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I didn't see mroga's full tweet as I don't have Twitter. Just the screen shot. Who brought up img's?
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Re: insurance company stuff.
I am increasingly alarmed, watching what is happening around me, about how we're being manipulated. By "we" I mean anyone working in a healthcare system, not just RadOnc, not just doctors.
OBVIOUSLY this isn't a novel thing for me to say. But specifically, it's the sheer number of our colleagues that have internalized "the system" which I find alarming. They recoil if you talk about money/reimbursement/anything of that nature. The messaging has been so persistent and thorough in our education, training, and practice that people have erected mental firewalls around economic/structural issues in medicine. So many people base their worldview around "clinical practice of medicine good, any other way of making a living by being a doctor is neutral-to-evil".
If someone thinks "being a good doctor" is grounded in being a fundamentally positive force for society, they need to realize that being a good steward of "the system" is intimately connected. You don't get to walk around believing your hands are clean because you, personally, don't know what the CPT-to-wRVU conversion is at your hospital, even though it's tied to your bonus. Beating the drum of "20 fractions is better than 44 fractions" on Twitter or in the Red Journal is not actually helping when 20 fractions at Anderson can cost 5x what 44 fractions cost elsewhere.
For the kids in the back: thinking about the financial side of practicing medicine in America DOES NOT make you a bad person. It's like teaching med students how to tell someone they have cancer. You didn't give that person cancer. They will have cancer regardless. You don't have magical powers to speak it into existence.
So learning and understanding how the system works "behind the scenes" is an important part of our role in society. Why are there even jobs at these giant insurance companies for doctors in the first place? How did we get here? Why would doctors (or nurses etc) go work there? I'm sure there are amoral psychopaths who will do anything for money, but they're in the minority.
I'm basically writing this to say: we, collectively, need to do a better job of not walling ourselves off from how the sausage is made. Because at some point, getting tunnel vision over 5 fraction vs 3 fraction SBRT but not knowing the difference in reimbursement between 99203 and 99205 because you find it "distasteful" becomes harmful to patients via unforeseen forces.
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Spot on.... Fraction shaming has always been in vogue, now it is creeping onwards to modality shaming as the MR Linac and particle therapy folks continue to push new data-free agendas.
Costs never come into the picture.. in fact ASTRO never brought up costs or utilizing cheaper sites of service during the "choosing wisely" campaign they put out (iirc, they put at least 2 lists out over the years). Yet as we both know, it's always been about the prices.
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I see a similar problem in my separate but related field. I have always been interested in the money side, but it has astounded me across both private practice and academics how many people don’t even understand the simplest thing of CPT to RVU for how Medicare reimburses. Much less the concept of collections.
It’s insane.
But I also echo the non stop gaslighting during medical school about how “we aren’t in it for the money” and “those guys sold out” or “are unethical”.
We had zero exposure to private practice during my Med school rotations.
20-30 years of this cultural inculcation plus calculated removal of private practice exposure and of course new graduates won’t have any idea of how the world works.
Dentistry and Optometry are not like this.
In other fields of medicine (mostly psychiatry in my experience) academic attendings are actually part time and have a private practice on the side. I have seen rare orthopedists and neurosurgeons who refused to join their physician organizations when founded, remaining independent and just keeping privileges as a grandfathered status. I can’t imagine someone getting privileges now at the academic places.
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This is a very insightful and important point that I wanted to emphasize. Faculty at MDACC and MSKCC satellites can't simply wash their hands of responsibility by saying "I'm salaried, so I don't care." You guys are what makes it possible for rampant "big Rad Onc" expansion which is driving up the cost of care for everyone.
Having someone from one of these mega academic centers study financial toxicity is like Bernie Madoff running a seminar on ethical investing.
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right, there's toxicity to not billing enough as well. As in, the Chief X Officers get upset collections aren't adequately covering expenses, they flex the hourly workers (therapists) in your small town who already could make twice as much locumsing, who then leave and can't be replaced, etc etc.
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Perhaps they are just proponents of the Cloward-Piven Strategy.
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Same issues for us in free standing. Not just a worry for hospital admins
Not quite. No assistant prof at MSKCC is responsible for over expansion. That is, frankly, a little silly assertion.
Bernie Madoff? Maybe the guy in Madoff’s mailroom
Should they not have taken the job… out of some sense of honor to the PP folks who were bought out some years ago? I don’t know about you, but my family comes first
“Sure, I need to find a job in city X, and my family has bills to pay… but it just wouldn’t be right” Nope.
Everyone always thinks the OTHER GUY should fall on his sword.
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Not just expansion but this idea of focusing on fractions rather than actual cost or the data behind more expensive treatment modalities. Expansion is part of it but when you see a certain msk professor focusing on parking charges and missing the forest for the trees, and then another one telling us they will still always use protons, data be damned, well you get my drift.
Expansion does likely drive over utilization as well, but that's a separate issue.
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Do you mean this assistant professor
Dr. Chino is quite even-handed in her critiques of financial toxicity… I know her well and her passionate interest in this topic is as honest as it gets.
Not really sure what she -or anyone else in her position- is supposed to be doing differently.
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The road to hell is paved with good intentions . . .
Everybody is out for #1 - can't argue with that. However, if your employer is the cause of the problem then you have no moral authority over the rest of us. What I know is that my reimbursement is probably < 10% of what "big Rad Onc" charges yet I am subject to the same costs (labor, equipment) as they are.
While that may be true, I am sure you still make more than Dr. Chino or myself.
So would you be willing take a pay cut -you know, to help out the system?
Every little bit helps… and brining down costs is the right thing to do.
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I wouldn’t disparage a doc for working at either a high cost nci center or evercore. Could easily have been me. I do take issue with fraction/modality shaming or sh-t on those who work for evercore. I think it is a hundred times more important to address high prices of large centers than fixing prior auth. In fact, if a course of 3d or imrt xrt is over 100k, how should it not be subject to prior auth/review?
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That wouldn't fix the system at all, talk about a red herring!
How is cutting the reimbursement to a freestanding doc (operating what is likely the low-cost practice in a given area) going to address the fact that Mayo, Anderson and msk are charging and collecting multiples of what any freestanding center charges and collects?
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Actually pay cut for freestanding docs in a normal market would drive more of them to work for those centers, worsening the problem.
Can’t say I disagree. I tend to prefer arguing for or against ideas rather than for or against people. If hypofx is known to have a better outcome (e.g. SBRT vs conv for early stage NSCLC), then I would push for hypofx. With breast and prostate, I less of an issue.
I feel badly for the docs who work for evicore… because I would hate it.
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Thanks to expansion, Optum and evilcore are the only things left available for some docs since we have little bargaining power as a specialty at this point.
What happens when you get terminated from your big health system/practice and the non compete is so big and ridiculous you have no other viable job to commute to? Can't just take your kids out of school, uproot your social network, stop taking care of nearby family members etc.
So what do you do?
Yep, WFH and make 6 figures helping out the bad guys screw the rest of us
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Of course it is a red herring. That’s the point!
Going after Dr. Chino (whom has actually published on PPS centers charging more)… because of where she works, is a red herring as well.
It always strikes me as silly when someone is ridiculed because they aren’t enough of a zealot for the critic’s cause. Perhaps Dr. Chino should simply quit?? Or maybe she should await input from SDN on which topic she should publish her next manuscript
Alternatively, if folks here feel passionately about these issues, maybe they write their own papers… rather than the hand wringing.
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It's probably universal, but especially in America, the path to becoming a doctor seems to make it very difficult to separate who we are as people and what we do for work. No single person can fix the system, no one should be falling on swords. If you're under 50 years old, this is something you inherited, not something you created.
People will use a tremendous amount of intellect and logic to debate the most trivial aspects of a random breast cancer trial because it's abstract. As soon as the topic turns "meta-RadOnc", to our jobs and our paychecks and our lives, it short-circuits critical thought and becomes "an attack" and hackles are raised.
While I don't always agree with her conclusions, I find Fumiko admirable. She shouldn't do anything differently. What the rest of us can do is just talk about the economics of medicine without taking it personally. I think this is incredibly challenging for 90% of doctors. Maybe more.
I talk about healthcare financials all the time and I still feel bad/shame when I do. Because that's "how I was raised"; that saving lives is only pure when you consider it in a vacuum. But I deeply believe it is irresponsible of me to ignore economics, even though I want to. I would rather be off reading the Wheel of Time series for the 7th time than typing on SDN right now.
If we all openly talked about meta-medicine with the same critical thought we use to eviscerate an NCDB paper, and minimize taking things personally or throwing stones ourselves, that would go a long, long way towards caring for our patients on a societal level.
We are all part of a broken system… and that broken system puts food on our tables.
It’s an impossible conflict of interest
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I know this has been said before, but it truly is the most insidious part of oversupply. I know of 2 moms working for evercore because they can’t move, both grads of top programs.
I know this was addressed to @Gfunk6 but it’s so wrong-headed. Maybe it was a joke, not sure.
It does not matter whether the mskcc radiation oncologist is less compensated than the private practice doc. Not least because doctor pay is not why healthcare is incredibly expensive in the country, as doc pay has been stagnant or declining for decades, and is 7.5% of healthcare spending (Kaiser Family Foundation). To suggest that rad oncs are overpaid and the cause of high costs of cancer care is just ridiculous.
What matters is what the organization charges (“costs to the system”) and what the patient is charged. If a private practice doc can provide the same or better service than NCI center, at much lower cost to the system and the patient, who gives a **** whether the private practice doc is raking it in?
I understand that the 50 NCI centers are supposed to use their higher pay rates to, you know, advance the field but are they doing that? Separate issue, but I would argue no, totally tone deaf in their mission to educate (no standards, case requirements a joke, incredible variation in training quality across residency programs, overtraining). Most advances off top of my head are not even from nci centers, apbi breast (Europe), tnt rectum (Europe), oligomet (Canada), induction for NPX (China), prostate stampede (UK), cervix brachy (europe), but probably nci centers record for research better than their record on education, which is abysmal.
For any organization outside healthcare, no one wrings their hands over the pay of the knowledge workers at their core. Netflix, when it undercut cable TV $60/month with its $15/month subscription, did its customers lost sleep over how Netflix software engineers are very highly paid? No! That’s not the point dude.
I would say the best & healthiest organizations are product centric and customer centric. Not engaged in pointless virtue signaling.
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@Gfunk6 was one of the first people on this forum to give me advice, some 10+ years ago. Hearing him comment on various disease processes, he sounds like a thoughtful oncologist, and his patients are lucky to have him. I am sure he earns every penny and I don't actually think he should take a pay cut. My comment was an intentional red herring, as an instructive comparison to blaming Dr. Chino for her employers' business decisions.
I don't agree with every single thing my department, division or hospital prioritizes. In fact, I spend a good amount of time advocating for my patients, trying to help them avoid the pitfalls in the system, speaking forcefully to people several rungs above me. Should I quit... or continue to fight like hell (when the situation calls for it)?
To argue that Dr. Chino shouldn't publish on financial toxicity because her boss overcharges insurance companies is... silly. It's a red herring. It's blaming one of the good guys for the actions of the bad guys... so should she quit, or fight like hell?
To be honest, Fumiko has been a good friend of mine for years (which may be why I have had a bit of a reaction to everyone's posts about this). I assure you, she's the real deal. She's the sort of person who can actually do some good to improve the system
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I had colleagues in (American) Med school who were “fluent” in English, more then enough to pass all tests, but struggled with communication with patients due to accent, vocabulary etc. Since much of medicine is communication they are less effective doctors for it and it is not racist to say so. My left leaning family will intentionally seek out US native doctors for that reason as their experiences with IMGs have not left favorable impressions. Fair? Of course not. But it is reality.
I strongly feel I am a less effective doctor when treating patients through an interpreter or with a patient who speaks English but with limited comprehension despite my best efforts. I obviously will give them the best treatment I can, but the “best” treatment is patient-centered, which suffers as communication does.
@Lamount
Understood. Definitely understand there are a lot of good people who work for the big academic centers, both great at what they do and good at heart. You included!
Obviously I don’t agree with some of what’s resulted from big RO actions, but academic/organizational power very concentrated at top. Probably most early/mid-career academic docs in same boat as community docs.
Understood. Definitely understand there are a lot of good people who work for the big academic centers, both great at what they do and good at heart. You included!
Obviously I don’t agree with some of what’s resulted from big RO actions, but academic/organizational power very concentrated at top. Probably most early/mid-career academic docs in same boat as community docs.
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Yeeeeah.
I'm sure our NCI crew did some stuff too, right?
[editor's note: 5 minutes after starting this post]
So I was about to make a joke about the "same day" palliative radiation stuff, because it's something I know many community docs do without publishing it, but when I went to go grab the link to one of the papers...everything that came up was from Canada, New Zealand, and Australia.
So instead, here's a neat paper from 1962:
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In our particular field, I don't believe that our weird, perverse market model, where the MSKCCs and Harvards and Hopkins are valued much more than community medicine, and where there are 60+ academic centers, yields results. You don't need massive diversity in investigator investigated trials to figure out the best indications and methods of implementation for XRT. You need enrollment in big trials. I suspect this is also true of surgery. Do we really think Japan/Korea/China aren't ahead of us regarding both thoracic and GI-onc surgery?
For general health outcomes, we pay double for inferior or equal outcomes. This is well characterized. Probably some of this is due to wealth disparity alone in our country. But, it's not clear to me that all those academic public health schools are worth a damn. They should all just be screaming "single payor!!" and switch to nursing.
For our crazy pharma spending, we get proportionate results.
US Pharmaceutical Innovation in an International Context - PMC
Objectives. We explored whether the United States, which does not regulate pharmaceutical prices, is responsible for the development of a disproportionate share of the new molecular entities (NMEs; a drug that does not contain an active moiety ...
www.ncbi.nlm.nih.gov
But all of our inefficiencies give us jobs. They also let niche medicine thrive and do heroic things.
I have heard that there is no fetal surgery in Sweden.
I like my community pay. But if I were subject to a national initiative, where all docs became federal employees, had all educational debt forgiven, and were all paid between 240K and 350K with a guaranteed upper middle class pension that kicks in at age 60 or 65, I would be fine and I would encourage my kids to consider the field.
But damn, that APM model that almost went through was the worst of all worlds. Was going to make PPS exempt academic types seem like corrupt Eastern Bloc bureaucrats to this lefty.
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To provide context, some of the preliminary practice changing work was done in the United States, ie., commercial-led APBI catheter based brachytherapy, Memorial Sloan Kettering rectal TNT, oligometastases (Weichselbaum, University of Rochester) whereas the confirmatory studies were done elsewhere simply because socialized healthcare may allow for more efficient trial accrual due to aggregating patients as opposed to the highly fragmented, competitive nature of US oncology. So despite our structural limitations, we are not a complete zero.
Obviously STAMPEDE was enabled by the UK Clinical Oncology model where prostate radiation oncologists also administered systemic therapy thus had more control and access to stage IV prostate patients not possible in the US. On the other hand, the lack of progress by "elite" US brachytherapy programs relative to Europe speaks to the failures of the NCI funded programs and this shows that their higher costs are not resulting in more innovation or better outcomes. They do produce very impressive virtue signaling and stunning overtraining.
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Admittedly, Memorial has impacted my practice significantly recently. Both TNT for rectal and oligoprogressive lung SBRT. Also impacted my thinking regarding MSI high rectal CA.
All within past couple years.
Also like their investment in really understanding metastases in solid tumors from a basic science standpoint.
Truth hurts.
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Obviously, to claim no major American RadOnc department has done anything of note in the past 20 years is painting with a comical brush.
To be more genuine: you would expect, after two decades of taking some of the "best" medical students from each class, ~20% having a PhD to boot, that there would be something more tangible to "show" for all that acquisition of talent.
I don't think RadOnc would look any different today if, instead of Matching an army of AOA/20+ publication "paper tigers", we had exclusively Matched people who had failed their first attempt at Step 1.
While exams and grades are pretty weak barometers of "skill as a physician", there was a whole narrative built around the "caliber" of student being granted admission to the Magic Walled Garden Club of Ionizing Wizards...
...and instead, it feels like we Matched into Theranos.
To be more genuine: you would expect, after two decades of taking some of the "best" medical students from each class, ~20% having a PhD to boot, that there would be something more tangible to "show" for all that acquisition of talent.
I don't think RadOnc would look any different today if, instead of Matching an army of AOA/20+ publication "paper tigers", we had exclusively Matched people who had failed their first attempt at Step 1.
While exams and grades are pretty weak barometers of "skill as a physician", there was a whole narrative built around the "caliber" of student being granted admission to the Magic Walled Garden Club of Ionizing Wizards...
...and instead, it feels like we Matched into Theranos.
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and now there is for other fields that have become competitive. it's a shell game. some rise, some fall
we all know there's no inherent importance to this. sometime rad oncs who matched in the 'golden era' like to continue to feel like they were better because it must have mattered, but it doesnt, it never has.
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What JD doesn't realize is that the shell game cycle for rad onc is likely over. Not it'll just be secular decline/stagnation.
Our bread and butter in a lot of cases has been reduced from 30-40 fx down to 5-20 and, in many cases, zero. The field is pushing more expensive tech and radiopharm that is the purview of "big rad onc"
No IMRT to save us this time either.
Our bread and butter in a lot of cases has been reduced from 30-40 fx down to 5-20 and, in many cases, zero. The field is pushing more expensive tech and radiopharm that is the purview of "big rad onc"
No IMRT to save us this time either.
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I think it's what is actually out there to discover. Right now, with the tools that are present for this generation, the paradigm changes and associated discoveries are elsewhere (personalized molecular medicine, immuno-oncology, epigenetics). There may be some big paradigm changing physical oncology discovery around the corner, but none of us will see it coming. (We need @TheWallnerus to find the most appropriate Thomas Kuhn's quote for this).
Happens in all fields. To an outsider (me), particle physics had a golden age from 1920s through 1960s. Not so much from 1980s to present. Plenty of smart kids have always gone into the field. It's just that the prior paradigm change has born it's fruit and nothing comparable (string theory or other) has come along.
Some people believe particle therapy is that paradigm change for us.
Top quark in 1990s... Higgs boson in 2012
I also think they deserve some credit for building a machine that is one of the only places in the solar system capable of attaining temperatures similar to a fraction-of-a-second after the big bang
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Predicted in 1973 and 1964 respectively. These experiments are hard though.
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I know next to nothing about particle physics but have heard tcriticisms that it is stagnant. Sounds like they were almost completely certain (like with black holes) the Higgs existed whether or not they could find it at cern. I think they were really hoping find evidence of string theory/super symmetry which they they did not.
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I heard that AI has predicted the structure (I'm guessing tertiary?) of every known protein. I mean WTF. This is the substrate for mad applied science advancements (see molecular medicine).
IMRT was somebody very smartly applying exponentially increasing computational power to a linac with an MLC in my opinion. Again all those calcs in a second were mind blowing at the time.
I know where I think the smart money is going forward.
IMRT was somebody very smartly applying exponentially increasing computational power to a linac with an MLC in my opinion. Again all those calcs in a second were mind blowing at the time.
I know where I think the smart money is going forward.
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The increased computation power was there, for sure. But there was also a fascinating, and pernicious at that time, "luddite-ism" in rad onc that was anti-innovation. E.g., Halperin was very against IMRT in its early days.
So, that "somebody" was a neurosurgeon. The ratio of of his contributions to rad onc versus how much rad oncs mention him or laud him is almost infinity!
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There aren't enough quality jobs out there for all the rad oncs. Someone is going to end up working those satellite jobs.
It would be great if there was a demand for rad oncs out there, so low quality positions either had to shape up or never fill. That is a fantasy.
In the end we all end up fighting for volume.
For employed rad oncs it's just a matter of who gives the better deal. Someone is always going to be skimming off the top of what I do.
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No one who works for MDACC is MSKCC is "corrupt," although Ben Smith/aileen chenn are beyong hypocritical. In terms of overall utility, a strong case can be made that those who work for evercore are doing more good/less harm than those who work for large centers. ie if one attaches 200k to a year of life (50k/year was commonly used by economists and ethicists when I was in medical school), then every 200k these docs overcharge the system, they are knocking off a year of life somewhere. So yes, those who get up and go to work for evercore are making the world better/less bad each day than those who work for some of these large centers under a utilitiarian framework. Certainly, utilitarianism would hold that those who treat prostates with protons are making the world a worse place.
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Cocaine is a hell of a drug
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For those of you who are having a hard time following this conversation, please see the "Great Circle of Life in Rad Onc"
Moral of the story? We are all screwed. All we can do is finger point each other into oblivion.
Moral of the story? We are all screwed. All we can do is finger point each other into oblivion.
