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I didn't feel like doing this on Twitter (my bat signal was indeed activated), but I know the relevant folks read this thread.
Natalie (and the others who think like her): you're only considering half the picture. I absolutely agree that it is a benefit to patients if we can achieve similar outcomes with easier/shorter regimens. Only a sociopath or a greedy liar would disagree with that statement.
However, you know what's even easier on patients? Having centers in the communities where patients live. When faced with driving to NYC or Houston 5-10 times for a "quick" SBRT treatment (consult, CTSIM, perhaps VSIM on a separate day, ~5 fractions, etc) vs 15-20 treatments in their hometown "not in the big city", I am absolutely certain that the majority of patients will opt to stay local.
However, by focusing our attention on fraction shaming instead of CMS reimbursement cuts and forced experimental financial models - driven by pharma lobbyists and cheered on by the PPS-exempt elite - we face the threat of rural linacs not remaining financially solvent. Sure, some of these linacs might be "rescued" by an academic conglomerate turning it into a satellite and staffed by an "Assistant Professor" of Radiation Oncology (some poor soul who graduated in the post-Golden Bubble era making a salary that would have been literally scoffed at by someone who had graduated in 2005 (even without adjusting for inflation), never making it to the Associate level because they're unable to meet absurd metrics...), but not every linac will be "saved" like that.
So, what is
actually more financially toxic? Receiving 20 fractions in the community you live in, with local doctors who know you and each other, where you can receive a continuum of care without hours of round trip driving, or receiving 5 fractions at The Ivory Tower, a 2 hour drive each way, with a healthcare team who will only interact with you for that brief period in your life because you can't afford/don't have the savvy to receive all of your care permanently at The Ivory Tower?
Since the linked paper is more about the drive time, and not the number of visits, it appears that patients would indeed prefer to stay local:
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Of course Sloan isn't RVU based. Why would they be? The institution (not the doctors) make more money off their SBRT regimens then community practices could ever dream of.
And therein lies the problem. I really like Fumiko and her work. I really like the idea of short and effective treatments for patients. I really like the idea that perhaps healthcare in America doesn't need to be run like a business. But what is actually happening here? We have doctors working in Ivory Towers pushing out paper after paper trying to reduce or omit radiation, while the institution they work for has negotiated unfathomable reimbursement rates to line the pockets of C-suite executives and shareholders. The Chairs of those departments have continued to push for a large resident labor force because of the profit margin on those residents which appease their overlords, the C-suite executives and shareholders. Meanwhile, pharma lobbyists work in Congress to cut chunks of the Oncology pie away from XRT to appease their overlords, the C-suite executives and shareholders.
Doctors are painted as villains and patients go into bankruptcy. But hey, I know the pCR rates from the German Rectal Trial off the top of my head, which is clearly what matters, right?
