RO APM indefinitely postponed...ASTRO still wants to politic

[Chartreuse Wombat]

ASTRO calls for a new value-based reimbursement structure for radiotherapy

On Aug 25, 2022, in reply to the final ruling on an alternative payment model for radiation oncology by the Centers for Medicare and Medicaid Services (CMS), Laura Dawson, Chair of the Board of Directors of the American Society for Radiation Oncology (ASTRO), expressed support for a value-based...

www.thelancet.com

ASTRO is preparing a new proposal for an alternative payment framework to share with stakeholders in late 2022. Apart from stressing the importance of episodic payments, the plan will also highlight strategies to assist patients belonging to socioeconomically marginalised groups to receive and to complete radiotherapy.

---

Members don't see this ad.

 

[metallica81788]

 

[elementaryschooleconomics]

Cool, I bet the PPS-exempt centers will trial this for the rest of the country right?

Right?

 

[BobbyHeenan]

How many people sitting on this ASTRO committee or assisting with the proposal will be exempt from any implications of this?

We need to see who is involved here. ONLY people with skin in the game should be drafting this.

 

[Chartreuse Wombat]

How many people sitting on this ASTRO committee or assisting with the proposal will be exempt from any implications of this?

We need to see who is involved here. ONLY people with skin in the game should be drafting this.

By definition skin in the game is COI....see what a trick they play.

 

[Gfunk6]

At the end of the day these APMs are designed to reduce payments from the Feds to hospitals and physicians - end of story. The bit about quality is nothing but a song and dance routine as explicitly telling people that APM is designed to cut reimbursement is crass.

Under normal circumstances, if such things are inevitable, it is better to be in the house during the planning of it than it is standing outside. However ASTRO does not advocate properly for the field as a whole and I have low confidence in the product of their efforts.

 

[OTN]

THE CALL IS COMING FROM INSIDE THE HOUSE

How about ASTRO look to their own 'leaders' from their own institutions and ask why they don't consider providing charity care to be part of their mission?

No, no, no...better to virtue signal through academic publication. Nauseating.

 

[BobbyHeenan]

By definition skin in the game is COI....see what a trick they play.

'Bureaucracy is a construction by which a person is conveniently separated from the consequences of his or her actions.'
~ N. Taleb

 

[Lamount]

I mean, IN THEORY, there are plenty of savings to be had without cutting take-home physician reimbursement. A clever and efficient APM COULD derive it's savings from making billing much more simple, thereby decreasing overhead and bolstering competition my making small practices more lucrative.

...but cleverness and efficiency rarely replace dumb and wasteful bureaucracies

A clever and efficient system would give a flat rate PER GIVEN RT INDICATION (i.e. one rate for locally advanced H&N, one rate for stage I lung -different from the rate for stage III lung, one rate for bone metastases etc...), and give more money for complicating factors, like retreatment with overlap, concurrent chemo etc...

It's not rocket science

 

[TheWallnerus]

ASTRO is driving me batty about this. If they hadn’t already driven me batty enough already. I don’t even know the motivations or ulterior motives at this point.

On the other hand, fellow rad oncs, there are MANY rad oncs in America who give 7 plus weeks of RT in advanced lung cancer. Who are doing 4 weeks of RT for bone mets. Six weeks of RT for breast. Won’t touch 5 and a half week prostate RT with a ten foot pole. And yes there is palliative proton radiotherapy. Lots of proton for breast at Loma Linda.

So radiation therapy, at a national level, is horribly inefficient for patients and for payors. What can be done. Anything?

 

[fiji128]

ASTRO calls for a new value-based reimbursement structure for radiotherapy

On Aug 25, 2022, in reply to the final ruling on an alternative payment model for radiation oncology by the Centers for Medicare and Medicaid Services (CMS), Laura Dawson, Chair of the Board of Directors of the American Society for Radiation Oncology (ASTRO), expressed support for a value-based...

www.thelancet.com

ASTRO is preparing a new proposal for an alternative payment framework to share with stakeholders in late 2022. Apart from stressing the importance of episodic payments, the plan will also highlight strategies to assist patients belonging to socioeconomically marginalised groups to receive and to complete radiotherapy.

"A CMS estimate suggested that the Radiation Oncology Model would generate hundreds of millions of dollars in cuts to radiation oncology, compounding the inflation-adjusted and utilisation-adjusted 27% decrease in the reimbursement relating to Medicare for radiotherapy that has occurred in the past 10 years."

"ASTRO is preparing a new proposal for an alternative payment framework to share with stakeholders in late 2022. Apart from stressing the importance of episodic payments, the plan will also highlight strategies to assist patients belonging to socioeconomically marginalised groups to receive and to complete radiotherapy."

Astro must be one of the dumbest medical professional orgs out there. Truly mind blowingly stupid.

 

[TheWallnerus]

"A CMS estimate suggested that the Radiation Oncology Model would generate hundreds of millions of dollars in cuts to radiation oncology, compounding the inflation-adjusted and utilisation-adjusted 27% decrease in the reimbursement relating to Medicare for radiotherapy that has occurred in the past 10 years."

"ASTRO is preparing a new proposal for an alternative payment framework to share with stakeholders in late 2022. Apart from stressing the importance of episodic payments, the plan will also highlight strategies to assist patients belonging to socioeconomically marginalised groups to receive and to complete radiotherapy."

Astro must be one of the dumbest medical professional orgs out there. Truly mind blowingly stupid.

One thing you can always rely on a rad onc for: thinking “If you think I’m dumb, it just proves my point that you are.”

Reminds me how much I used to love “The Sopranos.” Tony went to a lot of other people with “alternative payment models.” They either accepted his model or…

 

[communitydoc13]

mean, IN THEORY, there are plenty of savings to be had without cutting take-home physician reimbursement. A clever and efficient APM COULD derive it's savings from making billing much more simple, thereby decreasing overhead and bolstering competition my making small practices more lucrative.

A pro-fees practice with 3-5 docs can employ a single smart person to bill. Even with a much more rational APM, it's still going to take a single smart person to bill. Unless the cumulative deficit in pro collections with a new APM is miniscule or negative, it's going to be a loser financially for small practices.

I don’t even know the motivations or ulterior motives at this point.

Legacy. The board of ASTRO is filled with people established enough or in institutions large enough where actual collections for services mean very little to their personal future. A change in collections is not going to affect where they can send their kids to college or if the can retire at 60 vs 68. If a Canadian chair of the board can implement cost savings for American radiation oncology, they will be a global hero, right?

For the very established academic leadership, participating in a radical reform is much more important for career and even personal sense of accomplishment than ensuring that the field remain very lucrative. Now, lots of these folks would have had lower standings in their respective institutions if they hadn't been bringing in so much money to begin with. Also, they would have never gotten droves of overqualified applicants if there wasn't the expectation of excellent pay.

There is absolutely no interest on the part of ASTRO to advocate for how well private practitioners are paid. I'm surprised that anyone ever thought this.

 

[elementaryschooleconomics]

Legacy. The board of ASTRO is filled with people established enough or in institutions large enough where actual collections for services mean very little to their personal future. A change in collections is not going to affect where they can send their kids to college or if the can retire at 60 vs 68. If a Canadian chair of the board can implement cost savings for American radiation oncology, they will be a global hero, right?

For the very established academic leadership, participating in a radical reform is much more important for career and even personal sense of accomplishment than ensuring that the field remain very lucrative. Now, lots of these folks would have had lower standings in their respective institutions if they hadn't been bringing in so much money to begin with. Also, they would have never gotten droves of overqualified applicants if there wasn't the expectation of excellent pay.

There is absolutely no interest on the part of ASTRO to advocate for how well private practitioners are paid. I'm surprised that anyone ever thought this.

This is an extraordinarily important point.

Most specialties are bigger than RadOnc, and virtually all of them have several influential professional societies. There's always "the big one", usually with "American" somewhere in the name. But there's at least some actual representation from multiple practice environments.

Not here, not RadOnc. ACRO is a distant second, though they do good work.

We just have ASTRO, and it's run by geriatric academicians. The main "coin of the realm" for geriatric academicians has been, and will always be, their reputation. Patient care? The health of the specialty for the next generation of doctors? Nah bro.

LEGACY.

 

[deleted1116990]

Wonder if early career rad oncs will start shying away from partnership track positions due to the risk of bag-holding and just try and land the best salaried employed jobs they can.

 

[Fpg1245]

Wonder if early career rad oncs will start shying away from partnership track positions due to the risk of bag-holding and just try and land the best salaried employed jobs they can.

Early career rad oncs are idiots for trying to play the glass half full game with rad onc is a losing proposition long run. Most of them are in for some serious financial and geographic constraints. They best salaried job? If everyone suddenly tried to get a job of KPMG UPMC or Geisinger then why would they have to offer you a good salary? Oh wait, this is already happening.

The smartest early career rad oncs aren’t the ones trying to make the specialty work for them but the ones that are actively plotting an exit strategy.

The smartest move may be to take that underpaid academic job as fake faculty and make inroads with other specialties then retrain.

 

[deleted1111261]

Wonder if early career rad oncs will start shying away from partnership track positions due to the risk of bag-holding and just try and land the best salaried employed jobs they can.

For technical it’s possible

But the way business works, if the partnership was not valuable any more the firm would sell off the assets. Any technical partnership that is still running and plugging away is still probably doing okay.

Pro partnership - 95% - still better than not being a partner, bc you shouldn’t have more than nominal buy in. Partners tend to earn more than employed within same group (but there are exceptions)

 

[deleted1116990]

My point is that historically new graduates would prefer to take a 10th percentile salary for 2-5 years, sweat equity which would be recouped later with eventually a bigger pay off over the long run vs. taking a median MGMA job off the bat at HCA or something. It would be suboptimal to spend these critical early years only to end up in a situation where partner income has dramatically declined or worse not be offered partnership due to declining reimbursements or sale of the practice. In this environment, I'm wondering if more are just going to prefer to take the money upfront.

The smartest early career rad oncs aren’t the ones trying to make the specialty work for them but the ones that are actively plotting an exit strategy.

The smartest move may be to take that underpaid academic job as fake faculty and make inroads with other specialties then retrain.

I've looked at the option of retraining in rads or med onc. It's an extra 5-6 years all said and done assuming you can even get a spot somewhere. I'd be (solidly) middle aged by the time I'm done. I don't see this being a viable option for >95% of us. If someone has a story of a BC rad onc going back and doing another specialty, I'd love to hear it, because I have not heard of a single person actually doing this.

If there were a 2 year path to learn how to give chemo or read images, I'd be all over it. Beyond that, I'm sorry it doesn't make any sense, and the only other option is to live a modest lifestyle and save/invest as much as possible.

 

[communitydoc13]

If someone has a story of a BC rad onc going back and doing another specialty, I'd love to hear it, because I have not heard of a single person actually doing this.

The converse happened a lot (BC in IM or medonc with switch to radonc (particularly when 3 years training)). Multiple very prominent radoncs went this route. The difference is the intensity of training.

Going back to complete an IM residency in your 30s with likely subsequent fellowship when you can get a 300K+ job somewhere is approaching Tom Brady deciding to take hits to the head at age 45 or going full Neurosurgery when it comes to managing your relationship with your significant other.

Very hard to transition from a good sleep schedule to a bad one. Particularly when you are older.

 

[deleted1116990]

The converse happened a lot (BC in IM or medonc with switch to radonc (particularly when 3 years training)). Multiple very prominent radoncs went this route. The difference is the intensity of training.

Going back to complete an IM residency in your 30s with likely subsequent fellowship when you can get a 300K+ job somewhere is approaching Tom Brady deciding to take hits to the head at age 45 or going full Neurosurgery when it comes to managing your relationship with your significant other.

Very hard to transition from a good sleep schedule to a bad one. Particularly when you are older.

I did a real IM intern year (same as categoricals). In retrospect, I certainly wish I had done the other 2 years. But we are talking about going back and doing 80 hour weeks for at least another 2.5 years then a 3 year fellowship that's not much better with 2 board certifications to get past well into your 40s. I would love to meet the person that has actually done this. Tom Brady is at least getting paid $25M/year to risk his health and sanity. We will wake up at 5AM for $60k/year. It's a depressing pipe-dream best left in the past.

 

[temujim]

I did a real IM intern year (same as categoricals). In retrospect, I certainly wish I had done the other 2 years. But we are talking about going back and doing 80 hour weeks for at least another 2.5 years then a 3 year fellowship that's not much better with 2 board certifications to get past well into your 40s. I would love to meet the person that has actually done this. Tom Brady is at least getting paid $25M/year to risk his health and sanity. We will wake up at 5AM for $60k/year. It's a depressing pipe-dream best left in the past.

The institution that opens up a 1 year med onc fellowship (instructorship?) for rad oncs will be a hero. Even at my advanced tom brady age, may take a run at that.

 

[deleted1116990]

The institution that opens up a 1 year med onc fellowship (instructorship?) for rad oncs will be a hero. Even at my advanced tom brady age, may take a run at that.

Or a 2 year rads backdoor. Both I think are do-able and would be a win-win to rebalance oversupply in rad onc with undersupplies in those specialties. But, again, pipe dreams...

 

[communitydoc13]

The institution that opens up a 1 year med onc fellowship (instructorship?) for rad oncs will be a hero. Even at my advanced tom brady age, may take a run at that.

Considering the need for medonc in the community, I would bet someone could swing getting paid real money during the fellowship year to return and see medonc patients at hospital of present employment.

From an admins perspective, this might be better than hiring 3 medonc locums to fulfill role of single full time doc.

 

[medgator]

Considering the need for medonc in the community, I would bet someone could swing getting paid real money during the fellowship year to return and see medonc patients at hospital of present employment.

From an admins perspective, this might be better than hiring 3 medonc locums to fulfill role of single full time doc.

Considering the amount of skin cancer and h&n with the occasional lung i refer out for chemo or immuno or both, the combo pathway could be a real dual threat

 

[Fpg1245]

Considering the amount of skin cancer and h&n with the occasional lung i refer out for chemo or immuno or both, the combo pathway could be a real dual threat

Please academia will find someway to make it unbearably long and needlessly complicated that sucks even more of your soul. I love oncology but hate the people the run it with a passion.

 

[Fpg1245]

They love to scream about the shortages but when there’s actually one all of a sudden the willingness to solve it evaporates.

 

[thecarbonionangle]

Proton exception in the works? Many are saying it!

 

[RickyScott]

Hope this convinces anyone on the fence not to be a member.

 

[elementaryschooleconomics]

 

[grenz]

How many people sitting on this ASTRO committee or assisting with the proposal will be exempt from any implications of this?

We need to see who is involved here. ONLY people with skin in the game should be drafting this.

The ASTRO health policy committee is filled with private practice docs. The laws governing CMS are currently rigged against rad onc such that there will continue to be drastic cuts to increase pay for cognitive specialties. Some change needs to be enacted and APM would at least stabilize payments for the foreseeable future and also align financial incentives with hypofrac.

I think there’s a lot of knee jerk hate here against the APM because Medicare’s version of it was again rigged against rad onc. ASTRO’s version is mostly revenue neutral for rad oncs and not just meant to cut the specialty and provide a political win for Medicare

 

[Fpg1245]

The ASTRO health policy committee is filled with private practice docs. The laws governing CMS are currently rigged against rad onc such that there will continue to be drastic cuts to increase pay for cognitive specialties. Some change needs to be enacted and APM would at least stabilize payments for the foreseeable future and also align financial incentives with hypofrac.

I think there’s a lot of knee jerk hate here against the APM because Medicare’s version of it was again rigged against rad onc. ASTRO’s version is mostly revenue neutral for rad oncs and not just meant to cut the specialty and provide a political win for Medicare

Medicare’s version is heads I win tails you lose. There’s no way around it. They have to cut to spend elsewhere which is really the issue here.

The best astro is gonna muster is getting concessions on large ppfs exempt centers and proton therapy. Revenue neutral isn’t gonna cut it especially in community programs where they need those dollars to subsidize other depts.

A true Alternative payment model is a death knell for rad onc. The specialty will continue to evolve but it it won’t be doing anything exciting other than finding ways to cut staffing and labor costs while trying to convince grads this is good for them.

The fact that it has PP docs who are probably 20 years out minimum and will be out of the game in the next 10 years and is really not anything to cheer about.

 

[elementaryschooleconomics]

The ASTRO health policy committee is filled with private practice docs.

Where can we find a roster? I just went through my ASTRO account/the website/ROHub and I can't find anything on this committee.

 

[deleted1111261]

The ASTRO health policy committee is filled with private practice docs. The laws governing CMS are currently rigged against rad onc such that there will continue to be drastic cuts to increase pay for cognitive specialties. Some change needs to be enacted and APM would at least stabilize payments for the foreseeable future and also align financial incentives with hypofrac.

I think there’s a lot of knee jerk hate here against the APM because Medicare’s version of it was again rigged against rad onc. ASTRO’s version is mostly revenue neutral for rad oncs and not just meant to cut the specialty and provide a political win for Medicare

Filled? Who ?

You seem like a reasonable person. If what you’re saying is true, why aren’t they doing any outreach ? There is a paternalistic attitude about “we know best”, but we’ve been burned over and over. If there is even some outreach, it can be made better. Maybe this is an inevitability but that’s what you told us a few years ago. Here we are, lowering costs on our own, practicing cost effective medicine (at least in the community and at free standing centers; can’t speak for the university). We did so much educating on this with our episode - not one hand has reached out to say “hey- you’re passionate and thoughtful about this - let’s collaborate”

I am 100% certain if you all do these behind closed doors again and burn us all, the backlash will make the last few years seem cordial.

 

[RickyScott]

Cms reimbursement adjusted for inflation is down 20-30% over past 10 years, yet profits of large departments have probably increased x2.

 

[Mandelin Rain]

The issue is, if they came here and crowd sourced cost savings to present to CMS, the common sense solutions; ending PPS exemption for rad onc, decreasing reimbursement for low value care (protons, MRgWhatever, US guided skin cancer treatment BS that derms do), and a mechanism to reward docs for appropriately fractionating breast, prostate, and mets.....

...would be complete non-starters for the committee.

They would benefit the vast majority of rad oncs at the cost of a handful of select centers who have been reaming the system for years. That's not what they're looking for.

 

[BobbyHeenan]

The issue is, if they came here and crowd sourced cost savings to present to CMS, the common sense solutions; ending PPS exemption for rad onc, decreasing reimbursement for low value care (protons, MRgWhatever, US guided skin cancer treatment BS that derms do), and a mechanism to reward docs for appropriately fractionating breast, prostate, and mets.....

...would be complete non-starters for the committee.

They would benefit the vast majority of rad oncs at the cost of a handful of select centers who have been reaming the system for years. That's not what they're looking for.

It really is that simple:

1. End PPS exemption
2. Pay IMRT rate for protons for prostate-only treatments UNLESS enrolled in RANDOMIZED trial
3. Pay IMRT rate for any right sided breast cases UNLESS enrolled in RANDOMIZED trial.
4. End image guidance charges for "ultrasound" guided skin superficial kV treatments.
5. Stage I breast gets a flat rate. You can do waht you want (APBI, whole breast, protons, whatever). here's the rate.

Done.

That will save more money than APM and seems reasonable (to everyone except PPS exempt centers).

 

[Fpg1245]

The issue is, if they came here and crowd sourced cost savings to present to CMS, the common sense solutions; ending PPS exemption for rad onc, decreasing reimbursement for low value care (protons, MRgWhatever, US guided skin cancer treatment BS that derms do), and a mechanism to reward docs for appropriately fractionating breast, prostate, and mets.....

...would be complete non-starters for the committee.

They would benefit the vast majority of rad oncs at the cost of a handful of select centers who have been reaming the system for years. That's not what they're looking for.

Which is why places like this have no moral or even scientific authority to fraction shame. It’s clear they selectively follow the evidence (hypo frac on one hand but build proton centers on the other) and have all the rules stacked in their favor (ppfs exemptions, better commercial contracts).

 

[medgator]

I think there’s a lot of knee jerk hate here against the APM because Medicare’s version of it was again rigged against rad onc. ASTRO’s version is mostly revenue neutral for rad oncs and not just meant to cut the specialty and provide a political win for Medicare

It was rigged against certain rad oncs who were selected to be in the APM but specifically excluded PPS exempt places, many of which contain the very docs who helped author the APM. Good for thee, not for me.

ASTRO has never been a PP advocate, and opposed bundles and the IOAE that allowed rad onc ownership for years (including urorads). Bundling would have eliminated pricing disparities between more expensive and cheaper sites of service. Where do you think most of ASTRO leadership worked?

 

[Chartreuse Wombat]

Cms reimbursement adjusted for inflation is down 20-30% over past 10 years, yet profits of large departments have probably increased x2.

I work at a large department that is not PPS exempt. I can assure you that our margin has not increased two-fold. If you make this claim please provide evidence.

 

[grenz]

Filled? Who ?

You seem like a reasonable person. If what you’re saying is true, why aren’t they doing any outreach ? There is a paternalistic attitude about “we know best”, but we’ve been burned over and over. If there is even some outreach, it can be made better. Maybe this is an inevitability but that’s what you told us a few years ago. Here we are, lowering costs on our own, practicing cost effective medicine (at least in the community and at free standing centers; can’t speak for the university). We did so much educating on this with our episode - not one hand has reached out to say “hey- you’re passionate and thoughtful about this - let’s collaborate”

I am 100% certain if you all do these behind closed doors again and burn us all, the backlash will make the last few years seem cordial.

You seem to think I’m on the committee, but I can assure you I’m not. I just know this because of ACR and ASTRO conference panels that feature the committee members or members they’ve mentioned. Off the top of my head, Najeeb Mohideen at ROC, Lipscomb at Tennessee group, Manz, and at least one other. If you listen to these panels, their explanation for why ASTRO is pursuing this is both cogent and consistent

 

[Mandelin Rain]

Ending PPS exemption is lowest hanging fruit. Would save more that the entirety of the previous version.

 

[deleted1116990]

5. Stage I breast gets a flat rate. You can do waht you want (APBI, whole breast, protons, whatever). here's the rate.

Same with palliative/bone mets. I am tired of wasting my time arguing why 2D radiation planning is not appropriate in 2022.

 

[communitydoc13]

Ending PPS exemption is lowest hanging fruit. Would save more that the entirety of the previous version.

I fully agree with ending PPS exemption. I think most of congress knows its a boondoggle, but if you are a representative from a state with a PPS exempt facility, you are likely to want to keep it. These PPS exempt centers tend to be among the largest employers around.

ASTRO could certainly advocate for the removal of PPS exemption. I would like them to do that, but it won't get rid of it. The political barrier who might just be too big.

I do believe that if ASTRO really has a good faith concern regarding access, then they should look for solutions that help ensure that small, independent centers or hospitals remain viable. Agree with all of @BobbyHeenan recs.

Like many in the community, I overwhelmingly treat Medicare patients, with a significant amount of Medicaid and low cost Obamacare patients (some of whom we get insurance for contemporary to treatment or after the fact).

 

[Mandelin Rain]

Same with palliative/bone mets. I am tired of wasting my time arguing why 2D radiation planning is not appropriate in 2022.

Yup. Bone mets and stage I breast flat rate, you pick the modality and course.

Kind of a toe dip into a bundled care paradigm.

 

[deleted1111261]

You seem to think I’m on the committee, but I can assure you I’m not. I just know this because of ACR and ASTRO conference panels that feature the committee members or members they’ve mentioned. Off the top of my head, Najeeb Mohideen at ROC, Lipscomb at Tennessee group, Manz, and at least one other. If you listen to these panels, their explanation for why ASTRO is pursuing this is both cogent and consistent

I’ve never once argued against the rationale of episodic payments.

The way it was done was so shoddy and then Astro paraded it out like it was a show pony.

And then - If you disagree, then you are a very bad man.

Lottery, PPS exemption, discussion of various carve outs, historic rates that favor prior expensive care, brachy and palliative ridiculousness.

Any society would have said “thanks but no thanks” and start over considering the majority of us are out here treating patients.

 

[RickyScott]

I work at a large department that is not PPS exempt. I can assure you that our margin has not increased two-fold. If you make this claim please provide evidence.

Global negotiated prices have more than doubled over the past 10-15 years. This is reflected in the lists released by upenn and others. It is unlikely that upenn was charging 20k for a 3d plan and 300k for protons 10+ years ago. Cms reimbursement may be down, but it is reasonable to think radiation tracks global price increases.

 

[NotMattSpraker]

Where can we find a roster? I just went through my ASTRO account/the website/ROHub and I can't find anything on this committee.

One of my biggest gripes with ASTRO. I once suggested more transparency for things as simple as committee rosters when I was on the communications committee and it fell on deaf ears. Beyond transparency, most of these volunteers are great people and it would be great to highlight their work!

I do not believe that the majority of any ASTRO committee is in PP. If someone wants to share the roster for GR, that would be great.

 

[RickyScott]

One of my biggest gripes with ASTRO. I once suggested more transparency for things as simple as committee rosters when I was on the communications committee and it fell on deaf ears. Beyond transparency, most of these volunteers are great people and it would be great to highlight their work!

I do not believe that the majority of any ASTRO committee is in PP. If someone wants to share the roster for GR, that would be great.

Does Employment by a large community health system = private practice?

 

[deleted1111261]

I work at a large department that is not PPS exempt. I can assure you that our margin has not increased two-fold. If you make this claim please provide evidence.

I also find this hard to believe

I can believe that revenue has gone up a lot, but not profits. These places don’t run lean

 

[RickyScott]

I also find this hard to believe

I can believe that revenue has gone up a lot, but not profits. These places don’t run lean

I misused “profit”