to increase residency numbers (unlike in ER, for example, with HCAs programs). No one else in the market has had the market power and $$$ to buy up private practices at such a rate. No one else, when they do buy up freestanding centers, push the salaries as low as academia does.

I don't see how these arguments are reductionist.
 
radiation said:
Being reductionist on the real issues of rad onc is never going to get more people to the table and actually do things that will help the field
Click to expand...

Here's a reduction for you.

The biggest issue facing most trainees and practicing rad oncs is oversupply.

Academics controls the supply of residents, yet there has been and likely will be no significant movement to reduce supply.

This makes academics easy to blame.

Meanwhile many people, both within and outside of academics, are taking advantage of the oversupply to get cheap rad oncs, work them harder, and tighten the screws on more senior rad oncs.

All the other issues are a sideshow, and are either a cause of oversupply (e.g. hypofractionation and consolidation of rad onc positions into networks) or a result of oversupply (decreased rad onc salaries).
 
radiation said:
The story of rad onc's decline is much more complicated than "lets blame everything on academics".
Click to expand...

What's the story of rad onc's decline in regards to:

- decreased rad onc utilization
- increased rad onc costs
- decreased rad onc salaries

Do explain how "big academics" (Penn, MDA, UPMC, WashU, etc.) is an innocent bystander or unsung hero in the macro trends of rad onc over the last decade. Use short phrases. I'm just a PP gal.
 
OTN said:
1. It is the job of academic centers to do the research to figure out how radiation can be used effectively, thus...increasing utilization. Why is some of the more interesting work re: low-dose RT for arthritis, for example, being done on this board, rather than in academia? Good work on the cardiac stuff for sure, and Chris Crane has done great work on unresectable upper GI cancers, but it is undeniable that the vast majority of trials published in the last 10 years have been unoriginal "non-inferiority" studies just looking at different fractionation schedules.

2. Costs of hospital-based and academic practices are higher than those in private practice. This is a fact which was confirmed by the APM "update" which stated that APM reimbursements will result in higher freestanding and lower hospital-based reimbursements...and that's without even bringing up the 11 exempt centers. Let's revisit this issue on September 1st when MDACC is going to be required to list their prices.

3. Decreased radonc salaries: Absolutely due to academia, full stop. No one else has the power to increase residency numbers (unlike in ER, for example, with HCAs programs). No one else in the market has had the market power and $$$ to buy up private practices at such a rate. No one else, when they do buy up freestanding centers, push the salaries as low as academia does.

I don't see how these arguments are reductionist.
Click to expand...
So Texas law requires mdacc to release prices sept 1? Btw the 11 pps exempt centers can bill their special rates at all satellites within 35 miles of main campus.
 
yesmaster said:
What's the story of rad onc's decline in regards to:

- decreased rad onc utilization
- increased rad onc costs
- decreased rad onc salaries

Do explain how "big academics" (Penn, MDA, UPMC, WashU, etc.) is an innocent bystander or unsung hero in the macro trends of rad onc over the last decade. Use short phrases. I'm just a PP gal.
Click to expand...
There are no unsung heroes or innocent bystanders in the field. Each group has played in a role where we are today. Each group will need to hold themselves responsible going forward if we want to make any progress.

Academics bear the brunt of blame for overexpansion and oversupply. Decreased rad onc utilization is a function of dependence of reimbursement on fractionation. There are countless surgery vs. RT trials that have would have significantly helped utilization numbers if positive but never accrued. Would community by-in to enroll on these studies like community heme/onc did with immuno/targeted therapy? Certainly, but rad onc will never have the advantage of big pharma.

The actual total number of pts being treated with radiation as part of curative or palliative/oligometastatic is unknown, but this board would have you believe there is irrefutable data that there are less pts being treated. Decreased rad onc salaries is multifactorial, but clearly related to fractionation dependence and oversupply
 
OTN said:
3. Decreased radonc salaries: Absolutely due to academia, full stop. No one else has the power to increase residency numbers (unlike in ER, for example, with HCAs programs). No one else in the market has had the market power and $$$ to buy up private practices at such a rate. No one else, when they do buy up freestanding centers, push the salaries as low as academia does.

I don't see how these arguments are reductionist.
Click to expand...

YES YES YES YES YES YES YES
 
At U Penn if they deliver 8 Gy x 1 fraction, they collect an average of $27,000 from private payors.
At an average private practice (lot of variability here), assuming that Evicore let you treat a bone met with 25 fractions of 3D, reimbursement would be in in the ~$22,000 range.

Look at the two numbers above and also consider the massively reduced staff costs and machine wear/tear for delivering a single fraction of radiation versus five weeks of fractionated radiation.

Saying that private practice abuses fractionatin/IMRT and so does academics is a false equivalence. It is like trying to equate the morality of a chronic masturbator with a serial killer.
 
Gfunk6 said:
At U Penn if they deliver 8 Gy x 1 fraction, they collect an average of $27,000 from private payors.
At an average private practice (lot of variability here), assuming that Evicore let you treat a bone met with 25 fractions of 3D, reimbursement would be in in the ~$22,000 range.

Look at the two numbers above and also consider the massively reduced staff costs and machine wear/tear for delivering a single fraction of radiation versus five weeks of fractionated radiation.

Saying that private practice abuses fractionatin/IMRT and so does academics is a false equivalence. It is like trying to equate the morality of a chronic masturbator with a serial killer.
Click to expand...
Is there a moral problem with chronic masturbation?
 
Gfunk6 said:
It is like trying to equate the morality of a chronic masturbator with a serial killer.
Click to expand...
Not sure where you're going with this one but I like it nonetheless!

Considering what UPenn gets reimbursed, it's criminal how little they pay their junior attendings which, even at 280k, is a substantial increase from just a few years ago... The recent exodus of junior attendings makes a lot more sense now and should probably alarm anyone searching for a job there.
 
The greatest trick that was played on rad onc was to get us to quibble amongst ourselves on how low our treatments should cost and how many fractions we should give while this happens in the rest of medicine

yesmaster said:
It's great that IMRT and radiotherapy are being throttled for "cost control" aka padding the wallets of insurance company executives, whereas the FDA accelerated approval for a $56000/year Alzheimer's drug that might be as effective than dog piss.
Click to expand...
 
radiation said:
The greatest trick that was played on rad onc was to get us to quibble amongst ourselves on how low our treatments should cost and how many fractions we should give while this happens in the rest of medicine
Click to expand...

I treat a lot of brain. I'm still waiting to see a non-inferiority trial for glioblastoma of temozolomide only during RT, only after RT, or both. Or maybe we can do 3 months vs. 6 months adjuvant. Nope. The trials are trying to cut RT to 15 fractions from 30. If anything they tried a year of adjuvant TMZ vs. 6 months and it didn't work. They keep trying immunotherapy after immunotherapy and vaccine after vaccine, all of which fail in phase 2 or 3. But radiation is so bad we should cut it to 15 fractions or even 5 fractions (some trials with immuno even mandate altered fractionation based on nothing).

Almost nobody on the med onc side is working to give less chemo. If anything it's just more agents, higher doses, longer treatment times, etc.

In radiation we only seem to want to make ourselves obsolete. Eventually I guess we will.
 
Neuronix said:
I treat a lot of brain. I'm still waiting to see a non-inferiority trial for glioblastoma of temozolomide only during RT, only after RT, or both. Or maybe we can do 3 months vs. 6 months adjuvant. Nope. The trials are trying to cut RT to 15 fractions from 30. If anything they tried a year of adjuvant TMZ vs. 6 months and it didn't work. They keep trying immunotherapy after immunotherapy and vaccine after vaccine, all of which fail in phase 2 or 3. But radiation is so bad we should cut it to 15 fractions or even 5 fractions (some trials with immuno even mandate altered fractionation based on nothing).

Almost nobody on the med onc side is working to give less chemo. If anything it's just more agents, higher doses, longer treatment times, etc.

In radiation we only seem to want to make ourselves obsolete. Eventually I guess we will.
Click to expand...
For CATNON, only temodar after RT seems to be important, I bet its the same for GBM
www.thelancet.com

Adjuvant and concurrent temozolomide for 1p/19q non-co-deleted anaplastic glioma (CATNON; EORTC study 26053-22054): second interim analysis of a randomised, open-label, phase 3 study

Adjuvant temozolomide chemotherapy, but not concurrent temozolomide chemotherapy, was associated with a survival benefit in patients with 1p/19q non-co-deleted anaplastic glioma. Clinical benefit was dependent on IDH1 and IDH2 mutational status.
www.thelancet.com
 
RSAOaky said:
Not sure where you're going with this one but I like it nonetheless!

Considering what UPenn gets reimbursed, it's criminal how little they pay their junior attendings which, even at 280k, is a substantial increase from just a few years ago... The recent exodus of junior attendings makes a lot more sense now and should probably alarm anyone searching for a job there.
Click to expand...

Surprised to hear this. I have no knowledge of salaries at UPenn but heard rumors that they are one of the academic places (like MDACC) that actually pay academics well. If this is considered a good salary in academics :wow:

Perhaps there is strong incentive / bonus pay?
 
fiji128 said:
Absolutely crazy that the cash cow that is UPenn rad onc is now offering a $280,000 salary. A place that is building community proton centers and purposed a certified palliative care network. Also note one of their vice chairs is also chair of the rad onc RRC.

In 10 years that offer is likely to be $225,000 if nothing changes.
Click to expand...
Mandelin Rain said:
27k for 8Gy x 1.
280k for annual salary for a Medical Doctor.

Hmmmm......
Click to expand...
One of the payers handing out over 2k/fraction for protons per jordan johnson. Could pay a docs salary with just 2 prostate pts when all the codes added up. Penn is building proton centers in lancaster and cherry hill, and bought up 20+ practices all the way to the Jersey shore. I think they also bought the Princeton group. they must have 700-800 patients on beam? Strategy should be to overhire to keep docs hungry so that they overteat: if doc overtreats one pt a month, well worth it.
 
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