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

[deleted1111261]

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

Ugh. Yes, so many people make this claim for some reason.

I think for the youth, that’s what they call it. Basically, If someone other than university pays you, they call it private practice, because people like 2 categories instead of >2.

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Members don't see this ad.

 

[fiji128]

I don't really understand. CMS punted this whole APM thing. Why is Astro trying to get this re implemented?

 

[NotMattSpraker]

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

Don't know. But it seems reasonable to put names on a webpage so the volunteers can get credit and the members can know who is "advocating" for them (or not).

 

[fiji128]

Also, for some perspective, this is what real cost look like in cancer. "Analysts project that Amgen’s Lumakras will reach $346.75 million in sales this year and more than $1 billion in 2024." No survival benefit mind you.

New Cancer Drug Beats Chemotherapy in Study

Amgen’s Lumakras targets a mutation called KRAS that is common among many cancers.

www.wsj.com

 

[TheWallnerus]

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

THIS is why APM will be bad. It’s that private insurance will be “taught” and encouraged how to implement it

Medicare reimbursement is down by about 20 to 30% last 10y across rad onc because of code change values but also stagnation and drop off in RT utilization. But rad onc is still achieving financial growth thanks to insurances. That has covered a plethora of ills. APM would deeply threaten that gravy train imho

 

[medgator]

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).

Many of these patients also don't get seen at the nearest PPS exempt place because of contracting etc and most of the Medicaids and MA patients being "out of network" likely because they don't want to deal with lower reimbursement and evilcore/Optum etc

 

[medgator]

Ugh. Yes, so many people make this claim for some reason.

I think for the youth, that’s what they call it. Basically, If someone other than university pays you, they call it private practice, because people like 2 categories instead of >2.

It is community employment, should be called as such imo. Vs PP as a PSA or PP with freestanding ownership.

 

[medgator]

Also, for some perspective, this is what real cost look like in cancer. "Analysts project that Amgen’s Lumakras will reach $346.75 million in sales this year and more than $1 billion in 2024." No survival benefit mind you.

New Cancer Drug Beats Chemotherapy in Study

Amgen’s Lumakras targets a mutation called KRAS that is common among many cancers.

www.wsj.com

There was that stat at an ASTRO meeting after the turn of the century talking about how all of rad onc spend was basically equal to epo spending by med onc

 

[elementaryschooleconomics]

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.

Though it can be hard (or impossible) to tease out RadOnc-specific numbers from the public data, virtually everyone is claiming to be a nonprofit these days, which means completing the IRS form 990, which you can Google.

Using ProPublica, we can pull up Stony Brook. Here's 2012 vs 2020.

I'll refrain from editorializing.

 

[deleted1116990]

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

I was recruited under this lie out of residency. It's an anachronism from an era long ago where the options were working for yourself or working for a university as faculty. Trying to behave like you are a private practitioner when you have a boss and have to conform to policy that govern your compensation and work hours is not private practice and you will drive yourself insane trying to convince yourself otherwise and fight it. Pro-only groups and doctors with independent PSAs are kind of somewhere in between.

Put it this way, if there is an IT admin that has locked down your computer to such a degree that you can't change the vomit green wallpaper on Windows to whatever you want, you are not a private practitioner, sorry.

 

[deleted1111261]

what I take from that slide is Dr Ryu should ask for a raise

 

[Mandelin Rain]

Academic employment and non-affiliated hospital employment are the same thing. Neither is private practice. You have a boss, they have a boss, who also has a boss. You do what the boss says or you find a new job.

Pro-only/PSA groups are middle ground, where you have to be a partner to the hospital and work within it's ecosystem and play by their rules to a certain degree. But ultimately you get to decide what you do and run your business as you see fit.

Free standing private centers are very rare now, but what traditionally what most people thought of as private practice. Where you owned both the risk and the profits of your center.

 

[TheWallnerus]

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.

Though it can be hard (or impossible) to tease out RadOnc-specific numbers from the public data, virtually everyone is claiming to be a nonprofit these days, which means completing the IRS form 990, which you can Google.

Using ProPublica, we can pull up Stony Brook. Here's 2012 vs 2020.

I'll refrain from editorializing.

View attachment 359582

View attachment 359583

There's gold in them thar academic centers

 

[Fpg1245]

There's gold in them thar academic centers

It would be one thing if the people that actually worked there got any of it…but they don’t except of course the chairs.

 

[NotMattSpraker]

Academic employment and non-affiliated hospital employment are the same thing. Neither is private practice. You have a boss, they have a boss, who also has a boss. You do what the boss says or you find a new job.

Pro-only/PSA groups are middle ground, where you have to be a partner to the hospital and work within it's ecosystem and play by their rules to a certain degree. But ultimately you get to decide what you do and run your business as you see fit.

Free standing private centers are very rare now, but what traditionally what most people thought of as private practice. Where you owned both the risk and the profits of your center.

Haha ok. That's fine. While I disagree that academic and non-affiliate hospital employment are "the same thing", it doesn't really seem relevant to this conversation to argue over labels. I have had both types of jobs and there are some huge differences beyond rules and IT.

I still think ASTRO should just post who is on the committees and where they work so people can decide for themselves what motivations the committee members might have for their volunteer work.

 

[deleted1116990]

Academic employment and non-affiliated hospital employment are the same thing. Neither is private practice. You have a boss, they have a boss, who also has a boss. You do what the boss says or you find a new job.

Employment CAN be great. You can have a CEO that fights to bring you in at high compensation paying you out of tech, lets you set your own schedule and take time off as you see fit, shields you from the corporate b.s., etc. Can be very cushy especially in this environment where you just treat patients and somebody else does the heavy lifting. The downside is the CEO can leave or be replaced by corporate/owner with somebody antagonistic towards doctors, especially highly compensated ones, and either slashes your pay at the next contract renewal or tries to make you miserable so you quit.

I think the only zero risk situation for rad onc these days is working for the VA.

 

[deleted1111261]

Haha ok. That's fine. While I disagree that academic and non-affiliate hospital employment are "the same thing", it doesn't really seem relevant to this conversation to argue over labels. I have had both types of jobs and there are some huge differences beyond rules and IT.

I still think ASTRO should just post who is on the committees and where they work so people can decide for themselves what motivations the committee members might have for their volunteer work.

Yeah not the same thing as far a job goes

But, I mean you’re still owned by an institution.

Employment CAN be great. You can have a CEO that fights to bring you in at high compensation paying you out of tech, lets you set your own schedule and take time off as you see fit, shields you from the corporate b.s., etc. Can be very cushy especially in this environment where you just treat patients and somebody else does the heavy lifting. The downside is the CEO can leave or be replaced by corporate/owner with somebody antagonistic towards doctors, especially highly compensated ones, and either slashes your pay at the next contract renewal or tries to make you miserable so you quit.

I think the only zero risk situation for rad onc these days is working for the VA.

these exist but you may not have everything you want and you may not be as busy as you want, but there are a few kind and caring hospital jobs out there

 

[deleted1116990]

Yeah not the same thing as far a job goes

But, I mean you’re still owned by an institution.

these exist but you may not have everything you want and you may not be as busy as you want, but there are a few kind and caring hospital jobs out there

On the flip side, freestanding private practice CAN also be awful with exploitative partnership structures, greed, unsafe corner cutting due to lack of oversight, etc. I've had the pleasure of experiencing both toxic employed and PP situations.

 

[Doctorer]

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

Definitely not. Whether you get paid by RVU or new start or paper publication doesn't make a difference: you're employed. There's very little difference being employed in academic community practice versus by a health system. At the end of the day, someone else takes care of billing everything and pays you out of the collections.

 

[TheWallnerus]

On the flip side, freestanding private practice CAN also be awful with exploitative partnership structures, greed, unsafe corner cutting due to lack of oversight, etc. I've had the pleasure of experiencing both toxic employed and PP situations.

PP: the floor can be lower, but the ceiling can be greater

(The floor and ceiling here can refer to a great number of things, not just money)

 

[elementaryschooleconomics]

PP: the floor can be lower, but the ceiling can be greater

(The floor and ceiling here can refer to a great number of things, not just money)

 

[yesmaster]

If someone other than university pays you, they call it private practice, because people like 2 categories instead of >2.

It’s community practice. Community vs. academics. Locally sourced, farm-to-table vs. spam-in-a-can. Just kidding…. I deeply respect most of my academic colleagues.

I don’t feel like PSA or pro-only is private practice at all. Hospital employment and the relationships between admin & doctors also varies widely state-to-state.

May be blunt, but unless you’re hiring & firing, making major capital expense decisions, with technical ownership, and >90% mgma (which is for hospital employed jobs), it’s not PP.

 

[deleted1116990]

May be blunt, but unless you’re hiring & firing, with technical ownership, and >90% mgma (which is for hospital employed jobs), it’s not PP.

Agree but you are going to seriously rattle some people with this.
That said, there are some situations out there where a hospital employee is allowed to buy into the linac and collect a share of technical. It's rare but it happens. So is that more private-practice-sy than an independent doc(s) that gets a fixed $/wRVU paid to their LLC that they then pay themselves with? Maybe. Gets murky when your partner is the hospital. Sure, you have your own little independent bakery, but if you're paying protection money to the mob every week are you really independent?

 

[deleted1111261]

It’s community practice. Community vs. academics. Locally sourced, farm-to-table vs. spam-in-a-can. Just kidding…. I deeply respect most of my academic colleagues.

I don’t feel like PSA or pro-only is private practice at all. Hospital employment and the relationships between admin & doctors also varies widely state-to-state.

May be blunt, but unless you’re hiring & firing, making major capital expense decisions, with technical ownership, and >90% mgma (which is for hospital employed jobs), it’s not PP.

i don’t think it’s a “feeling” thing.

the way people are speaking is that private has virtue and employment has none

Employed = you are getting a regular paycheck, benefits, malpractice, etc. you are potentially part of a medical group. you have vacation days and arranging and paying for coverage is up to hospital.

Private = no W2. You eat what you kill. You pay for everything (malpractice, health insurance, retirement). You arrange coverage and pay out of pocket. Can be hospital or freestanding. Can be pro only or own machines.

Hiring / firing is a mirage. You can have this as an employed person if they give you enough authority and you may not have it even if you are in a single specialty private practice.

Money? I think I’m making more this year than partners at nearby private practice.

It’s all pretty sketchy.

 

[elementaryschooleconomics]

Money? I think I’m making more this year than partners at nearby private practice.

It’s all pretty sketchy.

Yeah I think there's a common misconception that "true" private practice (pro services agreement) will "always" (ish) make more money than academics or employed. I've definitely observed hospital-employed docs making more than pro-fee/PSA docs.

The only real truism, and I'm not even sure it's a concrete truism, is that PSA gives you more control...but also more risk.

 

[Mandelin Rain]

The thing about PSA is if you want to give yourselves 20 weeks vacation and 3 day weeks, you can. You can control your own retirement funds and health insurance options. And if you have a shift in referral patterns and have a banner year and make 1.5 million in pro, you keep it (reverse is obviously true as well). Whereas, **** like that would never fly in an employment model.

 

[deleted1111261]

The thing about PSA is if you want to give yourselves 20 weeks vacation and 3 day weeks, you can. You can control your own retirement funds and health insurance options. And if you have a shift in referral patterns and have a banner year and make 1.5 million in pro, you keep it (reverse is obviously true as well). Whereas, **** like that would never fly in an employment model.

I would say when I graduated, I really, really, really didn't want to work for a hospital. At this stage of life, that's probably the only type of job I want now. And, it is basically going to be all that's left. But, that is a huge loss to the community. Freestanding private practices generally provide excellent, cost effective care close to home. Pre-2010 or so, this seemed to be fine. Post 2010 or so, private practice became the enemy and policies and regulations actively were enacted to destroy them. And it continues...

At the same time, I think all of this is very malleable.

If I converted to a PSA (which was an option), if I said I was coming in for 3 days a week and they could hire someone else for the other 2, I'd be laughed out the door.

There's a fella I know who is employed and has a partner out west. They have done amazing work and have good relationship with C suite. They have arranged 3 days work weeks for each (well 4 day with one of those work from home, but the 5th day is off) and get full pay.

None of my hospital jobs had cap specified in the contract. One of my hospital jobs would attempt to slow you down but no explicit cap. If you hit greater than 95th percentile (or was it 99%?) they may consider re-education.

I think, in general - more autonomy with PSA / single or multi specialty private practice, more risk, more reward. In general - more safety and security in an employed job. But, there is a huge overlap between these models and I think finding fit is more important than anything else.

If you put each on in separate boxes, you may lose out on potentially good opportunities.

 

[deleted1116990]

The thing about PSA is if you want to give yourselves 20 weeks vacation and 3 day weeks, you can.

This is the number one thing for me. I pay my own coverage right now, and as such I rarely take it whereas when I was an employee I used every possible second. But there's something about knowing that you are in control of it that is immensely valuable. This aspect of being an employee makes you feel trapped. The "30 days PTO" provision really gives me anxiety because it's so rigid, and it's treated like a favor you have to ask for. You can't take an extended break or cut back if you want. It's balls to the wall until retirement or you quit. And of course, if you have a 30 day employment gap, you better be ready to explain that for literally forever. The thing is, with a PSA, even if your contract says your company is responsible for staffing the clinic with a BC doctor, if you're the only doctor and hire a different locums every other week, maybe not all but most hospitals are not going to be happy with that and eventually terminate the contract over continuity of care concerns.

None of my hospital jobs had cap specified in the contract. One of my hospital jobs would attempt to slow you down but no explicit cap. If you hit greater than 95th percentile (or was it 99%?) they may consider re-education.

I have seen unobtainable caps of something like 1.2M (a cap you don't care about) and also caps at 90% of MGMA (~800k). I don't get it. At that point you just say, if you feel you need to slow me down for compliance reasons I will bill on my own keep your benefits, thanks.

 

[NotMattSpraker]

This is all great info, too bad our ability to negotiate on these aspects has been totally destroyed by over supply.