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[Neuronix]

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UAB got rid of theirs with nsg buy in... Doing their TNs on an edge iirc. All about the local politics

Easier to convince neurosurgery when:
1) Using no PTV on their linac system to make plans look like GK (do you feel comfortable with zero PTV?)
2) Using old GK version and sources, so GK increasingly painful to treat on (I don't know how the institutional politics worked on not upgrading system?)

I don't know how much UAB's development of HyperArc also played into politics of this as well (i.e. royalties, consulting, publications, etc).

Where I trained the neurosurgeons tried to do the same to call the shots on GK and when it was being replaced, tried to induce a CK and locate it in their proximity.

All bluffs. Call 'em on it.

I'm just a peon, though I try not to work with the surgeons who just arbitrarily only want to use GK. Some of my colleagues like treating with GK or are neutral on it, so they can have the GK cases. I do like GK for certain difficult cases though. We have a high volume so we see some difficult stuff.

I should also note that linac SRS has some little caveats as well, not the least of which is that there's a million ways to do it and easy to **** it up if you're not careful.

 

[dieABRdie]

UAB got rid of theirs with nsg buy in... Doing their TNs on an edge iirc. All about the local politics

Having salaried neurosurgeons who have no RVU/bonus structure helps.

 

[SubserviantToABR]

Nothing to see here, everybody move along now…

 

[jondunn]

Is this true?

 

[RickyScott]

This is Capitalism 101.

I get to collect a "commission" (I assume you mean global billing) because I am the part owner of the practice in which the patient was treated. As the owner of the enterprise, I assume the financial risk of the practice and invested $$ to help build and grow the practice. Naturally, one would expect to get a return on this investment, which getting the global billing accomplishes.

You're suggesting our nurses, physicists (ours don't have doctorates), administrators should have a right to this global billing as well. Why should they? They don't own the practice, haven't taken on any financial risk, and aren't nearly as medicolegally responsible for the patients as we as physicians are. However, that doesn't even matter.

Our economic structure in this country is capitalism. You have to own the capital to get the ism. I, along with our other physician partners, own the capital. Our employees do not. "Deserve" ain't got nothing to do with it.

You could argue that larger institutions have larger philanthropic and research missions, blah blah blah, but then I would point out that we put more patients on clinical trials than any other institution in the country, deliver an enormous amount of charity care, and do it all at a cost 1/5th that of major academic medical centers. However, again, that doesn't matter. We own the practice, so we get to collect global billing. Doesn't have to be more complicated than that.

 

[Neuronix]

Is this true?

 

[elementaryschooleconomics]

Is this true?

I would bet a significant amount of money KO is giving an average retirement age for ALL physicians, not RadOnc alone.

 

[jondunn]

KO seems dumb

I don’t know it for a fact I just know it’s true

 

[DoctwoB]

Someone needs to run that study so you can get high impact results like this:

"The mean age (standard deviation [SD]) of urologists who are nearing planned retirement (69, SD = 8.2) was older than nonretiring urologists (48, SD = 10.3) (P < .01)"

https://escholarship.org/content/qt4jz2g1dk/qt4jz2g1dk_noSplash_ffbb4e96df0db109278d5070143588f7.pdf

In all seriousness though, it is important to know mean retirement age for workforce planning. Urology does a good job with annual AUA surveys, but even that is highly prone to selection bias as my guess is retired docs don't fill out the surveys. Meaning if the mean doc in the survey plans to retire at 65, but the survey fails to capture the doc who suddenly retired at 55 it will skew your results order. A better study may be at what age doctors stop billing medicare.

 

[SubserviantToABR]

If 58 was the radonc retirement age, 1/3 of my academic department would be gone and 50% of the private folks in the surrounding metropolitan area.

 

[SubserviantToABR]

Honestly, for some jobs (location, income potential, etc), your best bet is to check the obituary for a job than the ASTRO career board. At least in this neck of the woods, some of these people have been at their positions for 3-4 decades so you're just waiting for their death for that position to open up.

 

[jondunn]

Honestly, for some jobs (location, income potential, etc), your best bet is to check the obituary for a job than the ASTRO career board. At least in this neck of the woods, some of these people have been at their positions for 3-4 decades so you're just waiting for their death for that position to open up.

Yep as soon as Wally kicks it I’m taking over genesis. May even buy some of you out!

 

[elementaryschooleconomics]

Honestly, for some jobs (location, income potential, etc), your best bet is to check the obituary for a job than the ASTRO career board. At least in this neck of the woods, some of these people have been at their positions for 3-4 decades so you're just waiting for their death for that position to open up.

There's a geographic location I've been interested in since I first heard RadOnc was a thing.

The doc staffing it, when I looked, had been in practice there for about 20 years.

Perfect, I thought. There's a chance of retirement which could line up with my career timeline.

That was almost 15 years ago now.

That doc is still working there.

 

[medgator]

There's a geographic location I've been interested in since I first heard RadOnc was a thing.

The doc staffing it, when I looked, had been in practice there for about 20 years.

Perfect, I thought. There's a chance of retirement which could line up with my career timeline.

That was almost 15 years ago now.

That doc is still working there.

Have seen retired partners still locums at their prior practices well into their 70s....

 

[RSAOaky]

It's amazing how much one can miss in this thread after a brief hiatus. I'm going to necro the topic of physician compensation because it's an important one and one that benefits us all. Below are my thoughts on it all.

Information Asymmetry is real and we as physicians need to get better about correcting that. We do that by talking about compensation with one another and by not being weird about it (I know the last one is hard for us). Some of us are embarrassed to talk about our compensation, either because it's very low (wow, I learn way less than my peers) or very high (wow, I don't deserve this massive salary that I've worked decades to earn). We need to stop letting what someone earns influence our opinions of them, and simultaneously need to stop tying our own self worth to what we earn. Our employers know what we and our colleagues generate/earn, what our competitors pay, what the national averages are, etc. and if we think we are undercompensated, the only way we can hope to correct that is to know what is adequate compensation. This isn't always going to go in your favor, but from my experience in my renegotiations and my regional colleagues' experience in theirs, this has helped us all for the better.

To put my money where my mouth is, I have a circle of radonc friends that I speak with regularly, in a variety of positions, all around 3-5 years out working in or around large urban centers. None of the non-academic docs have a monetary compensation (talking salary + bonus and not including any 401k match or fringe benefits) that is under 500k and even the academic ones are closer to 400k than they are to 300k. This is a sample size of 10 and most are on the order of 18-25 patients on treat on average. These are all bright, hard working, charismatic people who practice standard of care radonc, make a great living, and whose health systems are all the better for employing them. They are all employed by health systems except for one, who is a busy member of a large multispecialty group with 25-30 on treat who I suspect makes closer to 700k+. All is not right in Denmark though. One of my colleagues is a member of the largest health system in my region, treating 25-30 with significant administrative titles and responsibilities, making closer to 500k which I would consider to be grossly under market. Of this group of 10, 8 have been in the same position since completing residency and 2 are on their second job.

I don't think the MGMA or ACRO numbers are that far off. The median starting salary is about 330-350k so is it so absurd to expect a 50-150k jump for an average early-mid career physician? I see that some of the members of this forum have taken exception to these numbers. There are certainly massive regional variations, but I'm just throwing my hat in the ring to say that my experience and those of my peers really matches the published medians. If your experience doesn't, then perhaps it's time to evaluate why not.

A note about the MGMA surveys, they report "compensation" which does include bonus and some other benefits which can skew the numbers up a bit though not by that much.

Now, on the topic of how much we SHOULD get paid, there was a fantastic presentation at the ARRO portion of the 2016 ASTRO meeting by Ben Falit that is worth tracking down if you have access. I'm not sure if he or anyone else has given it since, but I've pasted a great slide from it below. These numbers are going to be a bit different depending on how much IMRT/SRS/SBRT/Brachy/Hypofractionation you do. Also, average fraction number has shifted significantly downward over the last 6 years so this probably overestimates things a bit.

For those of you that are hospital employed (most of us these days) wRVUs or Work RVUs are what we typically talk about. Based on the 2018 MGMA survey, the 25th percentile $/wRVU was 46.9, median was 54.45, and 75th percentile was 66.86. I can tell you that two of the 3 major health systems in my area pay about the median $/wRVU and the 3rd (and largest) health system, which probably employs 20-30 radoncs, has its own way of determining compensation that is quite opaque and provides the worst compensation in the region.

I mentioned some caveats above that are important to consider and so feel free to tweak these numbers/formulas as you see fit. I personally think 500 wRVU is a more reasonable conversion these days but this is going to vary considerably by practice. Assuming 500 wRVU, 15 on beam = ~$400k TOTAL COMPENSATION, and 20 on beam = ~$550k TOTAL COMPENSATION so I don't think the numbers are all that far off..

I hope this is a helpful contribution to the discussion.

 

[TheWallnerus]

KO seems dumb

I don’t know it for a fact I just know it’s true

Sort of full re tar d

Can I say that?

 

[TheWallnerus]

It's amazing how much one can miss in this thread after a brief hiatus. I'm going to necro the topic of physician compensation because it's an important one and one that benefits us all. Below are my thoughts on it all.

Information Asymmetry is real and we as physicians need to get better about correcting that. We do that by talking about compensation with one another and by not being weird about it (I know the last one is hard for us). Some of us are embarrassed to talk about our compensation, either because it's very low (wow, I learn way less than my peers) or very high (wow, I don't deserve this massive salary that I've worked decades to earn). We need to stop letting what someone earns influence our opinions of them, and simultaneously need to stop tying our own self worth to what we earn. Our employers know what we and our colleagues generate/earn, what our competitors pay, what the national averages are, etc. and if we think we are undercompensated, the only way we can hope to correct that is to know what is adequate compensation. This isn't always going to go in your favor, but from my experience in my renegotiations and my regional colleagues' experience in theirs, this has helped us all for the better.

To put my money where my mouth is, I have a circle of radonc friends that I speak with regularly, in a variety of positions, all around 3-5 years out working in or around large urban centers. None of the non-academic docs have a monetary compensation (talking salary + bonus and not including any 401k match or fringe benefits) that is under 500k and even the academic ones are closer to 400k than they are to 300k. This is a sample size of 10 and most are on the order of 18-25 patients on treat on average. These are all bright, hard working, charismatic people who practice standard of care radonc, make a great living, and whose health systems are all the better for employing them. They are all employed by health systems except for one, who is a busy member of a large multispecialty group with 25-30 on treat who I suspect makes closer to 700k+. All is not right in Denmark though. One of my colleagues is a member of the largest health system in my region, treating 25-30 with significant administrative titles and responsibilities, making closer to 500k which I would consider to be grossly under market. Of this group of 10, 8 have been in the same position since completing residency and 2 are on their second job.

I don't think the MGMA or ACRO numbers are that far off. The median starting salary is about 330-350k so is it so absurd to expect a 50-150k jump for an average early-mid career physician? I see that some of the members of this forum have taken exception to these numbers. There are certainly massive regional variations, but I'm just throwing my hat in the ring to say that my experience and those of my peers really matches the published medians. If your experience doesn't, then perhaps it's time to evaluate why not.

A note about the MGMA surveys, they report "compensation" which does include bonus and some other benefits which can skew the numbers up a bit though not by that much.

View attachment 351667

Now, on the topic of how much we SHOULD get paid, there was a fantastic presentation at the ARRO portion of the 2016 ASTRO meeting by Ben Falit that is worth tracking down if you have access. I'm not sure if he or anyone else has given it since, but I've pasted a great slide from it below. These numbers are going to be a bit different depending on how much IMRT/SRS/SBRT/Brachy/Hypofractionation you do. Also, average fraction number has shifted significantly downward over the last 6 years so this probably overestimates things a bit.




View attachment 351666

For those of you that are hospital employed (most of us these days) wRVUs or Work RVUs are what we typically talk about. Based on the 2018 MGMA survey, the 25th percentile $/wRVU was 46.9, median was 54.45, and 75th percentile was 66.86. I can tell you that two of the 3 major health systems in my area pay about the median $/wRVU and the 3rd (and largest) health system, which probably employs 20-30 radoncs, has its own way of determining compensation that is quite opaque and provides the worst compensation in the region.

I mentioned some caveats above that are important to consider and so feel free to tweak these numbers/formulas as you see fit. I personally think 500 wRVU is a more reasonable conversion these days but this is going to vary considerably by practice. Assuming 500 wRVU, 15 on beam = ~$400k TOTAL COMPENSATION, and 20 on beam = ~$550k TOTAL COMPENSATION so I don't think the numbers are all that far off..

I hope this is a helpful contribution to the discussion.

Very helpful. Personally I’ve modeled that the 95% CI for the **avg** patients per RO under beam each day is 9-15. Hence that the avg could be $400k…. Look I know that this seems low. I think the orgs that are saying it’s %25+ higher don’t understand stats/population sampling or are doing a mild fleece job for some completely inexplicable reason.

I don’t understand this though

 

[RSAOaky]

Very helpful. Personally I’ve modeled that the 95% CI for the **avg** patients per RO under beam each day is 9-15. Hence that the avg could be $400k…. Look I know that this seems low. I think the orgs that are saying it’s %25+ higher don’t understand stats/population sampling or are doing a mild fleece job for some completely inexplicable reason.

View attachment 351673

I don’t understand this though

The graphic above is a ballpark conversion. So in order to average 10 patients on treatment, you would need 110 new starts a year, and would generate 5500 wRVUs (this is the number I use because it is the number that is most relevant to employed physicians). This is a ballpark estimated by 1 person and it will vary based on practice, it is empirically generated rather than modeled, and I don't know the background treatment mix that went into generating these numbers but I have found them to be roughly true.

If you have your own wRVU data you can come up with similar conversions for yourself and let us know how true these numbers are. The 3 variables you would need to know are the average number you have on treatment, # new starts, and # wRVUs.

I mentioned the caveats about these numbers in a previous post and will say again that it makes a difference. If you treat breast only and hypofractionate everything (for the record, I hypofrac all my intact breasts and 90% of my prostates) you're going to generate fewer wRVUs per patient on treat than someone who treats only prostates. If you do a lot of SRS or SBRT, you're going to generate more wRVUs per patient on treatment. Everyone's treatment mix is completely different and so these numbers are going to differ from person to person, but this is an average starting point for an average radonc who sees an average patient/treatment mix.

I do think the numbers are skewed up a bit because we really were not hypofractionating as much 6 years ago as we are now, but we also probably weren't doing as much SRS/SBRT/IMRT, so it's just hard to say. One day when I have the time I'll determine exactly what my numbers are.

With regards to avg patients on beam, I don't think you're that far off. I would put the global average at 12-15 though there are pretty wide variations in that. However, it's driven down by the academics treating 5-10 and driven up by busier practices treating 20-30. I know far more people treating around 10 than I do treating 25+.

 

[TheWallnerus]

The graphic above is a ballpark conversion. So in order to average 10 patients on treatment, you would need 110 new starts a year, …

I mentioned the caveats about these numbers in a previous post and will say again that it makes a difference. If you treat breast only and hypofractionate everything (for the record, I hypofrac all my intact breasts and 90% of my prostates) you're going to generate fewer wRVUs per patient on treat than someone who treats only prostates. If you do a lot of SRS or SBRT, you're going to generate more wRVUs per patient on treatment.

Only thing I’d add that if one makes 110 new starts a year equal 10 on beam, this means the AVERAGE length of treatment is 5 weeks or 25 fractions. Supposedly the national average is now 16 fractions, with which 110 new starts a year would equate to ~6.5 on beam on avg per day.

 

[TheWallnerus]

By “you” does he mean the entire specialty?

 

[communitydoc13]

By “you” does he mean the entire specialty?

A hard truth. We all know this will be the preferred paradigm in every site where organ preservation is not a goal. Oncology in general is actively probing everywhere the question of elimination of XRT for mitigating risk of regional failure.

 

[RSAOaky]

Only thing I’d add that if one makes 110 new starts a year equal 10 on beam, this means the AVERAGE length of treatment is 5 weeks or 25 fractions. Supposedly the national average is now 16 fractions, with which 110 new starts a year would equate to ~6.5 on beam on avg per day.

I'm not sure what the math is on that (not saying I disagree with you, so if you'd like to post it I'd like to see it), but lets role with it. I'm going to use 15 fractions instead of 25 fractions to make the math nicer. Also, SRS/SBRT will make it a bit difficult to back-calc average length of treatment from # on beam exactly but I think it's safe to assume that this is no more than 5-10% of volume and closer to 5%.

We're going to assume 50/50 IMRT/non-IMRT. If we are assuming that we are treating the same number of patients then it's only the number of treatments going down and so the planning charges are all going to be the same. So, from a wRVU standpoint, the difference between a 15 fraction course and a 25 fraction course is 2 OTV's regardless of technique (3.37 wRVU's a pop) and 10 CBCT's for the IMRT (0.85 wRVU's a pop).

case A:
110 new starts = 5500 wRVUs (assuming 25 fx/treatment)

Case B:
110 new starts = 4,291 wRVUs = 5500 wRVUs - (110 * 2 * 3.37) - (110 * 0.5 * 10 * 0.85)

Back-calcing this puts the number at 390 wRVU per patient on treat which seems very low. I think that as a field, some of what we have lost in fraction number we've gained in SRS/SBRT numbers (oligomets, SBRT spine, up to 10 lesion SRS) and more IMRT (rectal, hippocampal sparing) which mitigates this a bit. My average # fractions is closer to 4 weeks than it is to 3 weeks personally. I'd guess I treat 5% SRS/SBRT, 70% IMRT, and 25% 2D/3D with some negligible brachy in there. I'm about 10-15% palliative 90% definitive. I do 3 wks + boost for most of my breasts [so 4 weeks], 28 fx for most of my prostates, I don't do many single fraction palliatives (COME AT ME SIMUL), but I also don't do any SBRT for bone mets.

So looking at that conversion, 550 wRVU's may be on the high side and 400 is definitely on the low side, though both are well within the realm of possibilities depending on treatment mix. Based on my numbers this year though I can tell you I am around the 500-550 range.

 

[medgator]

A hard truth. We all know this will be the preferred paradigm in every site where organ preservation is not a goal. Oncology in general is actively probing everywhere the question of elimination of XRT for mitigating risk of regional failure.

We also know plenty of these patients aren't operable. Just look at the title slide. Way too much fud about this. NCCN still list chemorads and durva preferred for any stage 3, last i checked right? We never operate on stage 3 pts in my neck the woods because the prospective data never showed a benefit to surgery

 

[jondunn]

Back-calcing this puts the number at 390 wRVU per patient on treat which seems very low. I think that as a field, some of what we have lost in fraction number we've gained in SRS/SBRT numbers (oligomets, SBRT spine, up to 10 lesion SRS) and more IMRT (rectal, hippocampal sparing) which mitigates this a bit. My average # fractions is closer to 4 weeks than it is to 3 weeks personally. I'd guess I treat 5% SRS/SBRT, 70% IMRT, and 25% 2D/3D with some negligible brachy in there. I'm about 10-15% palliative 90% definitive. I do 3 wks + boost for most of my breasts [so 4 weeks], 28 fx for most of my prostates, I don't do many single fraction palliatives (COME AT ME SIMUL), but I also don't do any SBRT for bone mets.

So looking at that conversion, 550 wRVU's may be on the high side and 400 is definitely on the low side, though both are well within the realm of possibilities depending on treatment mix. Based on my numbers this year though I can tell you I am around the 500-550 range.

thank you!

 

[deleted1111261]

That’s actually pretty good proxy for most community practices. 550 wRVU x 15-20 on beam= 8250 - 11000 wRVU. That’s probably where most “busy” hospital employed docs live.

 

[deleted1111261]

I'm not sure what the math is on that (not saying I disagree with you, so if you'd like to post it I'd like to see it), but lets role with it. I'm going to use 15 fractions instead of 25 fractions to make the math nicer. Also, SRS/SBRT will make it a bit difficult to back-calc average length of treatment from # on beam exactly but I think it's safe to assume that this is no more than 5-10% of volume and closer to 5%.

We're going to assume 50/50 IMRT/non-IMRT. If we are assuming that we are treating the same number of patients then it's only the number of treatments going down and so the planning charges are all going to be the same. So, from a wRVU standpoint, the difference between a 15 fraction course and a 25 fraction course is 2 OTV's regardless of technique (3.37 wRVU's a pop) and 10 CBCT's for the IMRT (0.85 wRVU's a pop).

case A:
110 new starts = 5500 wRVUs (assuming 25 fx/treatment)

Case B:
110 new starts = 4,291 wRVUs = 5500 wRVUs - (110 * 2 * 3.37) - (110 * 0.5 * 10 * 0.85)

Back-calcing this puts the number at 390 wRVU per patient on treat which seems very low. I think that as a field, some of what we have lost in fraction number we've gained in SRS/SBRT numbers (oligomets, SBRT spine, up to 10 lesion SRS) and more IMRT (rectal, hippocampal sparing) which mitigates this a bit. My average # fractions is closer to 4 weeks than it is to 3 weeks personally. I'd guess I treat 5% SRS/SBRT, 70% IMRT, and 25% 2D/3D with some negligible brachy in there. I'm about 10-15% palliative 90% definitive. I do 3 wks + boost for most of my breasts [so 4 weeks], 28 fx for most of my prostates, I don't do many single fraction palliatives (COME AT ME SIMUL), but I also don't do any SBRT for bone mets.

So looking at that conversion, 550 wRVU's may be on the high side and 400 is definitely on the low side, though both are well within the realm of possibilities depending on treatment mix. Based on my numbers this year though I can tell you I am around the 500-550 range.

You should do 12-16 Gy single fx SBRT for painful bone met! It works better than 30/10 … in Houston, at least!

 

[jondunn]

 

[TheWallnerus]

I'm not sure what the math is on that (not saying I disagree with you, so if you'd like to post it I'd like to see it

Agree with your RVU modeling btw

Translating the number of new starts to number on beam is the simplest equation and underlies success or failure. It should be taught first day of residency.

B = S x Wf

B is number on beam per day, S is new starts per week, Wf is number of weeks of treatment. “On average” is assumed for all these variables, and it is very important to know that number versus just what it “feels like” how busy a place is.

In your example, it was 110 new starts in a year, and 10 on beam.

10 = (110/52 weeks) x Wf; Wf = 4.7 weeks

I rounded the 4.7 weeks to 5 weeks or 25fx.

If Wf = 3.2 weeks (16 fractions), B = 6.8 patients on beam on average per day.

There is never any situation where this equation doesn’t hold true.

 

[elementaryschooleconomics]

Agree with your RVU modeling btw

Translating the number of new starts to number on beam is the simplest equation and underlies success or failure. It should be taught first day of residency.

B = S x Wf

B is number on beam per day, S is new starts per week, Wf is number of weeks of treatment. “On average” is assumed for all these variables, and it is very important to know that number versus just what it “feels like” how busy a place is.

In your example, it was 110 new starts in a year, and 10 on beam.

10 = (110/52 weeks) x Wf; Wf = 4.7 weeks

I rounded the 4.7 weeks to 5 weeks or 25fx.

If Wf = 3.2 weeks (16 fractions), B = 6.8 patients on beam on average per day.

There is never any situation where this equation doesn’t hold true.

This is the painful truth I'm trying to teach my admin currently.

Admin statement:
"We're below our on-beam target".

ESE statement:
"We really need to revisit this".

Data:
We have had roughly equivalent numbers of CTSIMs performed in my department from 2019-2021
We actually were 13-20% "busier" in those years compared to 2018 (more patients simmed)
Like any community practice, most of our patients are breast and prostate (followed by lung)
Breast is probably 30%-40% of our patients at any given time
The new ASTRO "hypofrac anything" breast guidelines came out in 2018
I basically never do conventional for breast, whereas before 2018, many patients in my department received conventional (from Boomers)

In this moment, as of Friday, we're about 15% below our "on-beam" target. Admin is stressed.

However:
Almost all breast patients are now getting 33% fewer fractions
Breast patients are 30%-40% of our "on-beam" number
We're ~15% busier than 5 years ago
I still manage to keep us hovering around our on-beam target (and exceeding it)

I don't see how the bean counters don't 1) understand this and 2) actively work to try to change this metric.

Just kidding, I do know how they don't understand this. Math is hard. We get paid by the fraction. Logic generates $0.

 

[TheWallnerus]

This is the painful truth I'm trying to teach my admin currently.

Admin statement:
"We're below our on-beam target".

ESE statement:
"We really need to revisit this".

Data:
We have had roughly equivalent numbers of CTSIMs performed in my department from 2019-2021
We actually were 13-20% "busier" in those years compared to 2018 (more patients simmed)
Like any community practice, most of our patients are breast and prostate (followed by lung)
Breast is probably 30%-40% of our patients at any given time
The new ASTRO "hypofrac anything" breast guidelines came out in 2018
I basically never do conventional for breast, whereas before 2018, many patients in my department received conventional (from Boomers)

In this moment, as of Friday, we're about 15% below our "on-beam" target. Admin is stressed.

However:
Almost all breast patients are now getting 33% fewer fractions
Breast patients are 30%-40% of our "on-beam" number
We're ~15% busier than 5 years ago
I still manage to keep us hovering around our on-beam target (and exceeding it)

I don't see how the bean counters don't 1) understand this and 2) actively work to try to change this metric.

Just kidding, I do know how they don't understand this. Math is hard. We get paid by the fraction. Logic generates $0.

TL; DR
“Math is hard” … and our good deeds in rad onc WILL NOT go 100% unpunished.

 

[jondunn]

I think the difference in career earnings that a grad in 2022 thinks about when looking at their academic and private offers is MUCH smaller than 20 years ago. academic docs are making more and more, and there are fewer and fewer honeypot moneybanks in PP.

 

[temujim]

This is the painful truth I'm trying to teach my admin currently.

Admin statement:
"We're below our on-beam target".

ESE statement:
"We really need to revisit this".

Data:
We have had roughly equivalent numbers of CTSIMs performed in my department from 2019-2021
We actually were 13-20% "busier" in those years compared to 2018 (more patients simmed)
Like any community practice, most of our patients are breast and prostate (followed by lung)
Breast is probably 30%-40% of our patients at any given time
The new ASTRO "hypofrac anything" breast guidelines came out in 2018
I basically never do conventional for breast, whereas before 2018, many patients in my department received conventional (from Boomers)

In this moment, as of Friday, we're about 15% below our "on-beam" target. Admin is stressed.

However:
Almost all breast patients are now getting 33% fewer fractions
Breast patients are 30%-40% of our "on-beam" number
We're ~15% busier than 5 years ago
I still manage to keep us hovering around our on-beam target (and exceeding it)

I don't see how the bean counters don't 1) understand this and 2) actively work to try to change this metric.

Just kidding, I do know how they don't understand this. Math is hard. We get paid by the fraction. Logic generates $0.

Never you mind the corollary to these equations -- what is a feasible amount of work for the average rad onc that can be fit into 40 hours a week? Did a dive into this about 3-4 years ago and admin did not like the answer at all. IIRC 40 hrs/week was roughly~7500 wRVUs a year. Now this was local numbers, case mix, and a variety of time assumptions in regards to tasks, etc so YMMV. Non-starter of course for the admin blather about wellness and burnout.

 

[RickyScott]

I think the difference in career earnings that a grad in 2022 thinks about when looking at their academic and private offers is MUCH smaller than 20 years ago. academic docs are making more and more, and there are fewer and fewer honeypot moneybanks in PP.

Exactly. because the large academic centers charge so much more on the technical side, they can employ a lot of docs seeing 4 consults week

 

[TheWallnerus]

I think the difference in career earnings that a grad in 2022 thinks about when looking at their academic and private offers is MUCH smaller than 20 years ago. academic docs are making more and more, and there are fewer and fewer honeypot moneybanks in PP.

It’s almost like someone should look at reimbursement interquartile ranges and see if they have shrunk over time

 

[radiation]

Lets take the morality out of the discussion for a second and look at the pure economics of what the academic side is doing now. By focusing on technology (mri, proton, etc) to increase reimbursement, they are driving up reimbursement, albeit at the cost of centers that do not have the technology. This furthers the gap between the have and have nots, but moves towards increasing reimbursement for rad oncs who have the technology, skewing heavily for academics (which will always have a lower ceiling, but potentially higher floor in aggregate). If you extrapolate as whole, it will accelerate the movement to academics and the median will move towards the academic salary.

The cognitive dissonance of cost shaming community practice while simultaneously increasing their own costs on the academic side has been well documented on this site. But now look where community practice sits - more cost efficient care with lower reimbursement. What is the best strategy going forward now that the pandora's box has been open? If academics reverse course and stop seeking higher reimbursing technology with focus of cost-efficient care, where does that leave the field going forward salary wise? The history of the salary of the field to this point has been directly related to the ability to leverage new technology to increase reimbursement. Again, taking out how things "should be", and just being honest about how we have conducted business in the past, increasing our reimbursement has to be tied to some "new" thing

 

[thecarbonionangle]

It seems that being an at academic centre or large practice with access to technology with higher reimbursements like adaptive replanning, MRI LINAC, protons is a way to protect higher reimbursements while others are fractioned shamed and get their pay cut, the hallahan final solution. Everyone else can eat cake. The future is bright for the “average” RO.

 

[deleted941485]

Nothing to see here, everybody move along now…

Used car salesman command more respect.

 

[udrag14]

Never you mind the corollary to these equations -- what is a feasible amount of work for the average rad onc that can be fit into 40 hours a week? Did a dive into this about 3-4 years ago and admin did not like the answer at all. IIRC 40 hrs/week was roughly~7500 wRVUs a year. Now this was local numbers, case mix, and a variety of time assumptions in regards to tasks, etc so YMMV. Non-starter of course for the admin blather about wellness and burnout.

Man, the time it takes for auth and also getting approval on the backend is astronomical.

I have to defend each imaging now with a peer to peer. OnIy going to get worse from here.

 

[medgator]

Man, the time it takes for auth and also getting approval on the backend is astronomical.

I have to defend each imaging now with a peer to peer. OnIy going to get worse from here.

AIM is the worst... Won't even call back to schedule a p2p. They make the physician call in for the p2p with a phone tree and then will have no one available to talk you.

This of course happened after they deny services and send you a letter after the fact

 

[elementaryschooleconomics]

Never you mind the corollary to these equations -- what is a feasible amount of work for the average rad onc that can be fit into 40 hours a week? Did a dive into this about 3-4 years ago and admin did not like the answer at all. IIRC 40 hrs/week was roughly~7500 wRVUs a year. Now this was local numbers, case mix, and a variety of time assumptions in regards to tasks, etc so YMMV. Non-starter of course for the admin blather about wellness and burnout.

Oh yeah - admin is not ready for this conversation, because physicians are not ready for this conversation.

As a 5-day-a-week community generalist, I far exceed 7500 wRVUs. That honestly seems like a 0.5 FTE number to me.

But I am increasingly convinced there is no such thing as an "average" caseload/standard to measure ourselves against because of the small size of the specialty.

While no one knows, we're guessing 5000-6000 practicing RadOncs in 2022. We're spread out across the entire country in multiple environments: large academic, small academic, hospital employed, multi-specialty private, single-specialty private - in very rural, rural/suburban, urban, metro - with various technological capabilities, local competition (or collaboration), case mix - it goes on forever.

I'm very excited for the ASTRO Workforce study. We really have no idea what's going on. There are those of us who crunch numbers and they don't add up (oversupply), there are those who hang their hats on the PGY5 ARRO survey (everything's fine), there are weather vs climate observations (jobs seem OK this year compared to previous years) - are all of these true? None of them?

You would think ASTRO would have wanted a good handle on our economics years ago, but sand is a comfy place to rest your head, and ignorance is bliss.

 

[jondunn]

Oh yeah - admin is not ready for this conversation, because physicians are not ready for this conversation.

As a 5-day-a-week community generalist, I far exceed 7500 wRVUs. That honestly seems like a 0.5 FTE number to me.

But I am increasingly convinced there is no such thing as an "average" caseload/standard to measure ourselves against because of the small size of the specialty.

While no one knows, we're guessing 5000-6000 practicing RadOncs in 2022. We're spread out across the entire country in multiple environments: large academic, small academic, hospital employed, multi-specialty private, single-specialty private - in very rural, rural/suburban, urban, metro - with various technological capabilities, local competition (or collaboration), case mix - it goes on forever.

I'm very excited for the ASTRO Workforce study. We really have no idea what's going on. There are those of us who crunch numbers are they don't add up (oversupply), there are those who hang their hats on the PGY5 ARRO survey (everything's fine), there are weather vs climate observations (jobs seem OK this year compared to previous years) - are all of these true? None of them?

You would think ASTRO would have wanted a good handle on our economics years ago, but sand is a comfy place to rest your head, and ignorance is bliss.

Exactly why I’m glad Astro is spending the effort and money on getting this data and why I’m happy Chirag is at the head of it

 

[elementaryschooleconomics]

Exactly why I’m glad Astro is spending the effort and money on getting this data and why I’m happy Chirag is at the head of it

Chirag = champion of truth and justice.

I loved hearing Chirag's story on the Accelerators podcast vs the perception of the "Bloodbath" sequence of events.

Chirag: "Yeah so I hung out with residents for lunch and heard job stories and did the math and published it".

Everyone else: "Yeah so I hung out with residents for lunch and heard job stories and did the math and said absolutely nothing because I [appropriately] feared for my career."

 

[communitydoc13]

If academics reverse course and stop seeking higher reimbursing technology with focus of cost-efficient care, where does that leave the field going forward salary wise? The history of the salary of the field to this point has been directly related to the ability to leverage new technology to increase reimbursement.

Spot on.

This was known decades ago. The disconnect between community and academic radonc is almost intrinsic to the field at this point.

1. The community doc is going to be skeptical about meaningful clinical contributions of improved tech, whether protons or MRI linac, because they often can't afford to get them anyway. What we overwhelmingly experience is a decrease in indications and an exponential growth of tools for the community medonc. Is there a trial out there indicating that my 2mm margin single iso, 3 fraction linac based brain treatment for 7 mets is meaningfully inferior to the single fraction treatment at big academic center. No. Is there a difference in cost to society. Yes. Are more brain met patients being managed with systemic therapy? Yes.

2. The community doc sees different patients. They are older (often a decade older than clinical trial enrollees) and poorer. The incidence of cancer peaks in the 80s but these patients don't travel far. These patients benefit less from everything, including new tech, but are often more work. They overwhelmingly pay what medicare pays.

3. Because of disparities in compensation from payors, the community doc needs to see many more patients to justify their salary. They are increasingly in a world where tech and care is directly marketed to patients and where academic places are motivated to retain patients who live far away. As mentioned many times, extreme hypofractionation is mostly a retention tool.

4. The size of the field is just so conducive to clubbishness, chumminess and perverse social capital. Many academic radoncs (I'm sure @Neuronix @ramsesthenice and @Lamount are not in this group) do very little clinical work. I trained at a place where a breast attending often carried 10 patients (in an era of standard fractionation) and had full resident coverage. Networking, workgroup participation, and collaborative clinical trials work is how you get ahead in academics. This is not deep thinking stuff and every bright community doc, who now knows that they are not part of the club, is aware of this. I can't say I'm in awe of my academic colleagues.

5. Despite providing the care needed for the community and actually doing the work of addressing access disparities, it is the academic radonc in major centers that writes papers on these issues and furthers their career. Meanwhile the value of the community doc is degraded by the glut of trainees.

6. In a time gone by, community docs with ownership were much more wealthy than their academic peers. There was clear jealousy on the part of academics here and some mobility between academic and community practice in the era before overtraining. This is no longer the case and lateral mobility is very difficult for all docs. If you like playing the game, the sweet gig is likely a low clinical volume job at the mothership. These are the folks that tell us what to do.

 

[deleted1111261]

 

[deleted941485]

Spot on.

This was known decades ago. The disconnect between community and academic radonc is almost intrinsic to the field at this point.

1. The community doc is going to be skeptical about meaningful clinical contributions of improved tech, whether protons or MRI linac, because they often can't afford to get them anyway. What we overwhelmingly experience is a decrease in indications and an exponential growth of tools for the community medonc. Is there a trial out there indicating that my 2mm margin single iso, 3 fraction linac based brain treatment for 7 mets is meaningfully inferior to the single fraction treatment at big academic center. No. Is there a difference in cost to society. Yes. Are more brain met patients being managed with systemic therapy? Yes.

2. The community doc sees different patients. They are older (often a decade older than clinical trial enrollees) and poorer. The incidence of cancer peaks in the 80s but these patients don't travel far. These patients benefit less from everything, including new tech, but are often more work. They overwhelmingly pay what medicare pays.

3. Because of disparities in compensation from payors, the community doc needs to see many more patients to justify their salary. They are increasingly in a world where tech and care is directly marketed to patients and where academic places are motivated to retain patients who live far away. As mentioned many times, extreme hypofractionation is mostly a retention tool.

4. The size of the field is just so conducive to clubbishness, chumminess and perverse social capital. Many academic radoncs (I'm sure @Neuronix @ramsesthenice and @Lamount are not in this group) do very little clinical work. I trained at a place where a breast attending often carried 10 patients (in an era of standard fractionation) and had full resident coverage. Networking, workgroup participation, and collaborative clinical trials work is how you get ahead in academics. This is not deep thinking stuff and every bright community doc, who now knows that they are not part of the club, is aware of this. I can't say I'm in awe of my academic colleagues.

5. Despite providing the care needed for the community and actually doing the work of addressing access disparities, it is the academic radonc in major centers that writes papers on these issues and furthers their career. Meanwhile the value of the community doc is degraded by the glut of trainees.

6. In a time gone by, community docs with ownership were much more wealthy than their academic peers. There was clear jealousy on the part of academics here and some mobility between academic and community practice in the era before overtraining. This is no longer the case and lateral mobility is very difficult for all docs. If you like playing the game, the sweet gig is likely a low clinical volume job at the mothership. These are the folks that tell us what to do.

There is an open and frankly vicious contempt for community and PP rad onc versus academia the likes of which is unique to rad onc. I’ve never seen this in any medicine subspecialty or surg sub. It has to go beyond jealously…there has to be something more.

Now they are finally realizing their dream with pathways and the like…total control over them. You deviate from pathways be prepared to defend it. They’ll never be able to make more but they certainly have no problem ripping away any shred of pride or dignity you have as a community doctor.

Oh I’ve seen their version of the future of rad onc…it’s do as I say when I say.

 

[jondunn]

I’ve seen some really bad community care. I’m sad to say. The problem is everyone being painted with the same brush.

 

[temujim]

Lets take the morality out of the discussion for a second and look at the pure economics of what the academic side is doing now. By focusing on technology (mri, proton, etc) to increase reimbursement, they are driving up reimbursement, albeit at the cost of centers that do not have the technology. This furthers the gap between the have and have nots, but moves towards increasing reimbursement for rad oncs who have the technology, skewing heavily for academics (which will always have a lower ceiling, but potentially higher floor in aggregate). If you extrapolate as whole, it will accelerate the movement to academics and the median will move towards the academic salary.

The cognitive dissonance of cost shaming community practice while simultaneously increasing their own costs on the academic side has been well documented on this site. But now look where community practice sits - more cost efficient care with lower reimbursement. What is the best strategy going forward now that the pandora's box has been open? If academics reverse course and stop seeking higher reimbursing technology with focus of cost-efficient care, where does that leave the field going forward salary wise? The history of the salary of the field to this point has been directly related to the ability to leverage new technology to increase reimbursement. Again, taking out how things "should be", and just being honest about how we have conducted business in the past, increasing our reimbursement has to be tied to some "new" thing

Both pvt practice and academics are responding to the incentives of consolidation. Government regulations and to a lesser extent insurance companies are driving the market, if it can be described as such. Have a dark pessimistic view of this process, but hey maybe I'm wrong.

 

[TheWallnerus]

I’ve seen some really bad community care. I’m sad to say. The problem is everyone being painted with the same brush.

One of the best ways to get a yes answer to “Have you seen bad academic care” is ask a PGY5 rad onc resident.

 

[deleted941485]

Both pvt practice and academics are responding to the incentives of consolidation. Government regulations and to a lesser extent insurance companies are driving the market, if it can be described as such. Have a dark pessimistic view of this process, but hey maybe I'm wrong.

And since academics are who the govt listens to and are given preferential treatment…we all know how it ends

 

[jondunn]

One of the best ways to get a yes answer to “Have you seen bad academic care” is ask a PGY5 rad onc resident.

Of course