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Ray D. Ayshun

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Changing fractionation schemes is a natural reaction to APM as this is the original intent of APM- to mitigate over-fractionation. But changing how you actively manage a patient on treatment, regardless of fractionation scheme, is vastly different in my professional opinion.

And you shorten treatment course AND change your management / documentation patterns, then you're double-fisting yourself a world of pain in both financial and potentially quality measures....
Getting rid of 77427 wouldn't change how I actively manage my patients, just how I document doing so.
 
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Mandelin Rain

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Changing fractionation schemes is a natural reaction to APM as this is the original intent of APM- to mitigate over-fractionation. But changing how you actively manage a patient on treatment, regardless of fractionation scheme, is vastly different in my professional opinion. Changing the latter would serve to CMS the validation that doctors are less valuable and less necessary in RO treatment. With all this talk about over saturation of RO market, finding more excuses to remove yourself further from patient management does not add up.

If you shorten treatment course AND change your management / documentation patterns, then you're just double-fisting yourself a world of pain in both financial and potentially quality measures....
I think you're ascribing a level of granularity that doesn't exist at CMS.

Anyway...
1. I continue doing 4 weeks for breast and decide to skip 2 OTVs, performing only 2 rather than 4.
2. I do 1 week breast and decide to continue weekly OTVs and do 1.

I'm screwing the specialty with the first scenario, but the second scenario is a natural/intended consequence that doesn't screw the specialty? We're better validation our importance by doing 1 vs 2 OTVs? Seems incongruent.
 
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cancer_doc

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Getting rid of 77427 wouldn't change how I actively manage my patients, just how I document doing so.
your logic doesn't make sense to me from from both a business and quality perspective... You say you will continue to do the work, but you won't use a code or document it in a way that CMS need to recognize the work you are doing. While I am not in the first wave of RO-APM zip codes, I am unaware CMS has instituted a different coding / documenting structure for APM participants. You will still want CMS to see 77427 and other charges so they won't have the excuse to massacre the global pro fees in future cycles...
 
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Ray D. Ayshun

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your logic doesn't make sense to me from from both a business and quality perspective... You say you will continue to do the work, but you won't use a code or document it in a way that CMS need to recognize the work you are doing. While I am not in the first wave of RO-APM zip codes, I am unaware CMS has instituted a different coding / documenting structure for APM participants. You will still want CMS to see 77427 and other charges so they won't have the excuse to massacre the global pro fees in future cycles...
If there's simply one code for a treatment course, I'll check in with the patients, etc, regularly to see how they're doing, even if just passing in the department, hearing from techs etc. Prostates will generally have nothing, so in turn, I won't write a meaningless note to allow me to bill 77427. H&N's will have issues, which I'll document. 77427 is a way to get out of paying us as far as I'm concerned.

edit: I'm talking in theory. I see my patient's regularly, it's a small dept. just don't write a note everyday.
 
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RadOncDoc21

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If there's simply one code for a treatment course, I'll check in with the patients, etc, regularly to see how they're doing, even if just passing in the department, hearing from techs etc. Prostates will generally have nothing, so in turn, I won't write a meaningless note to allow me to bill 77427. H&N's will have issues, which I'll document. 77427 is a way to get out of paying us as far as I'm concerned.

edit: I'm talking in theory. I see my patient's regularly, it's a small dept. just don't write a note everyday.
Agree, we can document all day until the cows come home and in the end it doesn’t mean a damn thing.

I believe our system is flooded with unnecessary documentation to “justify our work” and there ultimately needs to be a purge!
 
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TheWallnerus

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Changing fractionation schemes is a natural reaction to APM as this is the original intent of APM- to mitigate over-fractionation. But changing how you actively manage a patient on treatment, regardless of fractionation scheme, is vastly different in my professional opinion. Changing the latter would serve to CMS the validation that doctors are less valuable and less necessary in RO treatment. With all this talk about over saturation of RO market, finding more excuses to remove yourself further from patient management does not add up.

If you shorten treatment course AND change your management / documentation patterns, then you're just double-fisting yourself a world of pain in both financial and potentially quality measures....
So your theory is that missing one or two OTVs in a 4 week regimen will be more a “tell” to CMS about rad onc value than migrating to one week radiotherapy for breast?

Do tell.

“Finding more excuses to remove yourself further from patient management does not add up.” ... This is what I call hypofractionation lol.
 
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If you shorten treatment course AND change your management / documentation patterns, then you're just double-fisting yourself a world of pain in both financial and potentially quality measures....
I agree, but you are unfortunately asking the people in RO APM zip codes to (a) take less reimbursement and (b) maintain their burden of documentation "for the good of the specialty."

This is against human nature.

The Oncology Care Model (OCM) for Med Onc definitely had bureaucratic burdens but fundamentally it was fee-for-service and participating practices were paid a "bonus" for high-performance on top of this.
 
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cancer_doc

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I agree, but you are unfortunately asking the people in RO APM zip codes to (a) take less reimbursement and (b) maintain their burden of documentation "for the good of the specialty."

This is against human nature.

The Oncology Care Model (OCM) for Med Onc definitely had bureaucratic burdens but fundamentally it was fee-for-service and participating practices were paid a "bonus" for high-performance on top of this.
There are really two points here in this ongoing thread and some of you are only focused on one (which I understand by one of my posts).
1. changing management patterns regardless of changing fractionation scheme
2. not documenting / capturing appropriate charges accordingly to the work you put in.

While I can understand the thought behind changing one fractionation schemes to another that have been clinically tested, I don't agree how that would change management patterns as I have not seen clinical data on whether 1 or 2 OTVs is non inferior to weekly OTVs in a 4 to 7 week course.. but it would say more that one is changing medical practice solely based on personal decision of "worth": if I don't feel I'm getting paid enough, then I will do less work..... etc.. But I do understand those who would rationalize this.

but to point #2: even if you decide to perform 2 OTVs instead of 4 in a 4-week course, and you do not charge nor document it appropriately, which was some of the messaging I interpreted by some individuals here, that COMPLETELY does not make sense to me. If you do the work, you should charge and documented, or CMS will only assume you didn't, and then you are just making it easier for them to unnecessarily lower future payments.
 
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Ray D. Ayshun

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There are really two points here in this ongoing thread and some of you are only focused on one (which I understand by one of my posts).
1. changing management patterns regardless of changing fractionation scheme
2. not documenting / capturing appropriate charges accordingly to the work you put in.

While I can understand the thought behind changing one fractionation schemes to another that have been clinically tested, I don't agree how that would change management patterns as I have not seen clinical data on whether 1 or 2 OTVs is non inferior to weekly OTVs in a 4 to 7 week course.. but it would say more that one is changing medical practice solely based on personal decision of "worth": if I don't feel I'm getting paid enough, then I will do less work..... etc.. But I do understand those who would rationalize this.

but to point #2: even if you decide to perform 2 OTVs instead of 4 in a week course, and you do not charge nor document it appropriately, which was some of the messaging I interpreted by some individuals here, that COMPLETELY does not make sense to me. If you do the work, you should charge and documented, or CMS will only assume you didn't, and then you are just making it easier for them to unnecessarily lower future payments.
Perhaps there's confusion about my statements re #2. If we gotta do OTVs for reimbursement, then yes, I'd keep doing it. OTOH, if a documented OTV is no longer a part of the package, then I'll be happy to not have to write a meaningless OTV not/spend time in a room with a patient at least weekly b/c I'm required to. It's one less thing to keep up with. OTVs are problems that aren't problems. It's not like I tell my sick H&N patients to wait for OTV day. I don't get paid for seeing a H&N patient in a room when it's not OTV day.
 
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communitydoc13

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I'm not changing anything. In fact, I may increase fractionation in some patients. We were always paid in a bizarre manner. Will see where the chips fall in terms of collections and the hospital's response. (Most doctors outside of radonc don't come close to paying for themselves with pro fees.) Definitely keeping OTVs. Nothing wrong with performative medicine. In fact, without the performative (i.e. human) aspect of medicine I'm guessing we could just cut our radonc workforce now by 60-70%.
 
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Lamount

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It will be interesting to see if there is an exodus of rad oncs from practices in the APM zips/and or practices moving. This could also take the form of belt-tightening and laying off therapists/Dosimetrists. If patient volumes go down and wait times go up, could that potentially kill the APM? Is it a forgone conclusion, or do they really want to see how it works? (Honestly asking)
 
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It will be interesting to see if there is an exodus of rad oncs from practices in the APM zips/and or practices moving. This could also take the form of belt-tightening and laying off therapists/Dosimetrists. If patient volumes go down and wait times go up, could that potentially kill the APM? Is it a forgone conclusion, or do they really want to see how it works? (Honestly asking)
We will soon find out. Any of that is on the table imo
 
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TheWallnerus

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There are really two points here in this ongoing thread and some of you are only focused on one (which I understand by one of my posts).
1. changing management patterns regardless of changing fractionation scheme
2. not documenting / capturing appropriate charges accordingly to the work you put in.

While I can understand the thought behind changing one fractionation schemes to another that have been clinically tested, I don't agree how that would change management patterns as I have not seen clinical data on whether 1 or 2 OTVs is non inferior to weekly OTVs in a 4 to 7 week course.. but it would say more that one is changing medical practice solely based on personal decision of "worth": if I don't feel I'm getting paid enough, then I will do less work..... etc.. But I do understand those who would rationalize this.

but to point #2: even if you decide to perform 2 OTVs instead of 4 in a 4-week course, and you do not charge nor document it appropriately, which was some of the messaging I interpreted by some individuals here, that COMPLETELY does not make sense to me. If you do the work, you should charge and documented, or CMS will only assume you didn't, and then you are just making it easier for them to unnecessarily lower future payments.
Now you’ve got it. If you do something, you should document it and bill it. APM causes us to question what are the somethings that should be done, or not. Weekly OTVs? IMRT for 8 Gy bone mets? Weekly physics chart checks (our biggest boondoggle?)? FWIW National Health Service “rad oncs” don’t have a concept of must-do weekly OTVs and those patients do fine obviously. One good thing about APM: I now feel like I have the freedom to IMRT and IGRT anything and everything I want.
 
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My department was previously on the participating zip codes for APM, but on the new .xls spread sheet it is no longer listed. Anyone else have a similar situation?
 

RadsWFA1900

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Now you’ve got it. If you do something, you should document it and bill it. APM causes us to question what are the somethings that should be done, or not. Weekly OTVs? IMRT for 8 Gy bone mets? Weekly physics chart checks (our biggest boondoggle?)? FWIW National Health Service “rad oncs” don’t have a concept of must-do weekly OTVs and those patients do fine obviously. One good thing about APM: I now feel like I have the freedom to IMRT and IGRT anything and everything I want.

They don't have rad oncs hence why they don't really care about fxs or RT for that matter. Its a minor part of a clinical oncs practice. They are too busy giving chemo and rounding on patients in the hospital. the less they have to do with it the better. They've handed off basically everything else to the technicians. There was no innovation in RO except cutting and APM s just a natural extension of that. Honestly where the hell are we gonna be in 2050?
 
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elementaryschooleconomics

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Honestly where the hell are we gonna be in 2050?
I'm almost certain the academic breast RadOncs will still be arguing over whether or not someone is "missing" breast tissue in chart rounds when a tangent falls just inside the medial wire vs just outside.

"You can take my opinion on the significance of a 0.4 degree difference in gantry angle...WHEN YOU PRY IT FROM MY COLD DEAD HANDS"
 
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RadOncDoc21

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I'm almost certain the academic breast RadOncs will still be arguing over whether or not someone is "missing" breast tissue in chart rounds when a tangent falls just inside the medial wire vs just outside.

"You can take my opinion on the significance of a 0.4 degree difference in gantry angle...WHEN YOU PRY IT FROM MY COLD DEAD HANDS"
Is this before or after we omit the one fraction of hyper super duper accelerated, partial focus breast RT for the 42.5 yr old, low-intermediate low grade 1z, ER/PR+, HER2-, cT1a1-e/2N0(sn-),ONCI-1 type score 1.8, ki-67 2.1%, HOS-, enzyme reductase-, right sided, clinical stage 1ac, pathological stage 0.1ae, radiographic stage A9, DCIS (int grade, focal-size€), invasive (low grade, 1-3 cells+) breast cancer?
 

TheWallnerus

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Is this before or after we omit the one fraction of hyper super duper accelerated, partial focus breast RT for the 42.5 yr old, low-intermediate low grade 1z, ER/PR+, HER2-, cT1a1-e/2N0(sn-),ONCI-1 type score 1.8, ki-67 2.1%, HOS-, enzyme reductase-, right sided, clinical stage 1ac, pathological stage 0.1ae, radiographic stage A9, DCIS (int grade, focal-size€), invasive (low grade, 1-3 cells+) breast cancer?
Thanks, Susan Komen!
 
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ramsesthenice

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Is this before or after we omit the one fraction of hyper super duper accelerated, partial focus breast RT for the 42.5 yr old, low-intermediate low grade 1z, ER/PR+, HER2-, cT1a1-e/2N0(sn-),ONCI-1 type score 1.8, ki-67 2.1%, HOS-, enzyme reductase-, right sided, clinical stage 1ac, pathological stage 0.1ae, radiographic stage A9, DCIS (int grade, focal-size€), invasive (low grade, 1-3 cells+) breast cancer?
It’s before but after the diagnostic PET-MRI with novel gene guided theranostic tools to make sure the disease is local. And after all of this, we will still give chemo just to be safe.
 
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RadOncDoc21

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It’s before but after the diagnostic PET-MRI with novel gene guided theranostic tools to make sure the disease is local. And after all of this, we will still give chemo just to be safe.
Right to reduce financial toxicity from the RT but instead have to pay for the lifetime of chemo/immunotherapy, the million dollar genomic testing and imaging. Don’t forget the surgeon also did b/l reconstructions.

She will also receive a lifetime of hormonal therapy just because it reduces the risk of recurrence by 0.00009% over 50 years! But thank God we spared her from receiving the 1 Gy of RT we were hoping to give so that the machine could have one patient treated that week.

Although the most recent trial from 2049 demonstrated that 1 Gy of super duper hyper accelerated focal RT reduced local recurrence by 92%, but who cares!
 
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Mandelin Rain

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Now you’ve got it. If you do something, you should document it and bill it. APM causes us to question what are the somethings that should be done, or not. Weekly OTVs? IMRT for 8 Gy bone mets? Weekly physics chart checks (our biggest boondoggle?)? FWIW National Health Service “rad oncs” don’t have a concept of must-do weekly OTVs and those patients do fine obviously. One good thing about APM: I now feel like I have the freedom to IMRT and IGRT anything and everything I want.
Yes. The only good part of APM would be I wouldn't have to write a note for every damn charge. Special Treatment Procedure note? Poof, gone. Treatment Planning Note? Yeah, I dictated my plan in the consult. Read it there. Random OTV on second day of treatment? Yeah, that's a quick "Hello" in the hallway and nothing more.

That, and as you said, using IMRT and IGRT on damn near everything with impunity. Because, "If it all costs the same, why not?"
 
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She will also receive a lifetime of hormonal therapy just because it reduces the risk of recurrence by 0.00009% over 50 years! But thank God we spared her from receiving the 1 Gy of RT we were hoping to give so that the machine could have one patient treated that week.

Although the most recent trial from 2049 demonstrated that 1 Gy of super duper hyper accelerated focal RT reduced local recurrence by 92%, but who cares!

This person gets it
 

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Yes. The only good part of APM would be I wouldn't have to write a note for every damn charge. Special Treatment Procedure note? Poof, gone. Treatment Planning Note? Yeah, I dictated my plan in the consult. Read it there. Random OTV on second day of treatment? Yeah, that's a quick "Hello" in the hallway and nothing more.

That, and as you said, using IMRT and IGRT on damn near everything with impunity. Because, "If it all costs the same, why not?"
IMRT/VMAT esp would be quicker to plan and deliver vs designing each field and then having to treat each field on the machine
 
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Yes. The only good part of APM would be I wouldn't have to write a note for every damn charge. Special Treatment Procedure note? Poof, gone. Treatment Planning Note? Yeah, I dictated my plan in the consult. Read it there. Random OTV on second day of treatment? Yeah, that's a quick "Hello" in the hallway and nothing more.

That, and as you said, using IMRT and IGRT on damn near everything with impunity. Because, "If it all costs the same, why not?"

Our group has some apm style contracts and we love it for all the reasons you mentioned. It really does simplify your life and allows you to practice however the heck you want. I'm able to do tons of palliative imrt, oligomets sbrt, and I can occasionally avoid the prostate guy with 0 side effects who wants to talk about everything other than his prostate cancer during an hour long otv. Existing providers will love it...the "problem" is it makes your life so easy that ur staffing needs (physicians and therapists) are significantly reduced.
 
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TheWallnerus

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Yes. The only good part of APM would be I wouldn't have to write a note for every damn charge. Special Treatment Procedure note? Poof, gone. Treatment Planning Note? Yeah, I dictated my plan in the consult. Read it there. Random OTV on second day of treatment? Yeah, that's a quick "Hello" in the hallway and nothing more.

That, and as you said, using IMRT and IGRT on damn near everything with impunity. Because, "If it all costs the same, why not?"
I have a slight let's say "worry" that our biller and coders and admins are still going to force the same level of documentation and bother for special treatment procedure, tx planning note, etc. Why? Because these people can not, or simply refuse to, think outside a box. They will still see that a "charge" (even though it is zero pay) is being submitted. And then if you try to say "well, we aren't getting paid" the coders and admins will say that this fraudulent because a code is still being submitted.

I hate that this will happen but I am already seeing hints.

Let's take the special treatment procedure (STP). How will these discussions go?

BILLER: Doctor I see you didn't do a note for STP on this patient.
MD: I didn't want to do a note.
BILLER: But the patient is getting concurrent chemo.
MD: So I am not doing those notes anymore because it's not worth my time.
BILLER: But we always did the notes before.
MD: I refuse to do the note.
BILLER: But we are submitting the code.
MD: Don't submit the code if we aren't doing the note.
BILLER: If the patient is getting chemo, it's an STP and we HAVE to do the note.

... yada yada
 
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ramsesthenice

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Our group has some apm style contracts and we love it for all the reasons you mentioned. It really does simplify your life and allows you to practice however the heck you want. I'm able to do tons of palliative imrt, oligomets sbrt, and I can occasionally avoid the prostate guy with 0 side effects who wants to talk about everything other than his prostate cancer during an hour long otv. Existing providers will love it...the "problem" is it makes your life so easy that ur staffing needs (physicians and therapists) are significantly reduced.
I've made it clear how big of a fan I am of something close to this (dx based reimbursement). Guy has prostate cancer. Do what you think is best in terms of number of fractions, image guidance, and radiation modality. Of course, this would assume that on the continuum of current reimbursement for the various options they set the price point somewhere in the middle. Me thinks they are going to set it closer to the lowest possible option and leave us with no option to make up the difference. And savings on overhead probably are not going to cut it.

Just have to see where things shake out. There are some plusses to be sure. Just need to get a sense of how they stack up to the possible negatives.
 
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I've made it clear how big of a fan I am of something close to this (dx based reimbursement). Guy has prostate cancer. Do what you think is best in terms of number of fractions, image guidance, and radiation modality. Of course, this would assume that on the continuum of current reimbursement for the various options they set the price point somewhere in the middle. Me thinks they are going to set it closer to the lowest possible option and leave us with no option to make up the difference. And savings on overhead probably are not going to cut it.

Just have to see where things shake out. There are some plusses to be sure. Just need to get a sense of how they stack up to the possible negatives.
Thoughtful Bundling = good. RO-APM is not this.
 
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Timmerman published a trial in the last 2 years. SBRT was inferior to brachy. It’s not going anywhere for GYN.

When people say brachy is dying what they really mean is prostate brachy is dying. Considering it use to be the lions share of the overall volume I can see where people are coming from. The only reason I do a lot of prostate brachy is I run a busy HDR program (mostly Gyn) and have all of the logistics and support staff in place. Start to finish our prostate HDR cases (so no pre planning) are around 2.5 hours. Literally everyone has to be good at their role or its a huge time sink which is precisely what happens without repetition. I could make an “argument” it’s better than SBRT but I can also “argue” platinum is more valuable than diamonds.
Good point. I cover a county hospital for gyn and I don’t see the volume changing. I do some prostate hdr but dialed way back recently because honestly sbrt is easier if you’re offsite and I wanted to focus on gyn
 

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Protons put us in the crosshairs. Health economists always use us as a poster child for everything that is wrong with medicine. Even though we are insignificant blip, optics are horrible. Remember some of the health economists at Harvard referring to protons as the “Death Star” of medicine in national news.
 
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Protons put us in the crosshairs. Health economists always use us as a poster child for everything that is wrong with medicine. Even though we are insignificant blip, optics are horrible. Remember some of the health economists at Harvard referring to protons as the “Death Star” of medicine in national news.
Part of it may be the fact that we eat our own
 
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RadsWFA1900

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Omg a health economist wants to cut something! News at 11.

Meaningful payment reform? Ha! If they are so interested in that then why don’t they go after Pharma? Oh that’s right because they own this country. So they go after the weakest link RO.

Health economists are the biggest waste of oxygen in the system
 
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Fantastic.

Health economists aren’t that bad, but coming out there and speaking unintelligently about something he doesn’t understand fully is poor form.

You’re right, though. The narrative for our specialty is so one sided and bad. Gil Lederman. The NY Times articles. The proton stories. Recent infighting and insulting of community doctors. Board exams. Having to SOAP 15+ % of candidates.

We need a new narrative. Impossible with old leadership.
 
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