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jondunn said:
Well ‘some’ patients may drive 1-2 hours but many can’t or won’t. That’s not the endgame solution for consolidation

It has to come with paid support for housing.
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I agree, but we cannot bring a linac to the patient's farmhouse and park it by the barn for a week. That is insane and doesn't demonstrate somebody who is really thinking critically about this problem. Just somebody spewing stream of consciousness nonsense on Twitter and trying to virtue signal.

Wanting to improve rural cancer care is a noble cause, for sure. But "halcyon on a truck" can only ever practically be a short term solution for a center while they build a vault and install a permanent machine or something.
 
Moonbeams said:
Most of them are not paying 800k. A lot of these ultrarural places are trying to pay somebody to come there for MGMA median, 5 day work week, 6 weeks PTO. They advertise for years. In other words, the same deal they could get in large midwestern city, if not worse. Anybody who takes one of these jobs for a standard salary and benefit package is a fool.

Kearney, Nebraska spams me once every couple of months. They claim 25 patients on treatment. If true, that job should pay 1M. No joke.
I have never been to Kearney, NE. I don't imagine it has a lot going on. I imagine it is hard to recruit to. Rad onc has a problem in that the field self-selected >90% of candidates for over a decade (peak rad onc) who would never go to a place like that for any amount of money. Still, if Kearney would pay a rad onc 100% of pro collections, which should be 1M+ in that practice if those numbers are true, and offered 12 weeks of vacation and an option to cover Fridays from home or something, that job would fill, I am sure of it. And it would almost certainly still be one of the highest revenue centers in the hospital.

The idea of not consolidating the surrounding Nebraska communities into rural linacs in 20k communities (yes, where some patients will have to drive in for an hour or two) and instead putting a linac with limited functionality and a team of support staff on a truck and driving around to each 2000 person town and delivering some ultrahypofractionated treatments is tone deaf and asinine from a logistical and basic common sense perspective.
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Yup
 
Moonbeams said:
Most of them are not paying 800k. A lot of these ultrarural places are trying to pay somebody to come there for MGMA median, 5 day work week, 6 weeks PTO. They advertise for years. In other words, the same deal they could get in large midwestern city, if not worse. Anybody who takes one of these jobs for a standard salary and benefit package is a fool.

Kearney, Nebraska spams me once every couple of months. They claim 25 patients on treatment. If true, that job should pay 1M. No joke.
I have never been to Kearney, NE. I don't imagine it has a lot going on. I imagine it is hard to recruit to. Rad onc has a problem in that the field self-selected >90% of candidates for over a decade (peak rad onc) who would never go to a place like that for any amount of money. Still, if Kearney would pay a rad onc 100% of pro collections, which should be 1M+ in that practice if those numbers are true, and offered 12 weeks of vacation and an option to cover Fridays from home or something, that job would fill, I am sure of it. And it would almost certainly still be one of the highest revenue centers in the hospital.

The idea of not consolidating the surrounding Nebraska communities into rural linacs in 20k communities (yes, where some patients will have to drive in for an hour or two) and instead putting a linac with limited functionality and a team of support staff on a truck and driving around to each 2000 person town and delivering some ultrahypofractionated treatments is tone deaf and asinine from a logistical and basic common sense perspective.
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Sir, do you not know about the sandhill cranes?
 
Moonbeams said:
Most of them are not paying 800k. A lot of these ultrarural places are trying to pay somebody to come there for MGMA median, 5 day work week, 6 weeks PTO. They advertise for years. In other words, the same deal they could get in large midwestern city, if not worse. Anybody who takes one of these jobs for a standard salary and benefit package is a fool.

Kearney, Nebraska spams me once every couple of months. They claim 25 patients on treatment. If true, that job should pay 1M. No joke.
I have never been to Kearney, NE. I don't imagine it has a lot going on. I imagine it is hard to recruit to. Rad onc has a problem in that the field self-selected >90% of candidates for over a decade (peak rad onc) who would never go to a place like that for any amount of money. Still, if Kearney would pay a rad onc 100% of pro collections, which should be 1M+ in that practice if those numbers are true, and offered 12 weeks of vacation and an option to cover Fridays from home or something, that job would fill, I am sure of it. And it would almost certainly still be one of the highest revenue centers in the hospital.

The idea of not consolidating the surrounding Nebraska communities into rural linacs in 20k communities (yes, where some patients will have to drive in for an hour or two) and instead putting a linac with limited functionality and a team of support staff on a truck and driving around to each 2000 person town and delivering some ultrahypofractionated treatments is tone deaf and asinine from a logistical and basic common sense perspective.
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Exactly. Locations/jobs like that are 7 figure jobs full stop. Anything less is a non-starter. Doesn't mean it couldn't be a great setup but as you said, some people will never move there for any amount of money.

I would have been all over that coming out of residency to build a nest egg for a few years, but those situations are now either non-existent or very rare.
 
metallica81788 said:
Exactly. Locations/jobs like that are 7 figure jobs full stop. Anything less is a non-starter. Doesn't mean it couldn't be a great setup but as you said, some people will never move there for any amount of money.

I would have been all over that coming out of residency to build a nest egg for a few years, but those situations are now either non-existent or very rare.
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It would be helpful if there weren't a massive field of locums in rad onc to keep these places operating while they try and recruit a sucker for years so that they were forced to pay what the market would bear for a permanent hire. But the CEOs have this option to keep it staffed (poorly) for $2500/day ($650,000/year). So that's what they do. You want to improve rural cancer care, maybe start with that problem and get rid of the substandard locums care going on out there.
 
Not that accreditation matters, but ACR/APEX should consider this.

Do you have a full time physician that works 80% of the year for at 2 out of last 3 years?

I mean, more than these freaking chart checks they are doing, a stable physician must matter to quality of care, right?
 
jondunn said:


Interested in what people think about this - does 20 on treat translate to 750-800 in pro fees?
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Not quite where I'm at. Payer mix and medicare geographic multiplier can be poor in many rural areas. Rural Minnesota for instance would be better than rural Appalachia (medicare multiplier).

What Simul says in that thread is 100% right though. What a good proactive administrator understands is that a stable, well liked rad onc in a rural single linac position can and will increase volumes. Even if you have to subsidize their salary over the pro fees, you make up for it in technical and downstream revenue (imaging, ER visits, procedures, chemo, etc). Even if you pay that doc 100K over their pro collections if they bump volume from say 18 to 23 under treat you come out WAAYYY ahead.

Unfortunately in my experience the only time admin will actually believe that is if they see what volumes look like with a train wreck department with revolving locums then are lucky enough to land a good full time person. Then they can experience the benefits and see it for themselves. They're skeptical otherwise.
 
jondunn said:


Interested in what people think about this - does 20 on treat translate to 750-800 in pro fees?
Click to expand...


I have worked in an area when that would generate 1M. I have seen others where it's mostly medicaid/self-pay and would be less.

Admin does not want you to know actual pro collections. The dirty trick they play is paying you proportionally less when you work proportionally more (the extreme is when they actually put an annual income cap on you). You work more and generate more revenue, but get paid a "bonus" (or sometimes none at all if you are flat salary) that is in reality 50% or less of the additional pro fees you brought in. To call it a production bonus is some 1984-level stuff. It's not a bonus. It's a marginal paycut.

BobbyHeenan said:
Unfortunately in my experience the only time admin will actually believe that is if they see what volumes look like with a train wreck department with revolving locums then are lucky enough to land a good full time person. Then they can experience the benefits and see it for themselves. They're skeptical otherwise.
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They are usually too stupid to understand it. Penny wise and pound foolish. In their mind the savings on locums while they wait for a sucker to accept a lowball salary is justified vs. the expense of compensating a full-time person properly who would increase volumes and revenue as the med oncs stop sending out complex H&N, GI, etc. to the nearest academic center.
 
medgator said:
Are those jobs still paying what they did a decade ago?
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I interviewed almost exclusively rural (pop. 50K or less). I had a single offer for $650K. That offer was promptly eliminated after the supervision rules changed. Otherwise... none of them exceeded $550K. Most did not break $450K.

The $700K+ jobs often mentioned on this board must not be listed. Gotta network for those rural practices.....
 
TheWallnerus said:
I feel like the only jobs (with any reliability) up in the 700 plus range are when the MD is doing their own billing.
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It’s true. Nobody is handing that out for anybody on the employed site unless you are the director of the Dept. Working in the boonies for 500K isn’t worth it.
 
dieABRdie said:
I interviewed almost exclusively rural (pop. 50K or less). I had a single offer for $650K. That offer was promptly eliminated after the supervision rules changed. Otherwise... none of them exceeded $550K. Most did not break $450K.

The $700K+ jobs often mentioned on this board must not be listed. Gotta network for those rural practices.....
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I think there is a lot of truth to this. The 650K+ rural rad onc job is out there but its rare. It's not like we are radiologist or med oncs.
 
I hear the Russians are doing this for themselves already

www.voanews.com

VOA Exclusive: Ukraine Says Photos Show Russia Dug Trenches in Chernobyl’s Radioactive Soil

Head of Ukrainian state agency provides VOA with photos he says he took on April 5
www.voanews.com www.voanews.com
communitydoc13 said:
Yes, but it starts with being able to pay and with having access to good primary care. Trying to solve rural health care disparities with a traveling LINAC is sort of like sending a bunch of us to Ukraine to perform battlefield XRT.
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RadsWFA1900 said:
It’s true. Nobody is handing that out for anybody on the employed site unless you are the director of the Dept. Working in the boonies for 500K isn’t worth it.
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There is a huge difference between treating 10 patients at a rural center and treating 25 patients at a rural center.

The hospital doesn't care.

10 patients? You get 550k.
25 patients? You get 550k. Maybe a 50k production "bonus" if we are feeling generous.

That's the problem.

I had a salaried offer in Kansas at one point for 450k for a hospital employed position that supposedly generated 15,000 wRVU (which comes out to $30/wRVU). I politely declined although I was pretty annoyed to waste my time interviewing like that for what turned out to be clearly an absurd offer, The recruiter (who informed me numerous times she declined her med school acceptance to raise children) was offended that I would turn down what she considered such a high salary and asked what the comparable offers I had received were. I told her $70/wRVU. No further discussion ensued. This kind of stuff goes on all the the time with rural hospitals. They are living on a different planet in terms of what they think they can get away with.
 
Moonbeams said:
There is a huge difference between treating 10 patients at a rural center and treating 25 patients at a rural center.

The hospital doesn't care.

10 patients? You get 550k.
25 patients? You get 550k. Maybe a 50k production "bonus" if we are feeling generous.

That's the problem.

I had a salaried offer in Kansas at one point for 450k for a hospital employed position that supposedly generated 15,000 wRVU (which comes out to $30/wRVU). I politely declined although I was pretty annoyed to waste my time interviewing like that for what turned out to be clearly an absurd offer, The recruiter (who informed me numerous times she declined her med school acceptance to raise children) was offended that I would turn down what she considered such a high salary and asked what the comparable offers I had received were. I told her $70/wRVU. No further discussion ensued. This kind of stuff goes on all the the time with rural hospitals. They are living on a different planet in terms of what they think they can get away with.
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This kind of stuff is so important and I'm glad we are opening up the box here. The more information all of us have, the better we all will do.
People need to be encouraged to be open with their offers (within their networks) and make sure what they are getting is fair. It is so bad when people have no idea what good comps are.

There should be appraisals for job offers. I am happy to offer my services!
 
Moonbeams said:
There is a huge difference between treating 10 patients at a rural center and treating 25 patients at a rural center.

The hospital doesn't care.

10 patients? You get 550k.
25 patients? You get 550k. Maybe a 50k production "bonus" if we are feeling generous.

That's the problem.

I had a salaried offer in Kansas at one point for 450k for a hospital employed position that supposedly generated 15,000 wRVU (which comes out to $30/wRVU). I politely declined although I was pretty annoyed to waste my time interviewing like that for what turned out to be clearly an absurd offer, The recruiter (who informed me numerous times she declined her med school acceptance to raise children) was offended that I would turn down what she considered such a high salary and asked what the comparable offers I had received were. I told her $70/wRVU. No further discussion ensued. This kind of stuff goes on all the the time with rural hospitals. They are living on a different planet in terms of what they think they can get away with.
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Because clearly it’s about the recruiter and their personal life LOL. Should have asked what their life choices have to do with a ****ty offer?
 
RealSimulD said:
This kind of stuff is so important and I'm glad we are opening up the box here. The more information all of us have, the better we all will do.
People need to be encouraged to be open with their offers (within their networks) and make sure what they are getting is fair. It is so bad when people have no idea what good comps are.

There should be appraisals for job offers. I am happy to offer my services!
Click to expand...

You should rate locums too

Got an offer for 1200/day for a 25-30 on treat in upstate NY. With 3-5 new patients a day. Turned that one down.
 
jondunn said:


Interested in what people think about this - does 20 on treat translate to 750-800 in pro fees?
Click to expand...

This very much depends on the complexity of what you're treating, your fractionation patterns, and the payor mix. It can be as little as $450-$500k if you conventionally fractionate everyone and have a very poor payor mix doing low complexity (mostly palliative and 3D) cases vs. $1MM with an excellent payor mix treating predominantly hypofractionated IMRT courses. I believe that average payor mix, average fractionation, average complexity is probably closer to $700k for 20 on treat.

The impact of fractionation is important to consider when we use number on treatment as a metric, and it's not necessarily the most straightforward. Consider these simple scenarios:

You have two practices. Practice A hypofractionates everyone and practice B conventionally fractionates everyone.

Scenario 1: Each practice has 100 new starts, who has more in professional fees?
This one's easy, it's practice B because they are doing more professional billing per new patient start.

Scenario 2: Each practice has 10 patients on treatment at all times, who has more in professional fees?
It's actually practice A, because a large portion of professional fees comes from consult and treatment planning. Using breast as an example, a 3 week breast course yields about 28 wRVUs whereas a 6 week course yields about 38 wRVUs, so even though both practices have the same number on treatment, the practice that hypofractionates everyone is actually yielding about 35% more in professional billing.
 
Moonbeams said:
I had a salaried offer in Kansas at one point for 450k for a hospital employed position that supposedly generated 15,000 wRVU (which comes out to $30/wRVU). I politely declined although I was pretty annoyed to waste my time interviewing like that for what turned out to be clearly an absurd offer, The recruiter (who informed me numerous times she declined her med school acceptance to raise children) was offended that I would turn down what she considered such a high salary and asked what the comparable offers I had received were. I told her $70/wRVU. No further discussion ensued. This kind of stuff goes on all the the time with rural hospitals. They are living on a different planet in terms of what they think they can get away with.
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That's when they start sponsoring visas....
 
RSAOaky said:
Scenario 1: Each practice has 100 new starts, who has more in professional fees?
This one's easy, it's practice B because they are doing more professional billing per new patient start.

Scenario 2: Each practice has 10 patients on treatment at all times, who has more in professional fees?
It's actually practice A, because a large portion of professional fees comes from consult and treatment planning. Using breast as an example, a 3 week breast course yields about 28 wRVUs whereas a 6 week course yields about 38 wRVUs, so even though both practices have the same number on treatment, the practice that hypofractionates everyone is actually yielding about 35% more in professional billing.
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jondunn said:
another reason why new starts are more useful in terms of metrics (as compared to on beam)
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RSAOaky's examples are solid imho but...

New starts and on-beam are both equally important. One way or the other, on-beam numbers will always be an informative metric re: new starts, but new starts will also be informative of on-beam. And both combine for reimbursement. New starts is "space," on-beam is "time," and reimbursement is "spacetime."

In Scenario 1, both practices are seeing the same number of consults per year but practice A loses out because they hypofractionate and will have about half the on-beam numbers as practice B. (Using the aforementioned math and ratios, expect practice A to have 100-[100*135 / 200] 32.5% less reimbursement than practice B.)

In Scenario 2, practice A is by definition* now having to see twice the number of new consults/starts as practice B in order to maintain 10 under beam. But even though they're seeing 100% more patients than practice B, they're only benefitting w/ 35% increased reimbursement.

*if the avg number of fractions in practice A is 15 and in practice B 30, but both maintain 10 under beam, practice A has to see twice as many consults per week as practice B to maintain its 10 under beam. Specifically, practice A has to see 3.3 new patients per week (173 new pts/yr), and practice B must see 1.7 new patients per week (87 new pts/yr).
 
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TheWallnerus said:
RSAOaky's examples are solid imho but...

New starts and on-beam are both equally important. One way or the other, on-beam numbers will always be an informative metric re: new starts, but new starts will also be informative of on-beam. And both combine for reimbursement. New starts is "space," on-beam is "time," and reimbursement is "spacetime."

In Scenario 1, both practices are seeing the same number of consults per year but practice A loses out because they hypofractionate and will have about half the on-beam numbers as practice B. (Using the aforementioned math and ratios, expect practice A to have 100-[100*135 / 200] 32.5% less reimbursement than practice B.)

In Scenario 2, practice A is by definition* now having to see twice the number of new consults/starts as practice B in order to maintain 10 under beam. But even though they're seeing 100% more patients than practice B, they're only benefitting w/ 35% increased reimbursement.

*if the avg number of fractions in practice A is 15 and in practice B 30, but both maintain 10 under beam, practice A has to see twice as many consults per week as practice B to maintain its 10 under beam. Specifically, practice A has to see 3.3 new patients per week, and practice B must see 1.7 new patients per week.
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I absolutely agree with you. I posed the example in this way because the poster quoted asked if 20 on treat really translates into 750-850k and I just wanted to point the ways that professional billing can vary. We tend to use number on treatment as a metric for how busy a practice is but these aren't always apples to apples comparisons given how fractionation patterns now vary.
 
Moonbeams said:
I have been paid literally double that rate to babysit a linac before, see zero patients, sign off on documents, and leave at 3PM. That was a nice gig.
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The "really good" rad oncs want the locumses (locumsi?) to see zero new patients while they're away
 
fiji128 said:
Seems like a larger version of what is happening in rad onc with the same root cause. I know people who went to pharmacy school in the early 2000's and admission was at least somewhat rigorous. Now just about anyone with a pulse can get in. Greedy "academics" never seem to want to clean up the messes they create.

Years of Rampant Expansion Have Imposed Darwinian Survival-of-the-Fittest Conditions on US Pharmacy Schools

The number of applicants to US pharmacy schools has been declining since 2013, leading to a national enrollment crisis. Enrollment challenges threaten the viability of many pharmacy programs. Some schools are better equipped than others to confront the risk of having to downsize or close...
www.ajpe.org www.ajpe.org

"Unprecedented academic expansion left in its wake a new era in which the Academy is facing a severe enrollment crisis. The number of verified Pharmacy College Application Service (PharmCAS) applicants has decreased every year since 2013 when it peaked at 17,617. The number had fallen to 15,335 by 2019, and based on a June 2020 PharmCAS update, is poised to fall another 11.0% to about 14,000 during the 2019-2020 admission cycle, which constitutes a drop of 20% since 2017. The average enrollment of an entering class has dropped annually since 2012, from 124 to 102. According to an American Association of Colleges of Pharmacy (AACP) survey completed in March 2020, of the 134 respondent schools, 62% reported not being able to fill the entering class in 2019, with a mean of 15.6 unfilled seats. The Academy has reached an ominous point of critical mass, in which the number of applicants is barely equal to the number of available seats."

"Gone are the days of guaranteed full-time, high-paying positions for graduates straight out of pharmacy school. Many pharmacy graduates are faced with accepting part-time or per diem positions, reduced salaries, difficult working conditions, undesirable locations, and/or unemployment. It is no wonder that fewer students are choosing pharmacy as a career. The value is not what it used to be.

Some pharmacy leaders downplay the role of academic expansion as the primary cause of diminishing enrollment based on the premise that an unstable economy and fewer high school graduates are precipitating factors. However, such inferences are contradicted by the growing number of applicants to some other health profession programs. From 2002 to 2018, enrollment in medical schools increased 31%. Total enrollment of the first-year classes in colleges of osteopathic medicine grew 27% from 2013 to 2018."

"Many current faculty members occupy positions within pharmacy schools that would not exist had it not been for years of academic expansion. Between 2006 and 2018, the number of full-time pharmacy faculty members rose 60%, from 4,121 to 6,574"
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Glad this was mentioned on the bird as well
 
This is so spot on.

There are so many jobs posted like this routinely. From Avera, other places in MN, SD, Portsmouth, OH, the list goes on.. 600k with a large sign on but a penalty for leaving before several years of misery. W2 income and hospital employee status. There is no justification for these types of offers in those locations.
 
radoncle said:
This is so spot on.

There are so many jobs posted like this routinely. From Avera, other places in MN, SD, Portsmouth, OH, the list goes on.. 600k with a large sign on but a penalty for leaving before several years of misery. W2 income and hospital employee status. There is no justification for these types of offers in those locations.
Click to expand...

And all are symptoms of an oversupplied physician workforce.
 
radoncle said:
This is so spot on.

There are so many jobs posted like this routinely. From Avera, other places in MN, SD, Portsmouth, OH, the list goes on.. 600k with a large sign on but a penalty for leaving before several years of misery. W2 income and hospital employee status. There is no justification for these types of offers in those locations.
Click to expand...

I know someone who interviewed for one of the Avera jobs (there are multiple posted). They have somehow acquired rad onc staffing for a few rural hospitals in the area. The amount of WTF involved in the offer is too long to even list here. I can't imagine who actually ends up in the roles as a permanent hire when hospitals in marginally more populated areas are offering contracts with only a little bit of WTF and still can't fill for years.
 
Moonbeams said:
I know someone who interviewed for one of the Avera jobs (there are multiple posted). They have somehow acquired rad onc staffing for a few rural hospitals in the area. The amount of WTF involved in the offer is too long to even list here. I can't imagine who actually ends up in the roles as a permanent hire when hospitals in marginally more populated areas are offering contracts with only a little bit of WTF and still can't fill for years.
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rural places do some shady things. some places i interviewed at openly told me that they would have med onc NPs serve as coverage when i was on vacation. I noped out of that very quickly.
edit: I don't want to paint rural places with broad strokes. It is not their fault always. But yes, some places want to even avoid paying locums coverage if they can get away with it if they have a full time Rad Onc on staff.
 
radoncftw said:
rural places do some shady things. some places i interviewed at openly told me that they would have med onc NPs serve as coverage when i was on vacation. I noped out of that very quickly.
edit: I don't want to paint rural places with broad strokes. It is not their fault always. But yes, some places want to even avoid paying locums coverage if they can get away with it if they have a full time Rad Onc on staff.
Click to expand...

Yep. One of the Avera sites was trying to do that, among many, many other things. If they think that is acceptable as a cost saving measure, then basically any hair-brained unethical dangerous idea admin comes up with to save a few pennies is on the table. And they own you so you will do as you are told.
 
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