Rad Onc Twitter

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I told ya it was coming to IIIb! I’ll never forget the day I saw the surgeon’s googly eyes regarding immunotherapy and how “easy” the med onc claimed it would be. I knew from that day forward, IIIb’s we’re gone. A tear came out of my left eye, but no one cared.
 
RadOncDoc21 said:
I told ya it was coming to IIIb! I’ll never forget the day I saw the surgeon’s googly eyes regarding immunotherapy and how “easy” the med onc claimed it would be. I knew from that day forward, IIIb’s we’re gone. A tear came out of my left eye, but no one cared.
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Just saw a IIIB yesterday.... Scv and hilar involvement, not sure how a surgeon is ever going to take that out, IO or not
 
medgator said:
IIIB and IV were always in that category although some talked about "wet" IIIBs (i.e. those with a pleural effusion)
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Yes. Those were the only IIIBs I excluded from thinking about irradiating, and poor PS IIIBs. Otherwise like a Sith to a Jedi, Stage IIIB was the rad onc’s speciality. Not anymore! Palpatinamab would make a good name for an IO drug.
 
Honestly how many IIIB patients would both be willing and able to under go a major surgery? From the ones I see in my clinic, this can't be more then 20% of that patient population. Yes, I also realize this new operable IIIB thing being pushed is just another example of the further eroding away of our bread and butter cases.
 
I am not sure this is IIIb they’re gonna surgerize from the vignette; looks like systemic only

Of course systemic only was a thing in IIIb antecedent to the IO era, but now in the IO era it is being presented as the only option for good PS IIIB

Which is concerning to me and my linac who just gets lonelier every day!
 
TheWallnerus said:
I am not sure this is IIIb they’re gonna surgerize from the vignette; looks like systemic only

Of course systemic only was a thing in IIIb antecedent to the IO era, but now in the IO era it is being presented as the only option for good PS IIIB

Which is concerning to me and my linac who just gets lonelier every day!
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My Linac threatened to leave me this week.
 
CurbYourExpectations said:
I agree with all of this.

Devil's advocate: RadOncs are probably working fewer FTEs these days by choice. Still making good money. PP has similar issues in almost all fields. RO residency spots are decreasing (down to ~170 from 200+ a few years ago). A job market analysis is on the way. The ARRO data has many flaws. APM probably needs to happen in some way to get away from fractions.

Do we know anything about the job market analysis? How many RadOncs there are and their FTE? How many patients per RadOnc are needed (from what I've seen other countries are aiming for lowish 200s)?

If we do get to 6000 RadOncs or if we are already there somehow we would get down to around 180 patients per RadOnc... which is not great. Need to expand what we are doing.
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We are at about 180 now; of these, 120 de novo “in that year” diagnosed patients and 60 previous year diagnosed and/or repeat irradiation patients

The per linac per year average is between 200 and 250
 
CurbYourExpectations said:
180 total patients or 180 cancer patients?
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180 total patients

A very reasonable number for total number of irradiated patients per year in the US is 1.1m, and reasonable number for rad oncs is 5500... eventually soon 6000. The 1.1m was 1.2m 20y ago, so this number is very stable. There is literally no evidence or metric published in the last 10 years which would even hint at this number going up; a miasma of declining cancer incidence, changes in lung cancer stage landscape, prostate cancer management and diagnosis changes, inability of RT to gain traction in terms of overall total utilization... it all adds up to 1.1m being the number for the foreseeable future (or slightly declining).

1.1m / 5500 = 200
1.1m / 6000 = 183
 
TheWallnerus said:
180 total patients

A very reasonable number for total number of irradiated patients per year in the US is 1.1m, and reasonable number for rad oncs is 5500... eventually soon 6000. The 1.1m was 1.2m 20y ago, so this number is very stable. There is literally no evidence or metric published in the last 10 years which would even hint at this number going up; a miasma of declining cancer incidence, changes in lung cancer stage landscape, prostate cancer management and diagnosis changes, inability of RT to gain traction in terms of overall total utilization... it all adds up to 1.1m being the number for the foreseeable future (or slightly declining).

1.1m / 5500 = 200
1.1m / 6000 = 183
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I thin 5500 is way too conservative. For some reason, my best guess was 6500 by 2025, but dont remember the data.
 
CurbYourExpectations said:
Scarb would know best. Hard to know for sure. Probably around 4000 created from 1990-2020 through traditional route. Doesn't include people who have come from Canada. Doesn't include those that came from other countries and did an alternative path.

Approx 100 people retiring per year recently, approx 190 on average coming out since then. 6500 I don't think would be realistic, that would be approximately 165 people entering the workforce yearly in the past 40 years to make sense.

To reach 6500 RadOncs in the US you would need ~165 per year for 40 years if everyone was retiring at 40 years of work. Doesn't seem possible, but who knows, most of this is assumptions and utilizing data available.

Best guess right now is 5500, may reach 6000, but won't reach much higher.

Can't remember, may be making this up, but charges from Medicare may count you twice if you're traveling to do your work.
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If there were 5350 in 2017 and we create 200 a year, then 6500 is very reasonable. Disproportionate amount of radoncs created in last 20 years- baby boom of sorts, so percentage retiring per year is going to be less than other specialties.
 
TheWallnerus said:
We are at about 180 now; of these, 120 de novo “in that year” diagnosed patients and 60 previous year diagnosed and/or repeat irradiation patients

The per linac per year average is between 200 and 250
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Wallnerus,

What are you seeing the average PC collection per patient come out to be? I am told before my time this was typically $3500/patient.
180 patients now * $3500 = $630k collections.
300 patients before * $3500 = 1.05M collections

Big difference. You've tracked the data showing the change in the patient number, but would be curious if you have data on what your "$3500" number is and how this has changed over the years (due to fractionation, reimbursement, etc).
 
Moonbeams said:
Wallnerus,

What are you seeing the average PC collection per patient come out to be? I am told before my time this was typically $3500/patient.
180 patients now * $3500 = $630k collections.
300 patients before * $3500 = 1.05M collections

Big difference. You've tracked the data showing the change in the patient number, but would be curious if you have data on what your "$3500" number is and how this has changed over the years (due to fractionation, reimbursement, etc).
Click to expand...

$3500 = about $60 / RVU = 60 RVUs per case. A head and neck is about 75 RVUs. I am sure breast is substantially less.
I think this number must be lower per patient now. I don't know what it is.
 
RealSimulD said:
60 RVUs per case.
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This is significantly higher than what I saw when I was employed. My clinic did about 11k wRVU over 270 patients in a year, so about 41 wRVU per case. The hospital's total expense between me and part time locums was about $72/wRVU, so that comes out to about $3k/patient they paid out for physician expense. Unknown how much hospital was skimming off the actual PC. But I am also somewhat skeptical $3500 is an accurate ballpark now.
 
Moonbeams said:
This is significantly higher than what I saw when I was employed. My clinic did about 11k wRVU over 270 patients in a year, so about 41 wRVU per case. The hospital's total expense between me and part time locums was about $72/wRVU, so that comes out to about $3k/patient they paid out for physician expense. Unknown how much hospital was skimming off the actual PC. But I am also somewhat skeptical $3500 is an accurate ballpark now.
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Sorry - I meant that if you are saying $3500 and then using $60/RVU (what I've received over last several years). Not that an average patient. I would guess it is what you are saying - 40ish
 
Moonbeams said:
Wallnerus,

What are you seeing the average PC collection per patient come out to be? I am told before my time this was typically $3500/patient.
180 patients now * $3500 = $630k collections.
300 patients before * $3500 = 1.05M collections

Big difference. You've tracked the data showing the change in the patient number, but would be curious if you have data on what your "$3500" number is and how this has changed over the years (due to fractionation, reimbursement, etc).
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Find one of the APM papers where they “value” the professional per disease site.

That’s the best estimate of real world professional these days IMHO. Take the PC value and divide by 36 or so to get an RVU estimate

If you had a practice that was equally balanced between bone mets, lung, prostate, and breast, you would average 60 RVUs per patient.

image.jpg
 
CurbYourExpectations said:
Do you know the average RVU per RadOnc and average per RVU paid per RadOnc?
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The full picture is not known. However...

The avg number of RVUs paid by Medicare to each RO per year is 9700. But 50% of all ROs in the US get less than 4200 RVUs per year from Medicare.

The average Miami Heat salary is a lot higher than the median Miami Heat salary.
 
CurbYourExpectations said:
Medicare that is a portion of pay there is also Medicaid, private numbers. A lot of docs are not working full time. Everyone here is making good money. Who is making **** pay for what they are doing? Let's be honest, there's already a work force analysis going on.

@medgator @RickyScott @thesauce
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I think 20% of US rad oncs get awesome pay

60% are ok

20% get excremental pay
 
TheWallnerus said:
The full picture is not known. However...

The avg number of RVUs paid by Medicare to each RO per year is 9700. But 50% of all ROs in the US get less than 4200 RVUs per year from Medicare.

The average Miami Heat salary is a lot higher than the median Miami Heat salary.
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Does anyone have reliable information on the distribution of salaries in medicine or RadOnc in particular. Do we think it is close to normal or Pareto? Pareto is everywhere.
 
Chartreuse Wombat said:
Does anyone have reliable information on the distribution of salaries in medicine or RadOnc in particular. Do we think it is close to normal or Pareto? Pareto is everywhere.
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Answering my own question. I think I remembered reading this

www.wsj.com

Small Slice of Doctors Account for Big Chunk of Medicare Costs

A tiny sliver of doctors and other medical providers accounted for an outsize portion of Medicare's 2012 costs, according to an analysis of federal data that lays out details of physicians' billings.
www.wsj.com www.wsj.com

1657136336673.png


I acknowledge that this is at the height of Medicare reimbursement for RadOnc
 
CurbYourExpectations said:
Do you know the average RVU per RadOnc and average per RVU paid per RadOnc?

With these numbers and average income per RadOnc being what it is, I am having trouble understanding why residents have poor decision making going into this field.
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CurbYourExpectations said:
Medicare that is a portion of pay there is also Medicaid, private numbers. A lot of docs are not working full time. Everyone here is making good money. Who is making **** pay for what they are doing? Let's be honest, there's already a work force analysis going on.

@medgator @RickyScott @thesauce
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The size of the workforce is growing. That is an incontestable result of doubling resident numbers. We have had the largest/most extreme proportional increase in all of medicine.

Utilization/indications are Almost certainly shrinking, and faces qasi existential threats to the job market in the future.

Typical radonc job is now in the Midwest w/no geographic flexibility. primary care earns similar income in the locations that radonc jobs are now available.
 
CurbYourExpectations said:
You got into medicine in the golden years. Things have changed, RadOnc makes great money. I got gaslighted into this, happy to be proven wrong. Someone show me their **** pay.
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Definitely know some docs that are less than 5-7 years out making under $350k but almost all of them are working at NCI centers along the east coast. For now, most are still doing ok salary wise ($400-600k), until this year, geographic slim pickings though
 
Chartreuse Wombat said:
Answering my own question. I think I remembered reading this

www.wsj.com

Small Slice of Doctors Account for Big Chunk of Medicare Costs

A tiny sliver of doctors and other medical providers accounted for an outsize portion of Medicare's 2012 costs, according to an analysis of federal data that lays out details of physicians' billings.
www.wsj.com www.wsj.com

View attachment 356936

I acknowledge that this is at the height of Medicare reimbursement for RadOnc
Click to expand...

I may be wrong here but a lot of that data is due to a number of providers being listed as the doctor on the technical charges when billing globally. So it looks like the physician made all the technical revenue because his/her name is tagged to that reimbursement.

If they're pulling the data the same way pro publica did, then I 100% know for sure a lot of rad oncs listed as "paid to provider" were not seeing the money listed as going to him/her. I knew a guy at a rural center that did not own any equipment, he was on salary, but this data had him making like 3 million per year (he did not) because all the technical charges were tagged to him. Knew another proton doc listed as multiple millions...which he did not make.

I'd imagine some of phenomenon present in a varying degree for med oncs that have the chemo drugs billed under them.

I bet too a good chunk of that optho stuff is lucentis (eye bevacizumab) drug reimbursement.
 
CurbYourExpectations said:
It's crazy, it's almost like everything shows us making good pay, but millionaire docs want to anonymously say residents are *******es. Has got to be for the residents benefit right?
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I think your mind seems made up.

It’s not today. I.e. we are not complaining about the weather. It’s the future if no changes are made.

It’s fine right now.

Looking at the math, I don’t know how an objective and rational person can feel comfortable about the future.
 
RealSimulD said:
I think your mind seems made up.

It’s not today. I.e. we are not complaining about the weather. It’s the future if no changes are made.

It’s fine right now.

Looking at the math, I don’t know how an objective and rational person can feel comfortable about the future.
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If I said to a person considering entering the bakery business

- price per loaf is falling
- carb lite eating is decreasing demand for bread
- some bakeries are trying to see if instead of sandwiches with bread, they can just put the ingredients in a bowl, and focus groups show people like them as much or better than sandwiches
- the number of baking schools nearly doubled, without any actual shortage conditions
- Subway and Jersey Mike’s are buying up all the bakeries, and employing the owners at lower pay
- studies showing 3/4 of loaf makes people slightly less happy but does not make them suicidal, so 3/4 loaf is now considered a full loaf

If someone knows this and still wants to go into bread business, that’s fine. But, a lot of people would wonder …
 
OpusRadoncum said:
Since "academic" places like Northwell aren't adjusting and still continue to take folks in the SOAP, what are your thoughts on "blacklisting" programs that SOAP and not hiring ANY residents from those programs? Those in hiring positions (medical directors, partners, etc.) would have to be vocal and take a stand to make it known to students that it isn't worth going to those programs for that reason alone.
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The hellpits that took warm bodies and continue to graduate them and the “leaders” at these places need to be held accountable. The residents matching there might have questionable judgement but i do not think the right to do is to hurt them professionally
 
Chartreuse Wombat said:
Answering my own question. I think I remembered reading this

www.wsj.com

Small Slice of Doctors Account for Big Chunk of Medicare Costs

A tiny sliver of doctors and other medical providers accounted for an outsize portion of Medicare's 2012 costs, according to an analysis of federal data that lays out details of physicians' billings.
www.wsj.com www.wsj.com

View attachment 356936

I acknowledge that this is at the height of Medicare reimbursement for RadOnc
Click to expand...
362K per rad onc in 2012

Some guy on the internet and twitter independently calculated and showed 335K per rad onc in 2019 (statistically, given the N, a 362K to 335K drop would be p<0.0001)… with proton MDs filling the upper echelons and about one third of all rad oncs getting less than 100K per year from Medicare. Just these numbers alone don’t tell whole picture; just like in lung cancer staging incidence, the dynamics of rad onc reimbursement are rapidly shifting with pronounced regression to the median. It should be noted that this is a classic sign of oversupply of labor or a product etc. Exclusivity becomes fungibility.

 
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CurbYourExpectations said:
Confirmed to be independent radoncs or were radoncs counted multiple times through billing? I think we all can look at those numbers and know they don't make sense from a smell test.
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They don’t make sense on the low side, not the high side. Every counting of practicing MDs done away from the Medicare database always counts more rad oncs than Medicare counts. It’s not a lot, but it’s not zero differential (eg Mudit C counted 5350 rad oncs in 2017, Medicare had about 4585). And there is a raft of rad oncs in the Medicare rolls who get very little from Medicare. Every row in the spreadsheet is a unique name. If any of the rows account for more than one MD entity, all the medians, means, etc calculated above are too high… not too low. That the avg rad onc gets 335K a year from Medicare and that 50% get less than $150K are “best case.”

What does pass smell test? That someone independently calculated 356K per rad onc in 2012 and someone else calculated 335K per rad onc in 2019. We all know and are aware of the plethora of reasons the average reimbursement per rad onc should be falling. *Even if* the calculations are individually incorrect, they appear proportionately correct.
 
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CurbYourExpectations said:
Completely agree RadOnc is worse than it used to be. Bring up these numbers to 75% of other specialties.

RadOncs make 350k starting working ~4 days a week. Make more at 5 years... and have a good and rewarding job.
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You're allowed to bring up those numbers to 75% of other specialties if it's also thrown in that:

1. You usually cannot choose the state in which you practice
2. If you lose your job, you most likely have to move yourself and your family far away to get another one
3. Taking vacation/time off is more difficult compared to other specialties
4. Option for part-time work- which is done very frequently in peds for example- is not there
 
CurbYourExpectations said:
Completely agree RadOnc is worse than it used to be. Bring up these numbers to 75% of other specialties.

RadOncs make 350k starting working ~4 days a week. Make more at 5 years... and have a good and rewarding job.

The oversupply is true, changes are being made. Numbers won't matter anymore, there will (hopefully) be very well vetted numbers soon which none of us will have control over. No use in perpetuating this.

(cut forward to me in 20 years unemployed and homeless...)
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Fine. I guess?

It’s a “tragedy” that 20 years ago the top residents would not accept starting offers less than 500K, and today….

Well. Tragedy is a bit hyperbole. Still. It was a downfall that enriched few and disenfranchised many.
 
CurbYourExpectations said:
Agreed, don't go into RadOnc if you need to work in a very specific area. Same can be said about a lot of specialties.
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Like? I was going to say path, but right now they actually have more demand in my neck of the woods than we do. Nuclear med maybe but that specialty is pretty much a dead man walking anyways.

I would say rad onc has the worst geographic availability for jobs out of any of the medical specialties out there outside of maybe EM
 
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CurbYourExpectations said:
No, I think you and Scarb are doing it correctly. ESE probably doing it the correctliest. I do not agree with treating people like they are inferior for thinking 400k treating cancer in a suburb is a bad move.
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ESE is also confused, because I can't figure out exactly how you guys are disagreeing, because I think we're all on the same page? Perhaps my brain is gummed up with moldy Wonder Bread.

Regardless, from what I think this conversation is about...I believe this is the "next big hurdle", as it were.

You'd be hard-pressed to find people outright denying the math doesn't add up now. It's a shame it took so long to happen (considering Ben Smith's "we're headed to an oversupply" paper was published in 2016). But, since an army of residents is financially beneficial to institutions, I can't say I'm surprised.

If someone were to come to me tomorrow and offer me a suburban RadOnc job for $400k a year, I would definitely be interested. My concerns about this being our future:

1) I happen to like the suburbs, but I know not everyone does.
2) So, if I don't want to be in the location of this particular job, can I take the same job but put it in a downtown metro area? A rural farmland?
3) Is this a 4/day a week with 15 on beam sort of job? Or 5/day a week with 40?
4) Is this both my salary floor and ceiling? Or can I make more with a bonus structure, or make less with an "at risk" structure?

Obviously, I could go on.

I just keep going back to the "golden handcuffs" thing. I think a lot of people would agree $400k for a 4/day a week, 10-15 on beam, 8 weeks of vacation a year job is pretty attractive. But once you get this job, is that "it"? Meaning, what if the job is 2,000 miles from your family, and your parents get sick and you want to be closer to home to help take care of them, but there's not any jobs within 300 square miles of your family? What if it starts as 3-4 days a week, 10 on beam, and a few years later it's 5 days a week with 40 on beam?

"Did you exchange a walk-on part in the war, for a lead role in a cage?"
 
medgator said:
Like? I was going to say path, but right now they actually have more demand in my neck of the woods than we do. Nuclear med maybe but that specialty is pretty much a dead man walking anyways.

I would say rad onc has the worst geographic availability for jobs out of any of the medical specialties out there outside of maybe EM
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CT surg?
 
CurbYourExpectations said:
Highly sought after areas are worse for all specialties job wise. RadOnc job market isn't good, but not as bad as some are painting it out to be, that is all I am saying. Transparency and balance.
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Again, not seeing it... Plenty of demand in many metros for rads, ent, gu, derm, psych etc. Gas path em and rad onc seem more tight
 
CurbYourExpectations said:
I agree, you should hire more. Just kidding, but all of them require more doctors per square area, so you will see more demand no matter what. Again, I agree RadOnc is below where it should be relatively, but will hopefully improve by decreasing spots and increasing what we are willing to do.
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Why should i hire to fix overtraining that didn't exist when i graduated? Demand for our services hasn't exactly gone up during that decade of expansion. Quite the opposite really.
 
I too agree with Larry that the hyperbole doesn’t help. The prediction that it will get bad is sound and based on good data.

To say it’s terrible today? Maybe for some, but many people still earning a lot of money for a 40 hour work week. We need to do all we can to preserve this
 
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