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jondunn said:
'yet there are no tangible consequences for not meeting these targets (no staff have been laid off, no capital expenses denied, etc'

this is the key, you nailed it. It's because there is still plenty of money coming in (maybe the same? maybe more?!) despite fraction numbers being down.

the math has changed, the game has changed
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It's absolutely insane to me.

Staff will run around all stressed after these meetings, but they really need to ask two questions:

1) Who derived these numbers, and how were they calculated?

2) If we're really so far "in the red", what are the consequences?

It appears to me, at least, that "not meeting budget" is a stick the MBAs use to beat the clinical staff over the head with. Because there's no invisible hand that's going to reach down from the sky and pump a department full of cash to keep the doors open "for the good of the community". This is America, after all.

If a RadOnc department is not meeting its operational costs, it will cease to exist. Period.
 
TheWallnerus said:
This math is good for Medicare and even private insurance out in most private practices. However, w/ insurance and at the Big Rad Onc places, all bets are off. 5 fraction prostate SBRT can easily out-reimburse 45 IG-IMRTs.
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I would imagine those same big rad onc places would have IMRT charges that are much higher than free standing too?

my guess is that both sbrt and imrt charges are higher, and that long course IMRT still will always win out.
 
elementaryschooleconomics said:
yet there are no tangible consequences for not meeting these targets
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jondunn said:
'yet there are no tangible consequences for not meeting these targets (no staff have been laid off, no capital expenses denied, etc'

this is the key, you nailed it. It's because there is still plenty of money coming in (maybe the same? maybe more?!) despite fraction numbers being down.
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I believe we will begin to see rad onc average salaries begin to fall. Everyone else (admins especially) will hold steady!
 
jondunn said:
I would imagine those same big rad onc places would have IMRT charges that are much higher than free standing too?

my guess is that both sbrt and imrt charges are higher, and that long course IMRT still will always win out.
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Not if you can "steal" patients and do that neat centralization trick to which you previously alluded
 
TheWallnerus said:
I believe we will begin to see rad onc average salaries begin to fall. Everyone else (admins especially) will hold steady!
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I think that's the only logical outcome.

1) The majority of positions RadOncs will be hired for are employed positions, not professional fee contracts (and/or technical). In the employed/academic medical center model, the reimbursement our work generates disappears into the giant pool of "The Hospital" and salary is dispensed by "The Hospital". Like a restaurant forcing everyone to pool tips at the end of the night, even if someone is working harder and generating more tips - the bosses will kindly grace us with a pre-determined amount for our services.

2) The justification/allure will be "full time employment (1.0 FTE) with only 3-4 clinical days per week".

All of our math/concerns about oversupply hinges on the assumption that all other things remain equal (ceteris paribus). But if the majority of RadOnc jobs become W2 employee gigs with salary independent of effort...heck, we might need 400 residents a year!
 
jondunn said:
I would imagine those same big rad onc places would have IMRT charges that are much higher than free standing too?

my guess is that both sbrt and imrt charges are higher, and that long course IMRT still will always win out.
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I would love to hear the negotiations. I am sure a place like mskcc that wants to sell a lot of 5 fraction sbrt to out of towners will negotiate especially high rates for sbrt and come down for conventional imrt?
 
elementaryschooleconomics said:
The only conclusion I have: all these numbers are completely invented.
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I think all of your numbers are spot on and are likely reflected in almost any clinic where thoracic surgery is somewhat available.

The small increase in total patients is also common. This is the baby boomer generation now being somewhere between 62 and 76. It is also a function of people living a very long time and getting patients close to 90 for various semi-palliative type treatments or skin cancer (or 2nd to 5th courses of palliative treatments for patients with stage IV cancers now living 2-6 years instead of 0-2).

When you are flush, the details get murky to admins. I am always amazed at how removed admin is from the practicalities of clinic and even their understanding of what investments will help them retain "easy money". They do notice rejected claims however. Fortunately, many of them believe that a new linac will create new patients.

TheWallnerus said:
I believe we will begin to see rad onc average salaries begin to fall.
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I agree. In my own setup I have every intention of preventing this by working with fewer doctor days (fewer FTEs) for the same amount of work going forward. This is antithetical to what most of society is doing (probably rightfully).

elementaryschooleconomics said:
The justification/allure will be "full time employment (1.0 FTE) with only 3-4 clinical days per week".

All of our math/concerns about oversupply hinges on the assumption that all other things remain equal (ceteris paribus). But if the majority of RadOnc jobs become W2 employee gigs with salary independent of effort...heck, we might need 400 residents a year!
Click to expand...
This is a more global trend. One thing about the massive shift to virtual work IMO is the understanding that many folks are making a pretty good living doing close to nothing. I suspect many of these "information economy" gigs that you need a decent college degree to get are actually just fluff. Most admin is a lot of fluff. Being an MD is one of those rare, well compensated/high credential jobs where you are actually doing discrete tasks for the bulk of your work day. It gets harder and harder to do this when you know more and more people working the equivalent of 3 days/week in their virtual gig and bringing home something in the proximity of 200k. This is not a direct threat to radonc, where there is a glut of young, over-credentialed docs who have just put too much investment in at all. But, it is a significant threat to healthcare in general.
 
'It gets harder and harder to do this when you know more and more people working the equivalent of 3 days/week in their virtual gig and bringing home something in the proximity of 200k. This is not a direct threat to radonc, where there is a glut of young, over-credentialed docs who have just put too much investment in at all. But, it is a significant threat to healthcare in general.'


yes, yes, yes. As I'm reaching my late 30's, I know so many people from college in this position, making 200-250k for what seems to be jobs of fluff. makes being an MD seem silly sometimes.
 
communitydoc13 said:
I think all of your numbers are spot on and are likely reflected in almost any clinic where thoracic surgery is somewhat available.

The small increase in total patients is also common. This is the baby boomer generation now being somewhere between 62 and 76. It is also a function of people living a very long time and getting patients close to 90 for various semi-palliative type treatments or skin cancer (or 2nd to 5th courses of palliative treatments for patients with stage IV cancers now living 2-6 years instead of 0-2).

When you are flush, the details get murky to admins. I am always amazed at how removed admin is from the practicalities of clinic and even their understanding of what investments will help them retain "easy money". They do notice rejected claims however. Fortunately, many of them believe that a new linac will create new patients.


I agree. In my own setup I have every intention of preventing this by working with fewer doctor days (fewer FTEs) for the same amount of work going forward. This is antithetical to what most of society is doing (probably rightfully).


This is a more global trend. One thing about the massive shift to virtual work IMO is the understanding that many folks are making a pretty good living doing close to nothing. I suspect many of these "information economy" gigs that you need a decent college degree to get are actually just fluff. Most admin is a lot of fluff. Being an MD is one of those rare, well compensated/high credential jobs where you are actually doing discrete tasks for the bulk of your work day. It gets harder and harder to do this when you know more and more people working the equivalent of 3 days/week in their virtual gig and bringing home something in the proximity of 200k. This is not a direct threat to radonc, where there is a glut of young, over-credentialed docs who have just put too much investment in at all. But, it is a significant threat to healthcare in general.
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Good Lord I feel this post in my soul.
 
The worst thing about working in corporate/tech/finance is that there is always a manager or boss breathing down your neck who could fire you at anytime. Maybe it’s the same in medicine, but less so?
 
voxveritatisetlucis said:
The worst thing about working in corporate/tech/finance is that there is always a manager or boss breathing down your neck who could fire you at anytime. Maybe it’s the same in medicine, but less so?
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Even worse in RadOnc. You have 2 ruthless bosses: Chairman and hospital side admin
 
elementaryschooleconomics said:
Well, the bigger issue (speaking for myself, in my personal day-to-day) is not that WE (the physicians) don't understand it's a bad metric, but the admins in our healthcare systems don't understand. "On beam" is very easy to measure, track, and compare to historical numbers - everything admin loves.

On that note - after reading the Todd Lung Tweetorial, I ran the numbers for my own hospital. All of these are true statements:

1) My hospital admin is still using "on beam" to set/track my department's budget.

2) The Lung Math uses an approximate 10-year comparison, 2013 to 2022.

3) 10 years ago, my hospital had one linac and didn't really do SRS/SBRT (small community hospital).

4) Currently, my hospital has two linacs and I frequently do SRS/SBRT.

5) Despite doubling our linear accelerators, our targeted "on beam" number has only increased approximately 30-35%. As we all know, reimbursements in general have been cut over the last 10 years.

6) Running the numbers for patients treated for lung cancer over the last 5 years (I don't have easy access to older data, and I can't drill down on staging easily), it appears my department has treated 33% fewer lung cancer patients, pretty much exactly in line with Todd's estimates. This makes sense, the LDCT recommendations came out in 2014 and needed time to be adopted.

7) I have my hospital's "Standard Charges" list, and I know that SRS and SBRT generate significantly higher reimbursement than conventional fractions. However, as far as I can tell, none of my admins appear to factor this in to their budget math.

8) In terms of total patients simmed per year, we are slightly busier now than 5 years ago, up approximately 12-15%.

9) Like the rest of the country, we have switched from all conventional fractions for breast/prostate to hypofrac for most patients.

10) In a meeting last week, I was told we are several hundred thousand dollars "below our targeted budget".

So we doubled our linacs, but only increased our targeted "on beam" number by 30%, while reimbursements were cut, are seeing less lung patients, using fewer fractions for prostate and breast, started doing a lot of SRS/SBRT which reimburses a lot more, are simming more patients, and being told we're not meeting financial targets, yet there are no tangible consequences for not meeting these targets (no staff have been laid off, no capital expenses denied, etc).

The only conclusion I have: all these numbers are completely invented.

I am incredibly interested to see this ASTRO economics report. Because this is JUST my little community hospital, these are numbers I can personally verify, and none of this makes sense to me.
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Anecdotally, I have seen more very locally advanced lung cancer in the wake of COVID, and also have seen an uptick in smoking. It wouldn’t surprise me to discover that some of the positive trends we have seen in screening and smoking cessation may have -at least temporarily- reversed.
 
communitydoc13 said:
It gets harder and harder to do this when you know more and more people working the equivalent of 3 days/week in their virtual gig and bringing home something in the proximity of 200k. This is not a direct threat to radonc, where there is a glut of young, over-credentialed docs who have just put too much investment in at all. But, it is a significant threat to healthcare in general.
Click to expand...

YES! This exactly. My partner WFH before they left their last job and the amount of hours they worked was both laughable and amazing.
 
jondunn said:
yes, yes, yes. As I'm reaching my late 30's, I know so many people from college in this position, making 200-250k for what seems to be jobs of fluff. makes being an MD seem silly sometimes.
Click to expand...

It's an odd phenomenon for sure. When I went to med school, there were very few avenues other than being a doctor that would earn you a W2 income > $200k. Earning that kind of income anywhere else almost always involved owning a business. At my old company, the only person with an income at that level was the CEO. The engineers, mid level mangers, IT guys all had a career ceiling around $120k. That wasn't that long ago. Now it seems everyone is making >$200k. And what has happened to rad onc income during that time?

It seems that our friends who studied econ in college or something, married somebody in tech whose jobs have basically boiled down to social media data harvesting to target online ads, now have a household income approaching $1M somehow, and this is common. I've noticed it a lot in the past couple of years. People my age hauling their kids through airports on vacations that are easily costing them $20-30k for the whole family. Buying 2M houses. Meanwhile I am studying for oral boards in my mid 30s in an apartment and trying to justify buying a $800 round trip domestic economy ticket for myself alone to visit family.

It seems like income is going way up for lots of people, but not for rad oncs. We used to have really great income for our skills. Comparatively, I'm not sure it's really great anymore when people are making $500k/year to work from home and target ads on instagram.

On the flip side, I'm not convinced this can last. The tech industry (among others) is prone to boom-bust cycles and plenty of people who were making a fortune in the early 2000s were unemployed a few years later triggering a recession when they could no longer afford their lifestyles. At least mass layoffs and the prospect of permanent unemployment and forced career change isn't something rad oncs have ever had to worry about. Yet?
 
Moonbeams said:
It's an odd phenomenon for sure. When I went to med school, there were very few avenues other than being a doctor that would earn you a W2 income > $200k. Earning that kind of income anywhere else almost always involved owning a business. At my old company, the only person with an income at that level was the CEO. The engineers, mid level mangers, IT guys all had a career ceiling around $120k. That wasn't that long ago. Now it seems everyone is making >$200k. And what has happened to rad onc income during that time?

It seems that our friends who studied econ in college or something, married somebody in tech whose jobs have basically boiled down to social media data harvesting to target online ads, now have a household income approaching $1M somehow, and this is common. I've noticed it a lot in the past couple of years. People my age hauling their kids through airports on vacations that are easily costing them $20-30k for the whole family. Buying 2M houses. Meanwhile I am studying for oral boards in my mid 30s in an apartment and trying to justify buying a $800 round trip domestic economy ticket for myself alone to visit family.

It seems like income is going way up for lots of people, but not for rad oncs. We used to have really great income for our skills. Comparatively, I'm not sure it's really great anymore when people are making $500k/year to work from home and target ads on instagram.

On the flip side, I'm not convinced this can last. The tech industry (among others) is prone to boom-bust cycles and plenty of people who were making a fortune in the early 2000s were unemployed a few years later triggering a recession when they could no longer afford their lifestyles. At least mass layoffs and the prospect of permanent unemployment and forced career change isn't something rad oncs have ever had to worry about. Yet?
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If that is truly the case. Certainly not something that I’ve noticed then yeah could be the beginning of a bubble. The crazy valuations mixed with really no where else to put your money makes it a great time to be in tech. Also 500K to these tech guys, that’s somebodies bonus for a mediocre year.
 
Moonbeams said:
It's an odd phenomenon for sure. When I went to med school, there were very few avenues other than being a doctor that would earn you a W2 income > $200k. Earning that kind of income anywhere else almost always involved owning a business. At my old company, the only person with an income at that level was the CEO. The engineers, mid level mangers, IT guys all had a career ceiling around $120k. That wasn't that long ago. Now it seems everyone is making >$200k. And what has happened to rad onc income during that time?

It seems that our friends who studied econ in college or something, married somebody in tech whose jobs have basically boiled down to social media data harvesting to target online ads, now have a household income approaching $1M somehow, and this is common. I've noticed it a lot in the past couple of years. People my age hauling their kids through airports on vacations that are easily costing them $20-30k for the whole family. Buying 2M houses. Meanwhile I am studying for oral boards in my mid 30s in an apartment and trying to justify buying a $800 round trip domestic economy ticket for myself alone to visit family.

It seems like income is going way up for lots of people, but not for rad oncs. We used to have really great income for our skills. Comparatively, I'm not sure it's really great anymore when people are making $500k/year to work from home and target ads on instagram.

On the flip side, I'm not convinced this can last. The tech industry (among others) is prone to boom-bust cycles and plenty of people who were making a fortune in the early 2000s were unemployed a few years later triggering a recession when they could no longer afford their lifestyles. At least mass layoffs and the prospect of permanent unemployment and forced career change isn't something rad oncs have ever had to worry about. Yet?
Click to expand...

Inflation has been a very, very real thing, especially since 2008, and it is accelerating. A manager of an In N' Out could make $160k a year in 2018. I'm sure it's more now.

Medicine, especially radonc, has a hard time keeping up with inflation, as we cannot raise our prices as quickly or easily as other industries can. CMS isn't going to increase our reimbursements by 7-8% this year. All we can do is try to see more patients and work harder to maintain our income. I've told my partner I'm not going to hire to replace her when she retires. I would rather hire someone than work harder, but it's clear that's not what's going to happen.
 
OTN said:
Inflation has been a very, very real thing, especially since 2008, and it is accelerating. A manager of an In N' Out could make $160k a year in 2018. I'm sure it's more now.

Medicine, especially radonc, has a hard time keeping up with inflation, as we cannot raise our prices as quickly or easily as other industries can. CMS isn't going to increase our reimbursements by 7-8% this year. All we can do is try to see more patients and work harder to maintain our income. I've told my partner I'm not going to hire to replace her when she retires. I would rather hire someone than work harder, but it's clear that's not what's going to happen.
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It would be hard to keep up with but as RO we don’t even have that option. The patients come when they come and believe me they ain’t coming like they used to.
 
voxveritatisetlucis said:
Considering that the 1,000,000 puts one in the 99.8th percentile, I doubt it’s very common for tech workers to make that. There are only 240,000 households in the country that make that
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Mostly finance and tech at the management level. The rest are entrepreneurs and Medicare fraudsters.
 
RealSimulD said:
Households?
doctor doctor couples earn mil routinely
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Yeah the NSX and practice owners. Dual surgeon couple which sounds miserable would also.

I don’t think hosp-hosp or peds-Derm couples will make it.

Doc couples sound miserable but the money is great. I’m sure the divorce proceedings are juicy for the lawyers too
 
Spouse can earn negative income and still reach >1mil if other spouse is a Mohs surgeon (or electronic brachytherapist a decade ago)
 
Is it that uncommon? I know RO - RO couples, RO - MO couples, RO - DR couples, RO - Derm .. I assume most of you have seen these types of folks? RO seem to marry well!
 
RadsWFA1900 said:
Must have missed the memo on that one
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It's actually a fact that most US MDs are specialists. Think back to your med school class. Less then a third went into IM/FM/PEDS at my med school. Of the ones that went into IM, most will end up as specialists.

There are a lot of radiologists, anesthesiologists, surgeons, surgical subs, cardiologists, GIs, med oncs, PM&R, pain med, psych, EM, etc out there making 500k plus or close to it who are married to a similar doc. Or one of those docs who is on the 75th percentile and a pcp will also do it.
 
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