Rad Onc Twitter

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medgator said:
Which kinda makes you wonder why it was posted in this thread in the first place đź’ˇ
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Yeah fair enough but I do think it is worth pointing out because nobody on twitter apparently looked at it, and it is a good lesson in "never let someone else tell you what you're worth without double checking their claim" which applies to any specialty.

Edit: I will admit I was surprised that Heme/Onc was not on there and that is why I looked into it. I don't think we're actually top 5 (and we weren't) but to say we had dropped below OB/Gyn or FP did not pass the smell test
 
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I rem
RealSimulD said:
I know people think of me being a MDACC/Ben Smith apologist, but let's at least attempt objectivity - nobody batted an eye in 2010. We certainly know that everybody likes a villain. The stuff with that department pushing out of town visitors to get treatment in Houston is icky. Saying that @OTN can't handle left sided breast treatment is reprehensible (I have no reason to believe he would make this up). Etc. etc. But, in 2009-2010, things were looking good. Whoever graduated around that time and stayed in community practice is probably still doing pretty well (I would say I'm in that group).

I graduated that year. We read it in the resident's office. It made sense to us, from what we saw in clinic. Even after 2004 CALGB publication, omission was quite uncommon. I presented Whelan at our faculty meeting as a resident and the vast majority of staff were not comfortable with 16 Fx treatment. Everyone (>99% of patients) were still giving 44 fx for prostate (even after 28 fx was shown to be a potential option; I think @Gfunk6 was one of the earlier adopters in my orbit). Many centers could not see patients fast enough and centers were opening up like crazy. People were doing very well and there was no thought that the bottom was going to fall out.

Not one person said anything at the time. "Anonymous" people on Twitter keep saying "we knew it, we knew it". Did you? Why would you hold back this information? If you had such certainty about this, why not post? I've been on SDN since undergrad probably. So have many other posters. They just forgot to say "The world is actually burning, Ben has it wrong"? We talk about everything important in RO here, but just ignored that completely?

Hypo, surveillance, omission, consolidation - we all knew this was possible, but based on clinical practice at the time, not a soul pushed back on the paper. In the last 6-8 years, history has been revised that "Everyone knew there was an issue, what a flawed article, blah blah blah, Ben Smith ruined the world and made airline travel, terrible, too!" Come on - look at the threads from 2010 here - we saw a lot coming, but no one said anything at the time of the publication of how bad it could even potentially get.

I will concede: in retrospect, that article had many flaws that no one pointed out and at the end of the day was WILDLY incorrect.

Yet, nobody published a rebuttal or a re-do - except ... the author himself in 2016. OOPS. We can't get people to admit they are full of **** on this forum when they make an error or a lie (even when caught). He publicly says, "I bungled this - we really need to re-evaluate". Yes, this is of little value to many of you and that's fine. But, think about what it takes to do that. What would be the motivation to correct an error? Nobody does that in this day and age.

It is very easy to play Monday Morning Quarterback, 5 years after the game, after you studied the tapes and media reports and interviewed the players.

HOT TAKE: Prediction of past events has high likelihood of accuracy.
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I remember very well when this paper was published. I was applying to residency at the time and a department chair passed the paper to me saying that the field will be increasing the number of training positions in future cycles. When I first read the paper my impression was wow there are about 10 assumption being made to arrive at what was probably a predetermined conclusion. All these programs were just itching to increase resident compliment and this paper gave them the justification to really go for it. I remember going to Astro around these years and hearing the worst possible thing for the specialty would be if there was a radiation center somewhere that was un or understaffed because we weren't training enough docs. Avoiding this was more important then the possibility of a physician oversupply. Astro and the academic echo chambers that control the training pipeline were all in with this type of thinking. Of course they got it dead wrong. I would guess probably >60% of "leadership" still maintain there is no oversupply issue and the real problem is with comments being made on the internet that they have no control over.
 
fiji128 said:
I rem

I remember very well when this paper was published. I was applying to residency at the time and a department chair passed the paper to me saying that the field will be increasing the number of training positions in future cycles. When I first read the paper my impression was wow there are about 10 assumption being made to arrive at what was probably a predetermined conclusion. All these programs were just itching to increase resident compliment and this paper gave them the justification to really go for it. I remember going to Astro around these years and hearing the worst possible thing for the specialty would be if there was a radiation center somewhere that was un or understaffed because we weren't training enough docs. Avoiding this was more important then the possibility of a physician oversupply. Astro and the academic echo chambers that control the training pipeline were all in with this type of thinking. Of course they got it dead wrong. I would guess probably >60% of "leadership" still maintain there is no oversupply issue and the real problem is with comments being made on the internet that they have no control over.
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The level of press given to Smith-1 was the level of press being given to the Trump Mar A Lago raid right now. Level of press given to Smith-2 equivalent to level of press given to that time a dog bit a postman.
 
HemeOncHopeful19 said:
Sorry I realize this is a relatively old post in the thread but I did not think it made much sense so I looked into it more.

It appears to most definitely NOT be a list of the "top 5 specialties by revenue generated" although I could see how someone would get that impression. It appears to be a random sampling of 5 specialties as far as I can tell and it is not very clearly worded in the report.

Rad Onc isn't on there of course.
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Shouldn’t path be on here. They bill a lot of technical?
 
pathology is like rad onc - we are downstream. we don't bring any money into the hospital other than what we oursleves do. this is different than other specialties. for example - primary care - hospitals are investing in primary care heavily as this drives other high revenue enterprises - heart and cancer being the big ones.
 
jondunn said:
pathology is like rad onc - we are downstream. we don't bring any money into the hospital other than what we oursleves do. this is different than other specialties. for example - primary care - hospitals are investing in primary care heavily as this drives other high revenue enterprises - heart and cancer being the big ones.
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Little bit different though, because on a given case I could decide to do:
1) 3D or IMRT
2) Replan multiple times or no
3) Use more "devices" on the 3D
4) Frequency of IGRT
5) Fractionation choices
6) Or SBRT!

And on it goes.

You can get Dr. X as a solo rad onc for one year in a hospital and see pretty significant swings in the technical collections vs Dr. Y with the same patient mix taking over in the next year.
 
TheWallnerus said:
Little bit different though, because on a given case I could decide to do:
1) 3D or IMRT
2) Replan multiple times or no
3) Use more "devices" on the 3D
4) Frequency of IGRT
5) Fractionation choices
6) Or SBRT!

And on it goes.

You can get Dr. X as a solo rad onc for one year in a hospital and see pretty significant swings in the technical collections vs Dr. Y with the same patient mix taking over in the next year.
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so much more to this in “mixed” settings with many private referring sources working at different hospitals

- convincing you referrings to do biopsies at your site
- having them do infusion at your site rather than other site
- having scopes, labs and imaging done in your hospital rather than other imaging center

This is when you “gator” and have as many people you refer to as refer to you.

Can really add to revenue. Simplified to think we don’t have ability to increase tech revenue
 
The tweet says "to a hospital," which probably means none of the data accounts for freestanding clinics while the average might be pulled down by bloated academic departments. Does "drive" mean something different than "bring?" Also, how does the average physician generate $2.4M with the top 5 having only those numbers?
 
TheWallnerus said:
Little bit different though, because on a given case I could decide to do:
1) 3D or IMRT
2) Replan multiple times or no
3) Use more "devices" on the 3D
4) Frequency of IGRT
5) Fractionation choices
6) Or SBRT!

And on it goes.

You can get Dr. X as a solo rad onc for one year in a hospital and see pretty significant swings in the technical collections vs Dr. Y with the same patient mix taking over in the next year.
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Sure but ultimately we don’t have the big multiplier effect that other specialties do

But yeah of course can vary from doc to doc
 
Reaganite said:
Great place, great people, and obviously one of the best cities in the world...only issue ive heard is pay is relatively low compared to insane col of area.
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Can't imagine pay will get you into a decent house there.... Just like new attendings probably rent in Palo Alto and SF right?
 
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TheWallnerus said:
Little bit different though, because on a given case I could decide to do:
1) 3D or IMRT
2) Replan multiple times or no
3) Use more "devices" on the 3D
4) Frequency of IGRT
5) Fractionation choices
6) Or SBRT!

And on it goes.

You can get Dr. X as a solo rad onc for one year in a hospital and see pretty significant swings in the technical collections vs Dr. Y with the same patient mix taking over in the next year.
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So true! Just to build on this list:

1) Do we biopsy the questionable lesion on PET?
2) Do we need more imaging? MRI? PSMA? Etc.
3) Do we send to speech Path?
4) Do they need chemo? Should send for consultation for concurrent?
5) Is this brain met large enough its resection? Should refer to neurosurg

Kind of silly to think we don't have multipliers, more so than many other fields!
 
Sheldor said:
So true! Just to build on this list:

1) Do we biopsy the questionable lesion on PET?
2) Do we need more imaging? MRI? PSMA? Etc.
3) Do we send to speech Path?
4) Do they need chemo? Should send for consultation for concurrent?
5) Is this brain met large enough its resection? Should refer to neurosurg

Kind of silly to think we don't have multipliers, more so than many other fields!
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Ask a hospital admin lmao. You’re mistaken if you think it’s the same.

An ENT is judged by how much downstream ancillary they bring in. WE are the ANCILLARY for their patients. Not the other way around.
 
jondunn said:
Ask a hospital admin lmao. You’re mistaken if you think it’s the same.

An ENT is judged by how much downstream ancillary they bring in. WE are the ANCILLARY for their patients. Not the other way around.
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Why does it matter if radonc has downstream revenue? (Salary is still set by supply and demand)
 
RickyScott said:
Why does it matter if radonc has downstream revenue? (Salary is still set by supply and demand)
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What I’m describing is demand.

If you hire an head and neck surgeon ENT, you’re going to have downstream cancer cash coming in. Hence hospitals interest in hiring them.

They’re worth way more than their pro fees.
 
RickyScott said:
Why does it matter if radonc has downstream revenue? (Salary is still set by supply and demand)
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jondunn said:
What I’m describing is demand.

If you hire an head and neck surgeon ENT, you’re going to have downstream cancer cash coming in. Hence hospitals interest in hiring them.

They’re worth way more than their pro fees.
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If the number of ents was doubled like with radonc, demand would evaporate (and demand is elastic- hiring 4 is not going to bring in 4x downstream rev of one in a small town). Without trash collectors the hospital would be condemed and no one could practice-should they be paid 100k more?. I am sure family practice produces more downstream rev than ent. Ent like uro and optho have responsibly managed their supply. Your worth - like a diamond- is based on your suppply.
 
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RickyScott said:
If the number of ents was doubled like with radonc, demand would evaporate (and demand is elastic- hiring 4 is not going to bring in 4x downstream rev of one in a small town). Without trash collectors the hospital would be condemed and no one could practice-should they be paid 100k more?. I am sure family practice produces more downstream rev than ent. Ent like uro, optho have responsibly managed their supply. Your worth - like a diamond- has to do with your suppply.
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I really think this is the hardest concept to communicate because it is essentially out of everyone’s control. It has less to do with working hard and knowing stuff which med students/residents/young attendings are good at doing and more to do with prevailing economics and other far more arbitrary factors
 
Agree with @RickyScott here. In a fairly affluent community, nearly all downstream revenue is coming from PCPs. I would say that three factors contribute to relatively low PCP pay. Their relative availability (although PCP shortage in rural or underserved urban places is probably the most important access issue to address), the relative comparability of APPs to MDs/DOs in their clinical space, and their lack of direct revenue generation.

We have made ourselves very available, have seen continued incremental decline in revenue generation, and I would discourage consideration of a pathway for non-docs to fulfill a comparable clinical role.
 
RickyScott said:
If the number of ents was doubled like with radonc, demand would evaporate (and demand is elastic- hiring 4 is not going to bring in 4x downstream rev of one in a small town). Without trash collectors the hospital would be condemed and no one could practice-should they be paid 100k more?. I am sure family practice produces more downstream rev than ent. Ent like uro, optho have responsibly managed their supply. Your worth - like a diamond- has to do with your suppply.
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none of that discounts anything that has been said.
 
also the tunnel vision around supply and demand IMO ignores some MAJOR influences on the types of jobs available now. Hospital consolidation has limited the upper limits of what free standing busy PP docs used to make, especially when you add in the other factors like hypofrac in a FFS model, decreasing indications for RT

it is not all supply and demand.

your standard hospital employed mid career doc makes 550-600 and probably can't make much more. that's the main difference from the past.
 
jondunn said:
none of that discounts anything that has been said.
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I just get the sense that multiple posters, both here and on twitter are emphasizing that reimbursement is determined by RVUS/ math formulas and changes in cms dollars. Samir Keole (who I totally respect) posted some rediculous formula for valure/worh/rvu. This is not directed at you, but it seems like a smokescreen is being put out to obscure the fact that our salaries/mobility/and worth have been trashed by astro/and the doubling of resident numbers. Yes, supply and demand is not everything, but it is 90%+ (medonc and path serve as excellent examples- 10 years ago medoncs had same amount of rvus but crappy salaries- what changed?). Many of us may not be ready to confront the underlying truth- astro totally trashed the field.
 
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communitydoc13 said:
Yeah, this is always crap. I asked a CFO about RVU formulation and they could not give a reasonable answer. I think RVUS are post-facto calculated to roughly fit market rates.
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I get paid 30% less $ per rvu than my partner because my volume is much higher. (it is fair because she does a lot of breast, gyn and low reimbursing sites and works just as hard). Our medoncs get more than double my dollars per rvu in order to turn their 6-7 k rvus into a high salary. I have heard of some large hospital systems deducting the cost of building space, nursing and secretarial salaries from total rvu x $.
 
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Fpg1245 said:
I really think this is the hardest concept to communicate because it is essentially out of everyone’s control. It has less to do with working hard and knowing stuff which med students/residents/young attendings are good at doing and more to do with prevailing economics and other far more arbitrary factors
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yeah you can't just produce 2x of us and expect 2x the work
communitydoc13 said:
Agree with @RickyScott here. In a fairly affluent community, nearly all downstream revenue is coming from PCPs. I would say that three factors contribute to relatively low PCP pay. Their relative availability (although PCP shortage in rural or underserved urban places is probably the most important access issue to address), the relative comparability of APPs to MDs/DOs in their clinical space, and their lack of direct revenue generation.

We have made ourselves very available, have seen continued incremental decline in revenue generation, and I would discourage consideration of a pathway for non-docs to fulfill a comparable clinical role.
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That being said, to not know that in the right setting, we can and do bring in ancillary revenue. In an integrated system? Not a whole lot. In a fragmented system, if you are seeing 400 consults a year and taking lead on a lot of the work up, you can generate revenue and do good for your system.

Just example, if a new doc comes in and starts ordering mpMRI for prostate (prior doctor did not order), that's something. If they start ordering PSMA testing for either new dx or surveillance, that's something. There are so many things - and maybe one has this assumption that we can't have external effects, but I think that is small thinking.

There are ROs that are providing high value to their hospital, because of what they do - not just because they are a warm body.
 
jondunn said:
your standard hospital employed mid career doc makes 550-600 and probably can't make much more
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Define “can’t”

The average rad onc getting paid 550 by the hospital is bringing in $3 to $4m with his rad onc work and at lease a half mil a year on top of that with ancillaries. If he was just doing his own pro billing he could make 50 or 100 more, more than likely.
 
metallica81788 said:
Is that really the case anymore? Do we know this? Because it doesn't feel like it to me.
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I'd say 450-500k seems more realistic/less optimistic for employed jobs.

Maybe the dudes who have been at a spot forever are making 600k employed now, mainly because it's tough to bust someone down from 1 million+ to 450k in 15 years, but it doesn't strike me that will be available to grads in the past decade as they age in.
 
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metallica81788 said:
Is that really the case anymore? Do we know this? Because it doesn't feel like it to me.
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It’s gone down, although MGMA would refute me. Recent Red Journal article shows Medicare nationwide reimbursing rad onc 22% less in 2019 vs 2010. So MGMA is right, or pulling numbers out its anus. Can’t really figure which. Also going down due to pure demand/supply as RickyScott eloquently pointed out.
 
TheWallnerus said:
Define “can’t”

The average rad onc getting paid 550 by the hospital is bringing in $3 to $4m with his rad onc work and at lease a half mil a year on top of that with ancillaries. If he was just doing his own pro billing he could make 50 or 100 more, more than likely.
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that's the point. that is what changed. consolidation made everyone employed or basically employed, compared to the past.

that's my point.
 
Mandelin Rain said:
I'd say 450-500k seems more realistic/less optimistic for employed jobs.

Maybe the dudes who have been at a spot forever are making 600k employed now, mainly because it's tough to bust someone down from 1 million+ to 450k in 15 years, but it doesn't strike me that will be available to grads in the past decade as they age in.
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genuinely don't know anyone who is employed in a non-academic setting that makes as low as 450k (who are more than 3 years out).

but I believe you of course, just goes to show anectdotes areent data i guess
 
RealSimulD said:
yup. this is why RVUs are complete trash. it is a joke that we've agreed to this. or been subjugated, whatever.
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As someone who gets paid this way, I don't disagree. To get to my number, I just picked a salary I liked and made the math work. Same approach as was suggested corporate probably takes. It's not a panacea. My experience with collections is that it's also trash, whether you convince yourself otherwise or not. The entirety of our economy and the concept of "fairness" is trash. I got a nice number and opted to devote my remaining brainspace to other endeavors. I couldn't care less how they get to the number, just that they get there.
 
TheWallnerus said:
Consolidation™

Brought to you by Rad Onc Oversupply®
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this is a reach

corporate machinations and hospital takeovers are at a way higher level and have nothing to do with how many residents are around.
 
Ray D. Ayshun said:
As someone who gets paid this way, I don't disagree. To get to my number, I just picked a salary I liked and made the math work. Same approach as was suggested corporate probably takes. It's not a panacea. My experience with collections is that it's also trash, whether you convince yourself otherwise or not. The entirety of our economy and the concept of "fairness" is trash. I got a nice number and opted to devote my remaining brainspace to other endeavors. I couldn't care less how they get to the number, just that they get there.
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Yeah you are right - collections is not a panacea.
 
Who is this Jordan Johnson and what does he get out of supervision fear mongering?

He sounds like our industry's version of a patent troll (a lawyer that makes a ton of money suing people on patent technicalities nobody cares about).

If you work in a hospital, direct supervision is NOT required. There is nothing to interpret here. You can supervise treatments and bill remotely. This is explicit. Having this clown try and suggest otherwise results in ignorant administrators treating us like blue collar employees punching a clock. If we are not legally required to be there, which we are not, then we decide when we need to be there. End of discussion.

The discussion I am interested in is freestanding. It sounds like some of you are treating freestanding without an MD in the building. How?
 
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jondunn said:
that's the point. that is what changed. consolidation made everyone employed or basically employed, compared to the past.

that's my point.
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jondunn said:
this is a reach

corporate machinations and hospital takeovers are at a way higher level and have nothing to do with how many residents are around.
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It does in the sense that everyone is basically salaried and that salary is going to be deteremined by what the next person would take for the same job. Rvus /cms reimbursement are just post facto manipulated to justify paying market rate.
 
TheWallnerus said:
It’s gone down, although MGMA would refute me. Recent Red Journal article shows Medicare nationwide reimbursing rad onc 22% less in 2019 vs 2010. So MGMA is right, or pulling numbers out its anus. Can’t really figure which. Also going down due to pure demand/supply as RickyScott eloquently pointed out.
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And for those residents/students who don't realize, private insurers typically reimburse as some negotiated percentage of what Medicare pays.
 
TheWallnerus said:
Define “can’t”

The average rad onc getting paid 550 by the hospital is bringing in $3 to $4m with his rad onc work and at lease a half mil a year on top of that with ancillaries. If he was just doing his own pro billing he could make 50 or 100 more, more than likely.
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I think the math has changed in the past 5 years. MGMA numbers have gone up while reimbursements have gone down. When I came out of residency I was hellbent on trying to do my own billing as I was comparing employment to what people had been collecting 8-10 years ago and it was clear the hospital was holding back a lot of the clinic's revenue from the employed physician. It looks like employment above the MGMA median with benefits will usually win out over billing independently from my math. I am in a busy clinic, and keep about 90% of my collections. After accounting for my personal expenses, I make basically what I did as an employee, maybe less if you account for benefits. It's disheartening to know that if I were treating the same patients 10 years ago I would be making 30-50% more.

The exception I guess would be a top 5% clinic, like 600 consults a year or something. And of course the intangibles of not being owned by the hospital.
 
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