Rad Onc Twitter

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sirspamalot said:
No conflict of interest here folks. Love that Ron grin. Ron is the epitome of nice, no question, but the fox in the henhouse is what we have here.

His underlings made hundreds of thousands of dollars a year helping practices bill and fine tune etc. Poorly paid low IQ admins loved the results... Can't fault it. But the total lack of boundaries between ASTRO, ASRT, ACRO and Ron are legend. Gotta tip the hat.

www.linkedin.com

When you ask friends if they’ll take pictures of you during your talk….. | Ron DiGiaimo

When you ask friends if they’ll take pictures of you during your talk….. haha …. Awesome time meeting and getting to know the incredible ASRT leadership team ASRT Foundation American Society of Radiologic Technologists Revenue Cycle Coding Strategies The Oncology Group RC Billing Regents Health...
www.linkedin.com www.linkedin.com
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I think a VERY healthy level of skepticism is needed for entities that aren't radiation oncologists that are involved heavily in any radiation billing, modeling, reimbursement, policy creation, etc. You can also apply some of that to anyone living in fantasy land NCI centers/PPS exempt centers.

I'm not saying they're bad people, but incentives are differently aligned and experiences/points of view are skewed.

#noskininthegame
 
Fpg1245 said:
Literally if that's all I have to do, Ill take that deal. I don't find them particularly taxing.
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Just like 5 or 6 more weeks until we are done for the year 🙂

The questions seem really lazy this year. I agree that it's not a big deal, but toss it on the pile of crap we do for literally no reason other than money or because some administrator thinks they are helping the world.

Cumulatively, its frustrating.
 
NotMattSpraker said:
Just like 5 or 6 more weeks until we are done for the year 🙂

The questions seem really lazy this year. I agree that it's not a big deal, but toss it on the pile of crap we do for literally no reason other than money or because some administrator thinks they are helping the world.

Cumulatively, its frustrating.
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Does every speciality have something like this (i.e re-cert exams or CME requirement)? If so, I will take this as it is a super easy way to meet that requirement. Between this and tumor board being "CME", I am set!
 
Lamount said:
Does every speciality have something like this (i.e re-cert exams or CME requirement)? If so, I will take this as it is a super easy way to meet that requirement. Between this and tumor board being "CME", I am set!
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Yes they all require some form of CME or re-cert exams. Even non medical fields like law have something like this required after the bar. Not something unique to rad onc at all.
 
Ah, I entered medical school as all the lifetime certifications were ending and there were a lot of grumbling from faculty about "MOC" and the cost and the process and...

...I didn't get it. Of course doctors should have lifelong requirements to assess competency and ability to practice. It seemed absurd to question.

To me, I use the memory of the first time I reacted to hearing it questioned as the "starting line" of what I thought medicine was vs what I found it to be.

I thought it was a meritocracy. I thought board certification assessed what it claimed to assess. I thought MOC was well designed and a good idea.

But....George W was president back then, and the iPhone hadn't come out. I was dumb.
 
elementaryschooleconomics said:
Ah, I entered medical school as all the lifetime certifications were ending and there were a lot of grumbling from faculty about "MOC" and the cost and the process and...

...I didn't get it. Of course doctors should have lifelong requirements to assess competency and ability to practice. It seemed absurd to question.

To me, I use the memory of the first time I reacted to hearing it questioned as the "starting line" of what I thought medicine was vs what I found it to be.

I thought it was a meritocracy. I thought board certification assessed what it claimed to assess. I thought MOC was well designed and a good idea.

But....George W was president back then, and the iPhone hadn't come out. I was dumb.
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There's gotta be that happy medium somewhere between MOC/10 year certs and grandfathered 2D-trained boomers who couldn't contour a parotid or a prostate bed correctly to save their life
 
Dy2FO2T.png
 
medgator said:


The bird is spicy today
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I remember calling the government relations electee a "proton pusher" and being chastised for it here. Both the chair and vice-chair have interest in proton facilities.

Well, 6(?) months later, ASTRO is "pushing" a proton policy, that I'm sure they'll "relate" to CMS to ensure continued reimbursement for dubious indications.

Can't say I'm shocked.
 
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Mandelin Rain said:
I remember calling the government relations electee a "proton pusher" and being chastised for it here. Both the chair and vice-chair have interest in proton facilities.

Well, 6(?) months later, ASTRO is "pushing" a proton policy, that I'm sure they'll "relate" to CMS to ensure continued reimbursement for dubious indications.

Can't say I'm shocked.
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Protons are a metaverse
 
TheWallnerus said:
Protons are a metaverse
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So you take the new NAPT driven proton model policy plus this paper. Billing resources are behind a very pricey paywall. The scientific content is mostly trash, and the rest you get it on Twitter or other journals.

I work in a highly competitive market without a single proton unit in the entire state.

Why in the world would I give money to ASTRO or the PAC at this point? They are going to need a massive change in priorities to convince me to ever come back.

1683729925207.png
 
NotMattSpraker said:
So you take the new NAPT driven proton model policy plus this paper. Billing resources are behind a very pricey paywall. The scientific content is mostly trash, and the rest you get it on Twitter or other journals.

I work in a highly competitive market without a single proton unit in the entire state.

Why in the world would I give money to ASTRO or the PAC at this point? They are going to need a massive change in priorities to convince me to ever come back.

View attachment 371127
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Yes.

Instead of pushing for protons and some APM version (largely drafted/influenced by people that will not be subject to an APM), the LASER focus of ASTRO should be stopping these cuts.

The fact is that if they can get protons paid for they're more than happy to take nominal medicare cuts elsewhere, it'll be a net positive at centers with proton capability.
 
BobbyHeenan said:
Yes.

Instead of pushing for protons and some APM version (largely drafted/influenced by people that will not be subject to an APM), the LASER focus of ASTRO should be stopping these cuts.

The fact is that if they can get protons paid for they're more than happy to take nominal medicare cuts elsewhere, it'll be a net positive at centers with proton capability.
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Effectively steal from the community to pay for them. Until community places start paying for them and losing millions on it.
 
NotMattSpraker said:
So you take the new NAPT driven proton model policy plus this paper. Billing resources are behind a very pricey paywall. The scientific content is mostly trash, and the rest you get it on Twitter or other journals.

I work in a highly competitive market without a single proton unit in the entire state.

Why in the world would I give money to ASTRO or the PAC at this point? They are going to need a massive change in priorities to convince me to ever come back.

View attachment 371127
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I trashed ASTRO PAC before it was cool (back when they were trying to kill multi-specialty ownership of linacs including by the RO via killing the stark law in-office ancillary exemption).
 
So is proton money evil only or do we throw the MRI-L angle in there into the grift stew/hog head cheese?
 
thecarbonionangle said:
So is proton money evil only or do we throw the MRI-L angle in there into the grift stew/hog head cheese?
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Unlike spacer gels or protons, both of which have lacking (and possibly adverse) data, i think you could at least make a use case for an MR-L with the mri imaging/targeting capability for certain sites (plus much cheaper than a proton unit)
 
medgator said:
Unlike spacer gels or protons, both of which have lacking (and possibly adverse) data, i think you could at least make a use case for an MR-L with the mri imaging/targeting capability for certain sites (plus much cheaper than a proton unit)
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Im pro tech obviously so im just playing devils advocate. So don’t get me wrong, i have an MRIL angle as well! Having said that, Im very skeptical about Kishan paper/margin isssue. MRIL will have to be held to same standards before justifying costs, even if “cheaper” than protons. NAPT approving proton ASTRO guidelines, no doubt viewray/elekta would be involved in MRIL “guidelines”. If i were buying an MRIL i’d choose Elekta due to superior Tesla magnet and better company, not on the verge of potential bankruptcy/sell off.
 
thecarbonionangle said:
So is proton money evil only or do we throw the MRI-L angle in there into the grift stew/hog head cheese?
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Proton has had decades to prove themselves and have not.

MRI-L is fledgling in comparison and there is sigificant interest in studying and proving utility of it - see prostate, pancreas. The brain stuff I'm less excited about.

A MRI-L policy paper would have people willing to put their NAMES on it and sign it. Not just the NAPT and Maryland Proton Center. Like real, named, radiation oncologists.

Real, named radiation oncologists are too embarassed to put their name on the ASTRO position paper.
 
thecarbonionangle said:
So is proton money evil only or do we throw the MRI-L angle in there into the grift stew/hog head cheese?
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We are in a pickle of sorts.

I strongly believe that protons have been oversold since the mid 2000s and their further adoption has been strictly cultural and economic and not based on good science.

But, if a new radonc intervention was developed, which was appreciably better than the standard of care, yet required the type of high capital investment and physics expertise that a community practice isn't gonna have, I would also probably want to crap on it.

If only we were developing pills, and the care model was in general community practice with academic expertise reserved for clinical trial type work.
 
communitydoc13 said:
We are in a pickle of sorts.

I strongly believe that protons have been oversold since the mid 2000s and their further adoption has been strictly cultural and economic and not based on good science.

But, if a new radonc intervention was developed, which was appreciably better than the standard of care, yet required the type of high capital investment and physics expertise that a community practice isn't gonna have, I would also probably want to crap on it.

If only we were developing pills, and the care model was in general community practice with academic expertise reserved for clinical trial type work.
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And it won’t be. The best you can hope for is becoming a cog in the academic profit machine under the guise of quality.

I’m post EBM at this point. I don’t care about the science anymore. I only care about job security and putting meat on the machine. If it means endorsing proton or MRIL without the most rigorous of tests fine. You want precedent for this type of behavior? (See literally every other field)
 
sirspamalot said:
Meat on the Machine

I heard that was, ironically, the next album title from Metallica.

Cracking Up Lol GIF
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Back in high school, a friend of mine had a band called “smile in the ice machine”. Similar concept. The meat has to be moved. Plenty of slime in our field. You betcha!
 
Fpg1245 said:
And it won’t be. The best you can hope for is becoming a cog in the academic profit machine under the guise of quality.

I’m post EBM at this point. I don’t care about the science anymore. I only care about job security and putting meat on the machine. If it means endorsing proton or MRIL without the most rigorous of tests fine. You want precedent for this type of behavior? (See literally every other field)
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At least medical oncology and pharma runs the trials. They aren't good trials, but they go through the motions to generate a piece of evidence.

In 2008, two guys from Harvard and MDACC literally wrote an editorial that we do not need RCTs for protons, the benefit is self-evident. It is embarrassing.
 
Fpg1245 said:
And it won’t be. The best you can hope for is becoming a cog in the academic profit machine under the guise of quality.

I’m post EBM at this point. I don’t care about the science anymore. I only care about job security and putting meat on the machine. If it means endorsing proton or MRIL without the most rigorous of tests fine. You want precedent for this type of behavior? (See literally every other field)
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Modality shaming needs to become a thing like fraction shaming, esp given the shameless push by protonistas in ASTRO with this most recent statement being put out.

ASTRO was happy to push less fractions to screw over community centers, but ignore costs of cares and financial toxicity at many of their member centers that were delivering shorter courses of treatment.

The emperor has no clothes
 
I don’t know about anyone else, but I don’t think this can translate into any REAL changes…

“they can lead image review, specific technical and/or clinical procedures, patient education and follow-up, clinical markup of treatment sites, care coordination, knowledge translation, research, and participate in clinical leadership”

…aren’t they doing that stuff already?

“Limited prescribing” sounds suspiciously like giving patients moisturizer

Seems more like they are trying to dress up the RTT role with a whole load of jibberish to entice more people train as RTTs. The RTTs I know are too bright to fall for this nonsense
 
Lamount said:
I don’t know about anyone else, but I don’t think this can translate into any REAL changes…

“they can lead image review, specific technical and/or clinical procedures, patient education and follow-up, clinical markup of treatment sites, care coordination, knowledge translation, research, and participate in clinical leadership”

…aren’t they doing that stuff already?

“Limited prescribing” sounds suspiciously like giving patients moisturizer

Seems more like they are trying to dress up the RTT role with a whole load of jibberish to entice more people train as RTTs. The RTTs I know are too bright to fall for this nonsense
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So they get an extra 2K a year in their paycheck for all this ****. If I remember Neha is at Penn and they are more than keen on using extenders for all kinds of stuff (see radiology)
 
Lamount said:
I don’t know about anyone else, but I don’t think this can translate into any REAL changes…

“they can lead image review, specific technical and/or clinical procedures, patient education and follow-up, clinical markup of treatment sites, care coordination, knowledge translation, research, and participate in clinical leadership”

…aren’t they doing that stuff already?

“Limited prescribing” sounds suspiciously like giving patients moisturizer

Seems more like they are trying to dress up the RTT role with a whole load of jibberish to entice more people train as RTTs. The RTTs I know are too bright to fall for this nonsense
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The best use I have personally seen was an RTT doing OAR contours for on-table adaptive cases. I worked with and without them and my ability to be happy covering adaptive cases went off a cliff without the ARTT. A supportive leadership would encourage departments to create a Rad Onc FTE to support implementation of on-table adaptive, but you know, ASTRO gonna ASTRO. So, that is one single use of an RTT that I think is outside their usual scope and deserves extra pay.

I bet there are a lot of interesting uses in countries that are either resource or bandwidth constrained that make a lot of sense.

My sense is we need more RTTs in the US and we need to encourage hospitals to treat them better. Maybe more than we need Penn to become more profitable. But what do I know. This is why I will never be ASTRO president or Red J EIC.
 
Fpg1245 said:
A 40 percent discount and still not low enough? What do they think RO APM will bring?
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RO-APM was performative and meant to further consolidate power among the PPS-exempt centers.

It's why the only clinical advisor for CMS was from Anderson.

It's why the GAO report from 2015, showing a half a billion dollars in savings if PPS-exempt status was ended...fell by the wayside in favor of pursuing this boondoggle with a potential savings of only $40 million....but all on the backs of the community.

Do I think there's some nefarious, overarching plot here?

Nah.

But ASTRO is really "it" in terms of American RadOnc professional societies, and it's run mostly by folks from PPS-exempt centers with protons.

No one votes against their own interests.
 
elementaryschooleconomics said:
RO-APM was performative and meant to further consolidate power among the PPS-exempt centers.

It's why the only clinical advisor for CMS was from Anderson.

It's why the GAO report from 2015, showing a half a billion dollars in savings if PPS-exempt status was ended...fell by the wayside in favor of pursuing this boondoggle with a potential savings of only $40 million....but all on the backs of the community.

Do I think there's some nefarious, overarching plot here?

Nah.

But ASTRO is really "it" in terms of American RadOnc professional societies, and it's run mostly by folks from PPS-exempt centers with protons.

No one votes against their own interests.
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APM as proposed by ASTRO was good policy and would have stabilized payments. Medicare’s version was terrible and they weren’t willing to listen to any stakeholders. I don’t know how it gets done, but we need a bundled payment system as fx inevitably go down and Medicare remains revenue neutral while also increasing primary care reimbursement.
 
Medicare cuts primarily affect independent centers and small community hospitals. Big centers leverage their size to negotiate increasing prices anyway. Astro will pay lip service to Medicare cuts but at the end of the day, the large universities still take in 10x cms.
 
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grenz said:
APM as proposed by ASTRO was good policy and would have stabilized payments. Medicare’s version was terrible and they weren’t willing to listen to any stakeholders. I don’t know how it gets done, but we need a bundled payment system as fx inevitably go down and Medicare remains revenue neutral while also increasing primary care reimbursement.
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Bundled payments won’t help rad onc despite decreasing fractions. It just won’t. If it did they wouldn’t be asking for a proton exemption. They’ll hold you to a number and then continue to ratchet it down for the same reason. They’ve already bled RO over the last 10 years. “Stabilizing” payments is completely meaningless in this environment. They aren’t stable they just continue to fall.

Increasing PCP reimbursements is a distraction. Makes it sound like they are doing something noble with the money by helping out lowly underpaid front line medicine. The reality is there are too many providers out there (MD DNPs PAs) to appreciably move the needle for them and the hospital networks most of them work for will never make up declines in procedural income with extra time billing codes.
 
grenz said:
APM as proposed by ASTRO was good policy and would have stabilized payments. Medicare’s version was terrible and they weren’t willing to listen to any stakeholders. I don’t know how it gets done, but we need a bundled payment system as fx inevitably go down and Medicare remains revenue neutral while also increasing primary care reimbursement.
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What do you think would have happened if ASTRO went in and offered to include proton therapy? I'm just curious. The fact is, it's very expensive for medicare among Rad Onc costs.

I've spent a lot of time talking to ASTRO reps about their APM proposal and what they were unhappy about. It never really matched what doctors were unhappy about, see Join Luh's editorial for an example. No one ever brought up protons. 🤷‍♂️
 
elementaryschooleconomics said:
RO-APM was performative and meant to further consolidate power among the PPS-exempt centers.

It's why the only clinical advisor for CMS was from Anderson.
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This really hits the nail on the head. Rad Onc as a field is such a minimal contribution to CMS overall cancer spend. Once CMS gets the authorization to negotiate drug prices (2025, I believe?), then the real cost savings can begin.
 
Gfunk6 said:
This really hits the nail on the head. Rad Onc as a field is such a minimal contribution to CMS overall cancer spend. Once CMS gets the authorization to negotiate drug prices (2025, I believe?), then the real cost savings can begin.
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I don’t like to gloat but serious Medicare drug negotiation (unlike in current form) would bring down drug costs but it is likely to be disappointing to those who thought radical savings were just around the corner

The problem I’ve noticed is that the big spenders rarely get touched. It’s the smaller less powerful and costly ones that get squeezed the most.
 
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