Rad onc with biggest decrease in applications of any specialty

[RO2019]

Job market is super strong this year

Haters wake up

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[ioa8992]

I am a recent residency graduate and wanted to offer my experience, which seems to be at odds with many of the views being expressed here.

I came out of a solidly middle-tier program. I wanted to find a job in a very specific city (not where I did residency) in a state where it is typically considered to be difficult to find a job, and started networking very early. I was able to get a job in that city that I am very happy with. All of the graduates from my middle-tier program from the past 5 years who I know personally have all secured jobs that they were very happy with, in cities they were very happy with. I personally do not actually know any rad onc graduates who are unhappy with the jobs they were able to find.

This is clearly not everyone's experience. But it's all of the first-hand knowledge I have of the job market.

 

[RO2019]

That’s the case for 99.9 percent of people in the field!

The toxic posters here have ZERO clue what they are doing to thought processses of unknowing med students. It’s sad actually. And it’s the same five voices (who are all RAKING it in in their sweet jobs)

 

[evilbooyaa]

I am a recent residency graduate and wanted to offer my experience, which seems to be at odds with many of the views being expressed here.

I came out of a solidly middle-tier program. I wanted to find a job in a very specific city (not where I did residency) in a state where it is typically considered to be difficult to find a job, and started networking very early. I was able to get a job in that city that I am very happy with. All of the graduates from my middle-tier program from the past 5 years who I know personally have all secured jobs that they were very happy with, in cities they were very happy with. I personally do not actually know any rad onc graduates who are unhappy with the jobs they were able to find.

This is clearly not everyone's experience. But it's all of the first-hand knowledge I have of the job market.

Congrats. I agree that the majority of graduates still get a job that they are happy with. Good job on networking early.

That being said, nobody is going to tell you that they're unhappy with the job they signed on for, right? Pretty big admission of failure. I imagine even people doing fellowships wouldn't publicly come off as 'unhappy'.

That’s the case for 99.9 percent of people in the field!

The toxic posters here have ZERO clue what they are doing to thought processses of unknowing med students. It’s sad actually. And it’s the same five voices (who are all RAKING it in in their sweet jobs)

Where in the training process are you? I'm not sure if you consider me 'toxic' as you and other newer members have been stating (and you're certainly well within your rights to consider me 'toxic'), but these are concerns that medical students should at least think about and not be completely ignorant about as they go through the application process. Should it stop everybody from applying to the field? No, of course not.

Not sure what you're referencing in regards to the bolded, but OK.

 

[GreyingRadOnc]

We need payment parity between hospitals/academic systems and freestanding centers. How academics preach cost control while billing 2x what freestanding centers do for the same service is beyond me.

I'd like to see proof of what you posted. Academic centers do sometimes negotiate better prices than freestanding centers, but they also face more costs (which is how they justify the expense). Training residents is inefficient and expensive. That is part of the reason they negotiate a higher rate and payers agree to it as part of the process of education. Also, payers may find that access to certain academic centers is attractive and allows for marketing. Lastly, academic rad oncs do not negotiate those contracts. Those centers have a team that negotiates those rates as part of a comprehensive billing arrangement. Rad Onc is a very small piece of such a contract.

Also lastly, it's a free market. Rates are negotiated. Having read some of these posts on this site you might think they frequent posters would like "medicare for all".

 

[RadOncDoc21]

I'd like to see proof of what you posted. Academic centers do sometimes negotiate better prices than freestanding centers, but they also face more costs (which is how they justify the expense). Training residents is inefficient and expensive. That is part of the reason they negotiate a higher rate and payers agree to it as part of the process of education. Also, payers may find that access to certain academic centers is attractive and allows for marketing. Lastly, academic rad oncs do not negotiate those contracts. Those centers have a team that negotiates those rates as part of a comprehensive billing arrangement. Rad Onc is a very small piece of such a contract.

Also lastly, it's a free market. Rates are negotiated. Having read some of these posts on this site you might think they frequent posters would like "medicare for all".

I would consider medicare for all.

 

[nkmiami]

I would consider medicare for all.

absolutely, you can’t cover pre existing conditions without some universal mechanism.

 

[GreyingRadOnc]

My main point of that post is that the attending job market (for either new grads or old grads) is not a good one now. Lateral or upward movement for established attendings is more difficult.

Additionally, the bolded line is an often quoted falsehood that is perpetuated by only those in Rad Onc. There is no evidence (that I am aware of) that that statement is at all true. Stark laws do not play a role in this. Maybe anti-trust, but not Stark. This exact thing is done in Derm, Plastics, Urology, and other in-demand specialties that have good job markets. Residency expansion seems to have slowed down recently, which is good.

ASTRO leadership are generally chairmen/women. Chairmen/women make more money for their department getting residents (even if they have to pay them out of their own pockets) rather than PAs/NPs. Chairs are generally the ones who make the decision on whether to expand or not. It's all the same people.

The job market is not bad this year. That's based on the number of jobs residents from my program have interviewed for and were offered. The job market is definitely shifting (see the IJROBP article) to different types of jobs but there are still jobs. Attendings and out of a few years have many options because they are off cycle and are board certified. If they are coming from a private practice and want to work at the open stanford job, then that's not likely.

I finished training almost 20 years ago. Everyone considered that job market to be amazing. Despite that I had to cold call many places and got a lot of "we don't need someone right now". The mantra in that era was 1) you can find a good job in an non-ideal area, or 2) you can find a job close to an ideal area....but usually not your ideal job in your ideal area. That's because it's Rad Onc and not IM or FM. They don't need and train so many of us. I never expected to have the perfect job in the perfect town, despite training at a great place and being liked by my program. Those are unreal expectations.

Most residents don't make money for a department. They can't independently bill for anything aside from managements and only if the hospital bothers to get them a state license. NP/PA's can bill for follow-ups. I think most chairs look at residency programs and expanding them for 2 reasons: 1) prestige. It's easier to recruit good faculty if you have a resident group that is doing research, available for teaching, etc. 2) To do the contouring for busy academic faculty. NP/PA's don't do that in most places for sure, but that only makes money if it's opportunity costs for faculty to see more patients. At my institution there is a hard block on adding new residents to the system. That's because they lose money on residents overall (medicare/govt payers give money for resident education but it's been static for many decades). You can only grow a program at my system if someone drops a residency slot. It's a zero sum game.

To my knowledge, no residency programs control the throughput year to year....that's in the US. If you can prove that I'd love to see it. I know Ben Slotman once said that he decides how many slots there are in the Netherlands based on phone calls to all the centers and their anticipated needs. I think that would be AWESOME but it will not happen in the US. They don't have an ACGME overseeing things the same way. Either way, academic chairs have NO control over how many residency spots are in the US and how it grows. NONE. They don't have a seat at that table. They did affect how boards exams shifted in time over the years (and least that's how it was described to me), but the other bit is untrue.

 

[Phantom1]

That’s the case for 99.9 percent of people in the field!

The toxic posters here have ZERO clue what they are doing to thought processses of unknowing med students. It’s sad actually.

Seriously agree. Rad Onc is a sweet field. Its competitive so dont expect that you can sit on your hands during residency and then land a job of your choice in a city if your choice. If you distinguish yourself there are great jobs and there will continue to be great jobs.

One thing I love about Rad Onc that is understated is the weekends and nights. Never having to stay overnight in a hospital and weekends can be really free depending on your situation... if I were a med student I would apply again without a doubt.

 

[DebtRising]

That’s the case for 99.9 percent of people in the field!

The toxic posters here have ZERO clue what they are doing to thought processses of unknowing med students. It’s sad actually. And it’s the same five voices (who are all RAKING it in in their sweet jobs)

I guess I would ask you to justify your claim that 99.9% of the field is happy when a published survey of 1700 practicing physicians reported some broad concerns about the job market and the nature of their choice.

I would also ask you to disprove the supply demand publication that predicts oversupply for a decade - which the work force survey also validates, not by creating a new model, but noting that with the current supply and hypofractionation, there are likely many more rad onc physicians than needed. Since it is the negative posts on this site discouraging medical students unjustly, in your opinion.

Sure I’m a broke record, but 99.9 % of the time I at least pretend to pay attention to the data. Fellowship expansion is always a sure sign of a robust job market.

 

[medgator]

That’s the case for 99.9 percent of people in the field!

The toxic posters here have ZERO clue what they are doing to thought processses of unknowing med students.

Troll alert

 

[medgator]

started networking very early. I was able to get a job in that city that I am very happy with.

And I'm sure that job never made it to the "ASTRO career center"

 

[OTN]

I'd like to see proof of what you posted. Academic centers do sometimes negotiate better prices than freestanding centers, but they also face more costs (which is how they justify the expense). Training residents is inefficient and expensive. That is part of the reason they negotiate a higher rate and payers agree to it as part of the process of education. Also, payers may find that access to certain academic centers is attractive and allows for marketing. Lastly, academic rad oncs do not negotiate those contracts. Those centers have a team that negotiates those rates as part of a comprehensive billing arrangement. Rad Onc is a very small piece of such a contract.

Also lastly, it's a free market. Rates are negotiated. Having read some of these posts on this site you might think they frequent posters would like "medicare for all".

The data is actually much worse than what I posted. I'm with a very large private practice, and our payers we negotiate with tell us academic centers cost 5x what we do with equivalent outcomes. This is internal data, I saw it, but I cannot share it. I certainly don't expect you to believe me, but that's what it is.

However, pay rates from insurers generally start with Medicare rates as a base/starting point, and as you know Medicare rates for hospital-based services are substantially higher than those for free-standing clinics for the same XRT services. You don't need "proof" for this, as it's published in the CMMS rates. As a result, yes rates are negotiated, but it's from a starting point which already is on uneven ground.

Academic centers are paid by the government to provide training for residents; it's not my understanding that payers are responsible for any additional expenses due to residents being in the clinic.

I certainly do agree that payers may want to include academic centers in their approved clinics, as it would help potentially attract patients.

Finally, I do not care in the least that academic radoncs don't negotiate those contracts. The "financial toxicity" of their patients should be their concern whether or not they were involved in contract negotiation, and we both know academic radoncs continually browbeat their community colleagues for what they see as overly-expensive care. It's hypocritical to do so while providing care which costs far more than it needs to.

 

[medgator]

I'd like to see proof of what you posted. Academic centers do sometimes negotiate better prices than freestanding centers,

I've never heard of that being the case. I know our practice charges half of what the hospital in town charges for a PET/CT and we are also less expensive radiation wise.

it's well known that hospital raise rates after acquiring independent/private practices and this occurs across multiple specialties

Same Doctor Visit, Double the Cost

 

[imhopeful432]

I've never heard of that being the case. I know our practice charges half of what the hospital in town charges for a PET/CT and we are also less expensive radiation wise.

it's well known that hospital raise rates after acquiring independent/private practices and this occurs across multiple specialties

Same Doctor Visit, Double the Cost

Its true hospitals get paid more than physician practices and has probably driven a lot of the consolidation. That being said, there are changes happening. The Balanced Budget Act of 2015 (BBA) disallowed provider-based billing by hospitals for newly acquired physician practices after 2015 and the trend of hospitals buying physician practices has flattened since 2015 (after a decade of rise). AMA is doing a lot of great work in this area.

 

[Fpg1245]

Its true hospitals get paid more than physician practices and has probably driven a lot of the consolidation. That being said, there are changes happening. The Balanced Budget Act of 2015 (BBA) disallowed provider-based billing by hospitals for newly acquired physician practices after 2015 and the trend of hospitals buying physician practices has flattened since 2015 (after a decade of rise). AMA is doing a lot of great work in this area.

Before we start cheering, consider those independent offices prior to the take over. They were saddled with EHR costs from government mandates and they were being nickle and dimed left and right by every commercial payer and CMS. They could barely get paid for the services they were providing because of documentation rules. Nobody could keep up with all the nonsense.

So when The big hospital in town wants to expand then why not go with them? They can hire whole bunch of biller/coder people and let the MBA types worry about revenue streams. And now people are complaining it costs too much after all the garbage they put these docs through.

If the payors especially CMS gave at least a whiff of consideration to these small and independent practices and recognized that they can provide good care at a reasonable cost maybe we wouldn’t be in this situation. But no instead they kowtowed to the AHA and decided that those evil greedy private docs should be driven out of bussiness and twist their arm into being a cog in the hospital machine. All under the guise of better healthcare. This is what you end up with. I don’t know a single graduating resident that would even consider going into PP let alone starting one. The deck is so stacked against you it isn’t even worth fighting especially with so much student debt.

In my opinion, the measures taken to promote site neutrality payments hurt heath systems and employed docs (which now I think comprises >50% of physicians in the US) more so than it helped the private practitioner. If the private practice rates were low enough to drive docs into the arms of the health system I don’t see how making it standard accross the entire industry helps any physician. Great it’s a level playing field and now everybody on the field is dying. These measures should have been coupled with more support in the form of better reimbursement for services rendered outside the confines of a health system. But of course that would mean admitting that those evil private docs actually do provide value and of course going hitting campaign contributions from the AHA.

 

[RickyScott]

Its not a complete lie, you dont know what your talking about. I heard as well from people at MSKCC they are hiring alot of positions. I also spoke with leadership of MD Anderson and they are hiring multiple positions. NYC and Houston TX, are those junk middle of nowhere cities??

Alot of overblown end of the world talk on this thread. Rad Onc is a small competitive field, the med students that applied this year are lucky that they will all match.

BTW there is unintended irony in this post. It would be like a path resident 10 years ago stating "Look Quest/Ameripath is hiring, so the job market is great!" when it was those very forces of consolidation/centralization by entities like Quest (along with the rapid expansion of residency spots) that threaten/destroyed the job market in path.

Centralizing/consolidative forces like MSKCC expanding into the suburbs are not positive for the overall job market. In radiation, we will also be affected by similar forces of consolidation/centralization to go along with hypofractionation and (more than) doubling of residency slots.

If MSKCC invested heavily in expanding into my area they could easily fold the departments of several smaller community hospitals-including mine- and freestanding centers and cut the radoncs in half. If they hired some radoncs to accomplish this, how could you cite this of proof of a flourishing job market.

IGNORE TROLLS, PATH IS A GOOD FIELD...CHECK IT OUT FOR YOURSELF

 

[evilbooyaa]

The data is actually much worse than what I posted. I'm with a very large private practice, and our payers we negotiate with tell us academic centers cost 5x what we do with equivalent outcomes. This is internal data, I saw it, but I cannot share it. I certainly don't expect you to believe me, but that's what it is.

However, pay rates from insurers generally start with Medicare rates as a base/starting point, and as you know Medicare rates for hospital-based services are substantially higher than those for free-standing clinics for the same XRT services. You don't need "proof" for this, as it's published in the CMMS rates. As a result, yes rates are negotiated, but it's from a starting point which already is on uneven ground.

Academic centers are paid by the government to provide training for residents; it's not my understanding that payers are responsible for any additional expenses due to residents being in the clinic.

I certainly do agree that payers may want to include academic centers in their approved clinics, as it would help potentially attract patients.

Finally, I do not care in the least that academic radoncs don't negotiate those contracts. The "financial toxicity" of their patients should be their concern whether or not they were involved in contract negotiation, and we both know academic radoncs continually browbeat their community colleagues for what they see as overly-expensive care. It's hypocritical to do so while providing care which costs far more than it needs to.

Just an aside, in the interest of unbiased reporting, the only real thing I can find in regards to higher reimbursement from Medicare suggests that freestanding centers get paid MORE, at least in prostate cancer, based on this SEER analysis: http://ascopubs.org/doi/full/10.1200/jop.2015.005694

Figure 2 shows the data.

Not a ton published, obviously, but just a data point.

 

[seper]

Nice paper, thanks. I guess it says that real-life payout to freestanding centers is higher than to the hospitals. Reading this forum, one would think the opposite is true.

Just an aside, in the interest of unbiased reporting, the only real thing I can find in regards to higher reimbursement from Medicare suggests that freestanding centers get paid MORE, at least in prostate cancer, based on this SEER analysis: http://ascopubs.org/doi/full/10.1200/jop.2015.005694

Figure 2 shows the data.

Not a ton published, obviously, but just a data point.

 

[GreyingRadOnc]

Troll alert

Highly ironic.

 

[Mandelin Rain]

Highly ironic.

Playing that long game troll. Fourteen years of troll free posts, just to pounce now. Impressive strategy.

 

[nkmiami]

I was under the impression that medicare reimbursement is always higher for hospital centers and the fees are set and posted by CMS. The issue with prices are the rates that private insurers pay are hidden by NDAs. Very few pts have (or would want) straight medicare. They have either medicare with supplement or medicare advantage/managed medicare. Stanford cant charge medicare 25,000 for an MRI (the rate is set by CMS), but they can do this to a private insurer or individual (prior post). Another post had a link to mednet where the Mayo clinic was claiming to charge 60,000 for stereo to a bone met.

The problem is the prices

"They were shocked a few months later when a bill arrived with a startling price tag: $25,000. The bill included $4,016 for the anesthesia, $2,703 for a recovery room, and $16,632 for the scan itself plus doctor fees. The insurance picked up only $1,547.23, leaving the family responsible for the difference: $23,795.47."

 

[medgator]

Highly ironic.

99.9% figure?

Give me a break...

 

[GreyingRadOnc]

The data is actually much worse than what I posted. I'm with a very large private practice, and our payers we negotiate with tell us academic centers cost 5x what we do with equivalent outcomes. This is internal data, I saw it, but I cannot share it. I certainly don't expect you to believe me, but that's what it is.

However, pay rates from insurers generally start with Medicare rates as a base/starting point, and as you know Medicare rates for hospital-based services are substantially higher than those for free-standing clinics for the same XRT services. You don't need "proof" for this, as it's published in the CMMS rates. As a result, yes rates are negotiated, but it's from a starting point which already is on uneven ground.

Academic centers are paid by the government to provide training for residents; it's not my understanding that payers are responsible for any additional expenses due to residents being in the clinic.

I certainly do agree that payers may want to include academic centers in their approved clinics, as it would help potentially attract patients.

Finally, I do not care in the least that academic radoncs don't negotiate those contracts. The "financial toxicity" of their patients should be their concern whether or not they were involved in contract negotiation, and we both know academic radoncs continually browbeat their community colleagues for what they see as overly-expensive care. It's hypocritical to do so while providing care which costs far more than it needs to.

What payers tell you in negotiations doesn't need to have any connection with reality. A negotiation is just that, and they can say anything they want. If the payer chooses to pay the difference it's up to them. Note: most insurance companies that sell health insurance are doing quite well. CEOs from health insurers are THE top paid (I have a link I can't share) of all CEO groups. To that end, only the insurers pay "financial toxicity" if the treating docs keep within the policy guidelines. None of that is passed to a patient beyond their deducible and I'm sure that no RT course, from any center, is less than a deductible.

Academic centers are "paid by the govt" thru medicare/medicaid, but it has been frozen, I believe since the 70's and doesn't come close to covering the costs associated with training. Insurers also pay for clinical trials under the concept that improving health care is part of the mission. I also don't think that academic centers "provide care which costs far more than it needs to"....what is that based on? Most private practice physicians make much more than academic physicians. The highest margin in all of medicine is at Gunderson Lutheren in LaCrosse, WI, which is a private practice hosptial with private practice doctors. If you look at the top 10 hospitals in the US for profit, only 2 are academic centers: (can't share link...healthcare affairs from 2016, vol 35, issue 5)

Unfortunately I can't post links here yet....

 

[nkmiami]

What payers tell you in negotiations doesn't need to have any connection with reality. A negotiation is just that, and they can say anything they want. If the payer chooses to pay the difference it's up to them. Note: most insurance companies that sell health insurance are doing quite well. CEOs from health insurers are THE top paid (I have a link I can't share) of all CEO groups. To that end, only the insurers pay "financial toxicity" if the treating docs keep within the policy guidelines. None of that is passed to a patient beyond their deducible and I'm sure that no RT course, from any center, is less than a deductible.

Academic centers are "paid by the govt" thru medicare/medicaid, but it has been frozen, I believe since the 70's and doesn't come close to covering the costs associated with training. Insurers also pay for clinical trials under the concept that improving health care is part of the mission. I also don't think that academic centers "provide care which costs far more than it needs to"....what is that based on? Most private practice physicians make much more than academic physicians. The highest margin in all of medicine is at Gunderson Lutheren in LaCrosse, WI, which is a private practice hosptial with private practice doctors. If you look at the top 10 hospitals in the US for profit, only 2 are academic centers: (can't share link...healthcare affairs from 2016, vol 35, issue 5)

Unfortunately I can't post links here yet....

But, how many patients have straight medicare (which pays 80% and doesnt cover prescriptions)? Almost all have either a supplement or managed medicare/medicare advantage. The government is paying the medicare component (which are known and standard), but then the supplement/managed medicare payments kick in and that is the big black hole and the source of price issues.

Lets give an example: say medicare reimburses 2,000 for imrt plan, we know the government will pay stanford that, but if stanford charges 10,000, the supplement/managed medicare will kick in to pay the differential (are they paying 4000, 5,000 9,000?) and that is hidden behind NDAs and supposedly the source of spiraling health costs.

Dominant health systems have a lot of leverage in these situations. For example, can an insurance plan oriented towards middle class/upper middle class refuse to deal with Partners in Boston, UPMC in Pittsburgh, Stanford/UCSF in SF, UPENN in phil etc

 

[GreyingRadOnc]

99.9% figure?

Give me a break...

According to wikipedia

In Internet slang, a troll (/troʊl, trɒl/) is a person who starts quarrels or upsets people on the Internet to distract and sow discord by posting inflammatory and digressive, extraneous, or off-topic messages in an online community (such as a newsgroup, forum, chat room, or blog) with the intent of provoking readers ...

Posting that most people are finding a job doesn't seem to qualify as a troll. Posting doom and gloom about a great profession, on boards frequented by the youth of the profession that don't have the perspective of time and experience, is trolling.

 

[GreyingRadOnc]

But, how many patients have straight medicare (which pays 80% and doesnt cover prescriptions?) Almost all have either a supplement or managed medicare/medicare advantage. The government is paying the medicare component (which are known and standard), but then the supplement/managed medicare payments kick in and that is the big black hole and the source of price issues.

Which don't relate to what a patient is paying aside from they pay for the supplemental. Remember that RadOnc is paid by fraction, not by course or diagnosis. If you bill 30/10 for bone mets and charge 1/5 of what an academic center charges, but they do 8/1....than it's still cheaper to do 8/1.

 

[nkmiami]

Which don't relate to what a patient is paying aside from they pay for the supplemental. Remember that RadOnc is paid by fraction, not by course or diagnosis. If you bill 30/10 for bone mets and charge 1/5 of what an academic center charges, but they do 8/1....than it's still cheaper to do 8/1.

who cares what the patient pays- thats not the point. Its macroscopically what society pays/cost to the system. When drug companies like Martin Shekelis inflate costs 25,000% for an old medicine, they always cut the patient a break/copay assistance/compassionate free drug if necessary, because they are making the windfall off the insurance that pay, but obviously this is horrible for the system.

And your above example is not correct if you are implying that 30/10 is 10x times 8x1. In our hospital it is about double to triple. (kind of makes me doubt you are a greying radonc.)

 

[GreyingRadOnc]

who cares what the patient pays- thats not the point. Its macroscopically what society pays. When drug companies like Martin Shekelis inflate costs 25,000% for an old medicine, they always cut the patient a break, because they are making the windfall of the insurance, but obviously this is horrible for the system.

And your above example is not correct if you are implying that 30/10 is 10x times 8x1. In our hospital it is about double to triple. (kind of makes me doubt you are a greying radonc.)

So you are saying your don't charge per fraction? This isn't considering the fixed costs of sim, management, etc. Point is that longer course RT is more expensive than shorter course.

So, nkami...you're assertion is that academic centers are driving up the costs of health care due to crazy billing relative to private practice settings. If that were the case than the article from health affairs would show academic systems occupying the majority of the top 10 systems....which isn't true. It's only 2 of 10.

 

[nkmiami]

So you are saying your don't charge per fraction? This isn't considering the fixed costs of sim, management, etc. Point is that longer course RT is more expensive than shorter course.

So, nkami...you're assertion is that academic centers are driving up the costs of health care due to crazy billing relative to private practice settings. If that were the case than the article from health affairs would show academic systems occupying the majority of the top 10 systems....which isn't true. It's only 2 of 10.

No. Regional consolidated/ monopolistic systems, many of which are not academic. Like a power company, you dont need national dominance, you just need a regional monopoly to drive up prices

Sutter Health in Northern California is in the news and being sued by the state of CA for this kind of behavior: California hospital giant Sutter Health faces heavy backlash on prices - Los Angeles Times UPMC in pitt, Florida Hospital in Orlando-

"In his 49-page complaint, Becerra cited a recent study finding that, on average, an inpatient procedure in Northern California costs 70% more than one in Southern California. He said there was no justification for that difference and stopped just short of dropping an expletive to make his point."

"A major court ruling in California could be a deterrent to other hospital systems," said Ge Bai, an assistant professor at Johns Hopkins University who has researched hospital prices nationwide. "We're getting to a tipping point where the nation cannot afford these out-of-control prices."

Reflecting that sense of public desperation, Sutter faces two other major suits — from employers and consumers — which are wending their way through the courts, both alleging anticompetitive conduct and inflated pricing. Meanwhile, California lawmakers are considering a bill that would ban some contracting practices used by large health systems to corner markets."


In cancer, because of the nature of the disease, you can achieve dominance/monopoly pricing power with a name like MSKCC or MDACC, but fo

 

[imhopeful432]

But, how many patients have straight medicare (which pays 80% and doesnt cover prescriptions)? Almost all have either a supplement or managed medicare/medicare advantage. The government is paying the medicare component (which are known and standard), but then the supplement/managed medicare payments kick in and that is the big black hole and the source of price issues.

Lets give an example: say medicare reimburses 2,000 for imrt plan, we know the government will pay stanford that, but if stanford charges 10,000, the supplement/managed medicare will kick in to pay the differential (are they paying 4000, 5,000 9,000?) and that is hidden behind NDAs and supposedly the source of spiraling health costs.

Dominant health systems have a lot of leverage in these situations. For example, can an insurance plan oriented towards middle class/upper middle class refuse to deal with Partners in Boston, UPMC in Pittsburgh, Stanford/UCSF in SF, UPENN in phil etc

Medicare Advantage pays almost the same exact amount as Medicare FFS pays for physician services. Their rates are tied to Medicare FFS rates and not commercial payer rates. Stanford can't charge the supplement 10k extra. Happy to share some references or wikipedia how Medicare Advantage works.

But you're right re: negotiating power = higher reimbursement to academic centers for patients under 65 with pure commercial insurance.

Too much mis-information on this thread!

 

[nkmiami]

Medicare Advantage pays almost the same exact amount as Medicare FFS pays for physician services. Their rates are tied to Medicare FFS rates and not commercial payer rates. Stanford can't charge the supplement 10k extra. Happy to share some references or wikipedia how Medicare Advantage works.

But you're right re: negotiating power = higher reimbursement to academic centers for patients under 65 with pure commercial insurance.

Too much mis-information on this thread!

I wasnt reffering to physician services/ fees, which are not the major component of health care costs or hospital profits. To be fair, let me verify that facility fees are negotiated, but happy to see references on that. (the only misinformation i have seen are your claims of a robust job market) Either way, thats also why many regional monopolies dont take much medicare advantage (and incidentally, why I get half my patients)

From MSKCC website
"If you are enrolled in a Medicare Advantage plan, please contact your insurance carrier to determine your benefits and coverage at Memorial Sloan Kettering since your access may be limited."

 

[MegaVoltagePhoton]

The data is actually much worse than what I posted. I'm with a very large private practice, and our payers we negotiate with tell us academic centers cost 5x what we do with equivalent outcomes. This is internal data, I saw it, but I cannot share it. I certainly don't expect you to believe me, but that's what it is.

However, pay rates from insurers generally start with Medicare rates as a base/starting point, and as you know Medicare rates for hospital-based services are substantially higher than those for free-standing clinics for the same XRT services. You don't need "proof" for this, as it's published in the CMMS rates. As a result, yes rates are negotiated, but it's from a starting point which already is on uneven ground.

Academic centers are paid by the government to provide training for residents; it's not my understanding that payers are responsible for any additional expenses due to residents being in the clinic.

I certainly do agree that payers may want to include academic centers in their approved clinics, as it would help potentially attract patients.

Finally, I do not care in the least that academic radoncs don't negotiate those contracts. The "financial toxicity" of their patients should be their concern whether or not they were involved in contract negotiation, and we both know academic radoncs continually browbeat their community colleagues for what they see as overly-expensive care. It's hypocritical to do so while providing care which costs far more than it needs to.

Ah yes, of course, I'm sure you have the data. Your people are looking into it, and they can't believe what they're finding, right?

It is 100% true that the narrative on this forum is being driven by a few posters shouting loudly and often non-sensically, with no evidence. It's very telling that these are generally posters who have been attendings for years in private practice. I wonder, could they have anything to gain by thinning the market of new grads? Could they have anything to gain by making sure that a generation of upcoming rad oncs are considered "subpar" because the caliber of med students dropped?

I wonder.

Also, I wonder, will they admit that as much as "academic leaders" are to "blame" for hypofractionation, so are the private practice docs who ignore data for hypofractionation, practice absurbidities like scalp-sparing IMRT, and, generally speaking, abused IMRT to make a nice living, eventually leading to rad onc getting put on the radar as a high-billing specialty? Will they admit that?

 

[medgator]

According to wikipedia

In Internet slang, a troll (/troʊl, trɒl/) is a person who starts quarrels or upsets people on the Internet to distract and sow discord by posting inflammatory and digressive, extraneous, or off-topic messages in an online community (such as a newsgroup, forum, chat room, or blog) with the intent of provoking readers ...

Posting that most people are finding a job doesn't seem to qualify as a troll. Posting doom and gloom about a great profession, on boards frequented by the youth of the profession that don't have the perspective of time and experience, is trolling.

It does if it goes against what has been published in the literature recently. Which it does.

https://www.redjournal.org/article/S0360-3016(15)00337-5/abstract

Maybe you could help me find the "99.9%" figure in that paper...

 

[medgator]

also why many regional monopolies dont take much medicare advantage (and incidentally, why I get half my patients)

Ditto. They preferentially contract with us because we are the value based provider and they don't want to contract with the hospital system that costs them more and also happens to compete with them in the insurance market....

 

[medgator]

.

Also, I wonder, will they admit that as much as "academic leaders" are to "blame" for hypofractionation, so are the private practice docs who ignore data for hypofractionation, practice absurbidities like scalp-sparing IMRT, and, generally speaking, abused IMRT to make a nice living, eventually leading to rad onc getting put on the radar as a high-billing specialty? Will they admit that?

You mean like what academic leaders are doing with protons? Hate to use anything that sounds even remotely "trumpian" but there really is blame to go around on both sides.

 

[GreyingRadOnc]

It does if it goes against what has been published in the literature recently. Which it does.

Maybe you could help me find the "99.9%" figure in that paper...

It was only 96%, using a flawed methodology that assumed a person wasn't employed if they didn't reply to the survey or couldn't be found by internet stalking. Note however, that of the respondents there was an average of 2 offers. You only need 1 offer to be employed.

One thing that's important to remember about the field of Rad Onc is that it's small and the world doesn't need a million of us. When I went in to the field I assumed I wouldn't necessarily find the job I wanted in the city I wanted as a first job. About 50% of rad oncs change jobs...they find a good option closer to where they want or a better group for them which wasn't available when they were finishing up. I really wanted to be in my home town when I finished residency but they had hired 2 residents in the 2 years that preceded my graduation. Hence, in a mid sized group, there was no job for me. Over the past decade they have approached me 2 or 3 times about a job opportunity but I've been happy so didn't pursue it. That's reality for Rad Onc and for all small subspecialized groups. If you want 100% employment in the idea city consider primary care....but I bet they don't offer employment rates at 100% (or even 96%). They also don't make as much money or have as good of a lifestyle, workwise, as we do. It's a tradeoff and most residents know that.

 

[GreyingRadOnc]

You mean like what academic leaders are doing with protons? Hate to use anything that sounds even remotely "trumpian" but there really is blame to go around on both sides.

Academic leaders aren't pimping protons. I'd like some proof of that. I have a friend who is a CPC chair at a proton center and his view of ASTRO is that they protect private practices and are hostile to protons. Also, most academic centers don't have protons. Just the big ones. Take Philly (please)....3 academic centers, 1 proton center. NYC, a bazillion academic centers and no real proton center. Boston...3 academic centers, 1 proton center. Chicago, 3'ish and 1 proton center which was pvt practice until recently.

 

[Haybrant]

Ah yes, of course, I'm sure you have the data. Your people are looking into it, and they can't believe what they're finding, right?

It is 100% true that the narrative on this forum is being driven by a few posters shouting loudly and often non-sensically, with no evidence. It's very telling that these are generally posters who have been attendings for years in private practice. I wonder, could they have anything to gain by thinning the market of new grads? Could they have anything to gain by making sure that a generation of upcoming rad oncs are considered "subpar" because the caliber of med students dropped?

I wonder.

Also, I wonder, will they admit that as much as "academic leaders" are to "blame" for hypofractionation, so are the private practice docs who ignore data for hypofractionation, practice absurbidities like scalp-sparing IMRT, and, generally speaking, abused IMRT to make a nice living, eventually leading to rad onc getting put on the radar as a high-billing specialty? Will they admit that?

Right there is a cabal of shouting conspirators out there that are trying to take the luster off the field! It’s just not sensical to think there would be a problem when residency spots have increased from 140 to 200, not sensical at all! It doesn’t take a genius to think this might have some effect despite your rose colored glasses. This has directly lead to a drop in number and quality of applicants and that will continue

 

[medgator]

It was only 96%, using a flawed methodology that assumed a person wasn't employed if they didn't reply to the survey or couldn't be found by internet stalking. Note however, that of the respondents there was an average of 2 offers. You only need 1 offer to be employed.

One thing that's important to remember about the field of Rad Onc is that it's small and the world doesn't need a million of us. When I went in to the field I assumed I wouldn't necessarily find the job I wanted in the city I wanted as a first job. About 50% of rad oncs change jobs...they find a good option closer to where they want or a better group for them which wasn't available when they were finishing up. I really wanted to be in my home town when I finished residency but they had hired 2 residents in the 2 years that preceded my graduation. Hence, in a mid sized group, there was no job for me. Over the past decade they have approached me 2 or 3 times about a job opportunity but I've been happy so didn't pursue it. That's reality for Rad Onc and for all small subspecialized groups. If you want 100% employment in the idea city consider primary care....but I bet they don't offer employment rates at 100% (or even 96%). They also don't make as much money or have as good of a lifestyle, workwise, as we do. It's a tradeoff and most residents know that.

Glad you agreed that the 99.9% figure was bs. Telling everyone that 99.9% of people are getting the job they want in RO is trolling, plain and simple. The facts do not bear that out.

Rad onc has always had a problem of geography when it comes time for looking for a job. Residents coming in have known this for years. Despite that most people still do it expecting to be able to end up somewhere on a list of preferred geographic locales.

Nor so for the class of 2014 though

Seventy-one percent felt the job market was worse than what they anticipated when entering residency. Thirty-three percent found no job openings in their geographic area of preference.

 

[medgator]

Academic leaders aren't pimping protons.

Protons were marketed heavily during the last several years for prostate ca in my neck of the woods by the local academic center. Patients would come in, requesting it.

The finances of most proton centers built in the last several years have been predicated on treating a large volume of prostate ca, not peds and retreats.

So even if the academic leaders weren't marketing it to the general public, their marketing depts were.

http://ascopubs.org/doi/abs/10.1200/jco.2014.32.15_suppl.e16098

 

[MegaVoltagePhoton]

You mean like what academic leaders are doing with protons? Hate to use anything that sounds even remotely "trumpian" but there really is blame to go around on both sides.

Is that all you can come up with in response?

Spoiler alert -- I agree with you. Academic institutions pimping protons are foolish. However, that is literally a "whatabout" "counter". You can't deny what I said, which is that it was largely private practice that milked the teat of IMRT dry and put rad onc in the sights of Medicare and payor snipers. So to be logically consistent, you can't just blame academics for protons and ignore the problems caused by private practice.

Moreover...are we seriously considering places like Hampton, Loma Linda, and Scripps (all proton centers) as "Academic"? These are obviously private practice entities with a thin veneer of academia at best. MDACC, MGH, yes, you have a point. They shouldn't be farting around with protons for prostate.

 

[MegaVoltagePhoton]

Right there is a cabal of shouting conspirators out there that are trying to take the luster off the field! It’s just not sensical to think there would be a problem when residency spots have increased from 140 to 200, not sensical at all! It doesn’t take a genius to think this might have some effect despite your rose colored glasses. This has directly lead to a drop in number and quality of applicants and that will continue

This is circular reasoning at its finest. Yes, a shouting cabal on SDN, a widely read forum, created a widespread perception that there is a vast oversupply/demand problem. Literally every large thread devolved into the same echo chamber, with multiple topics dedicated solely to this. Then, eventually, the number of applicants dropped. So since the applicant number dropped, there must have been an oversupply problem after all!

Yes, I do think it's shady that the most outspoken critics of the residency expansion are private practice docs who are years into their private practice careers, already made bank, and were afraid of their own job security and financial compensation if there were more grads coming out. Needless to say it is the same group that largely consists of anti-hypofractionation individuals.

Now, the well is poisoned, and many of the graduating grads will be viewed as substandard the specialty as no longer competitive. Your jobs are highly secure.

Oh, never mind -- the conspiracy theory only works if we're blaming "academics" for wanting more people to write their notes, not if the conspiracy theory is about private practitioners protecting their own turf.

Yeah, well, mission accomplished for you.

 

[medgator]

Is that all you can come up with in response?

Spoiler alert -- I agree with you. Academic institutions pimping protons are foolish. However, that is literally a "whatabout" "counter". You can't deny what I said, which is that it was largely private practice that milked the teat of IMRT dry and put rad onc in the sights of Medicare and payor snipers. So to be logically consistent, you can't just blame academics for protons and ignore the problems caused by private practice.

Moreover...are we seriously considering places like Hampton, Loma Linda, and Scripps (all proton centers) as "Academic"? These are obviously private practice entities with a thin veneer of academia at best. MDACC, MGH, yes, you have a point. They shouldn't be farting around with protons for prostate.

Sure, I'll give that to you... Personally I do my part/don't contribute to that problem though by following ebm and guidelines. And I've been a long-standing proponent of bundles to counteract that problem (you know the concept astro opposed for years, thereby protecting higher hospital-based per fx reimbursement)

PPs aren't driving the specialty into the ditches though with the rampant, unfounded 50% increase in residency slots the last decade or this recent debacle regarding board certification/ABR. No whataboutism there

 

[medgator]

This is circular reasoning at its finest. Yes, a shouting cabal on SDN, a widely read forum, created a widespread perception that there is a vast oversupply/demand problem. Literally every large thread devolved into the same echo chamber, with multiple topics dedicated solely to this. Then, eventually, the number of applicants dropped. So since the applicant number dropped, there must have been an oversupply problem after all!

Yes, I do think it's shady that the most outspoken critics of the residency expansion are private practice docs who are years into their private practice careers, already made bank, and were afraid of their own job security and financial compensation if there were more grads coming out. Needless to say it is the same group that largely consists of anti-hypofractionation individuals.

Now, the well is poisoned, and many of the graduating grads will be viewed as substandard the specialty as no longer competitive. Your jobs are highly secure.

Oh, never mind -- the conspiracy theory only works if we're blaming "academics" for wanting more people to write their notes, not if the conspiracy theory is about private practitioners protecting their own turf.

Yeah, well, mission accomplished for you.

Yes I'm sure none of the recent resident job survey numbers published in the red journal corroborating what was on this forum had anything to do with it....

And you still can't rebut the fact that there was a 50% increase in residency spots this decade with trends towards decreased demand in multiple disease sites as we move to observation and hypofx in some patients.

private practitioners protecting their own turf.

More grads are actually better for entrenched private practices, lower salaries, more supply etc. Not a difficult thing to figure out. Do you think everything is a conspiracy theory?

 

[smith2009]

PPs aren't driving the specialty into the ditches though with the rampant, unfounded 50% increase in residency slots the last decade or this recent debacle regarding board certification/ABR. No whataboutism there

Bingo.

 

[RickyScott]

I am probably the number one alarmist, "hater," fearmonger here.

1) Residency slots have more than doubled (90 to 200 and growing) since the early 2000's so how can that not impact the job market. Oldgreyradonc, who has an opposing view, even admits that it was not a cakewalk to get a job back then, before the expansion. In what world do you live in that this has no bearing on a job market already faced with hypofractionation and hospital consolidations and shouldnt lead to concern?

2) Notion of private practice: Most radoncs are like myself, employed by a community hospital, according to surveys, and salaried. I am "private practice" because I dont work for a university is nonsensical. I have never seen a penny of technical fees. I have always received a salary and RVU production bonus that has no incentive for IMRT treatments, which is by far the most common form of employment. Presently, I know of one or 2 docs in desirable metropolitan areas that get any kind of technical component. And if I was truly in private practice and greedy, I would be totally in favor of more residents to exploit.

3) How would I benefit from lower quality applicants in terms of jobs five years from now? Residency slots are unchanged. There would still be the same number of docs coming out with MSKCC Harvard and MDACC, etc on their resumes, very desirable to my administrators? Lower quality docs ultimately just deligitimize the entire field and lead to less innovation, which is not in my interest.

4)fees: if the same hospital procedures are on average 70% more expensive in Northern california vs Southern, isnt it completely reasonable that there are much larger differentials between MSKCC and 21 C in yonkers/wescherster? Our own reimbursement for stereo for bone is about 4-5x less what the Mayo clinic says they charge on mednet.

5) Yes, 10-15 years ago imrt was exploited by private practice- Beams and Schemes is a seminal article, but now it is the academic centers who are expanding with satellites. At the heart of the issue, however, is the fixed cost nature of radiation economics (so price increases are tremedous windfall) but now, the landscape tremendously favors the large hospital systems with tremendous negotiating clout due to presence or reputation. And when they acquire relative pricing advantages, it only financially makes sense for them to acquire rivals, set up satellites. There is so much academic and lay literature on prices in these systems (not utilization) as the single biggest issue in health care. It makes front page of NY times/wash post/la times several times a year as well as JAMA, etc-

6) if a medstudent wants to investigate the job market, rotate, speak with residents and junior attendings. Find out why locums rates havent changed in 20 years and are lower than daily salaries with benefits, see if there is mobility with junior faculty etc, Has there been a growth in "fellowships" in recent years.

 

[Mandelin Rain]

I still can't figure out how someone believes more residents doesn't benefit entrenched private practitioners. I can hire anew grad for less money, less favorable terms, and no partnership track? Yes, please.

There's literally 3 groups of people it benefits; department chairs, hospital admins, and entrenched private practice owners.

I think that the people here 1. can do math, and believe that math doesn't lie and 2. are concerned about fairness beyond "it only takes 1 offer to be employed" style nonsense.

I don't live or work in all markets so I won't pretend to know what the job situation is like nationwide. Here, in my market, it's not as bad as portrayed on this site. We're hiring. It's a great job. But, I get that many rad onc residents don't want to move here for whatever reason. I also don't think that you can look at one year of job openings and declare the problem doesn't exist. Especially on the back of a decade long bull market that saw retirement portfolios swell by 20% last year. One-off events impact the job market in unpredictable ways, but math always wins. Greater supply + lesser demand = lousy outcome. If the stock market drops 30% this year, I wish all the 2020 graduating rad oncs good luck.

 

[scarbrtj]

practice absurbidities like scalp-sparing IMRT

Many smart, well-meaning people opined about ways to prevent alopecia from WBRT for years. Your point seems to be that when it comes to giving a patient alopecia or not--give it to them if it costs money to prevent it. In a different era, doctors who tried to prevent side effects in their patients were lauded versus impugned. The med oncs don't seem to sweat it. With IMRT it costs a few extra thousand dollars to effectively prevent a CTCAEv5 Gr2 toxicity. With protons it costs maybe $100 million to give a Gr2 toxicity. And IMRT is still focused on as the absurdity. To paraphrase Albert Brooks it's like saying the problem with the terrorists is they put too much oil in their hummus. The no-hair theorem in astrophysics is related to the information paradox (ie a black hole doesn't have a "memory" of its infallen matter); why can't we in radiation oncology associate memory and hair, too, for WBRT? (BTW, doing hippocampal sparing dramatically lowers the alopecia toxicity... IMRT was never "scalp-sparing" with a scalp OAR... the tech was simply leveraged to allow multifield WBRT which made the XRT overall more skin sparing; e.g. less skin toxicity with a 4-field pelvis vs AP/PA pelvis.)

 

[evilbooyaa]

This is circular reasoning at its finest. Yes, a shouting cabal on SDN, a widely read forum, created a widespread perception that there is a vast oversupply/demand problem. Literally every large thread devolved into the same echo chamber, with multiple topics dedicated solely to this. Then, eventually, the number of applicants dropped. So since the applicant number dropped, there must have been an oversupply problem after all!

Yes, I do think it's shady that the most outspoken critics of the residency expansion are private practice docs who are years into their private practice careers, already made bank, and were afraid of their own job security and financial compensation if there were more grads coming out. Needless to say it is the same group that largely consists of anti-hypofractionation individuals.

Now, the well is poisoned, and many of the graduating grads will be viewed as substandard the specialty as no longer competitive. Your jobs are highly secure.

Oh, never mind -- the conspiracy theory only works if we're blaming "academics" for wanting more people to write their notes, not if the conspiracy theory is about private practitioners protecting their own turf.

Yeah, well, mission accomplished for you.

But the most recent published data DOES state there is an impending oversupply of radiation oncologists. Like, published in red journal. Many who are most vocal (at least on SDN, without fear of obvious retaliation) about limiting residency expansion are CURRENT or recently graduated residents.