The coming COVID financial apocalypse

[Reaganite]

Honest question as someone fairly new to the field... right now, the technical reimbursement for IMRT is about twice that of 3D. Was the ratio the same in the golden era of IMRT?

It's definitely not 2:1 in freestanding these days with all the IMRT code bundling. It's getting closer and closer to a wash. IMRT treamtent code + prof IGRT is barely more than 3D treatment code + prof/tech IGRT. (I did the calc in a random geography and the difference is $40/day globally). Also, some of the per field calc and sim codes you get with 3D are bundled into the IMRT planning codes which negates the big difference in the IMRT vs. 3D plan code.

Also, regarding the difference back in the "golden era," the ratio was highly geographically-dependent (vs. now where the differences are minor), but definitely not 10:1 freestanding. You can actually go to the medicare website and look up historical reimbursement for old XRT codes. In the 2000's it looks like IMRT treatment code ranged from 600-1000 per fraction vs 3D which seemed to range 200-300ish. Several of my older colleagues quote 50k as the high end of reimbursement for prostate IMRT "back in the day."

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[medgator]

 

[OTN]

For someone at the University of Chicago, Ralph sure has a very poor understanding of how monopolistic markets lead to price gauging of consumers.

 

[HardenedBeam]

IMRT utilization for anal cancer. Remember: there is no P3 data showing benefit. P2 retrospective comparison data (vs 3DCT) had a negative primary endpoint (RTOG0529). Moreover, a real P3 randomized trial in rectal cancer (IMRT vs. 3DCT) was negative as well (similar location).

IMRT 2x+ cost over 3DCT.

 

[BobbyHeenan]

That's fair (re: anal cancer).

But way more signal there for benefit than in prostate.

 

[medgator]

IMRT utilization for anal cancer. Remember: there is no P3 data showing benefit. P2 retrospective comparison data (vs 3DCT) had a negative primary endpoint (RTOG0529). Moreover, a real P3 randomized trial in rectal cancer (IMRT vs. 3DCT) was negative as well (similar location).

IMRT 2x+ cost over 3DCT.


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And? Is protons better than imrt was to 3D at even a bigger cost differential than that?

You're welcome to prove that it is (most of us know that it likely isn't at that cost differential).

 

[2014XRT]

For someone at the University of Chicago, Ralph sure has a very poor understanding of how monopolistic markets lead to price gauging of consumers.

He is saying we need a few centers only around the country for niche causes, and that there are way too many centers now, and that people with proton centers are potentially going to bias the data in their favor if they are running the trials.

Do you disagree, OTN?

 

[medgator]

He is saying we need a few centers only around the country for niche causes, and that there are way too many centers now, and that people with proton centers are potentially going to bias the data in their favor if they are running the trials.

Do you disagree, OTN?

He's ignorant of how many centers have already been built and are currently in operation based on that tweet. Do you disagree?

 

[2014XRT]

He's ignorant of how many centers have already been built and are currently in operation based on that tweet. Do you disagree?

from reading plenty of his other tweets, I believe he is quite aware. His post is poorly worded because he's an old man (see any of his other tweets) but he is saying we only needed a few.

 

[OTN]

He is saying we need a few centers only around the country for niche causes, and that there are way too many centers now, and that people with proton centers are potentially going to bias the data in their favor if they are running the trials.

Do you disagree, OTN?

And I'm saying that, with only a few centers, their pricing would become monopolistic very quickly, as we've seen academic institutions take advantage of in other markets (cough, cough Mayo cough cough).

He's not the US radonc czar. It doesn't matter in the least how many proton centers he thinks we "should" have.

On top of all that, why would consolidation of proton centers prevent problems with data bias?

 

[Mandelin Rain]

Even if one of the few proton machines across the country is located in town, institutions will do whatever they can to keep even the most appropriate patients from going out of system. Right Ralph?

 

[2014XRT]

And I'm saying that, with only a few centers, their pricing would become monopolistic very quickly, as we've seen academic institutions take advantage of in other markets (cough, cough Mayo cough cough).

He's not the US radonc czar. It doesn't matter in the least how many proton centers he thinks we "should" have.

On top of all that, why would consolidation of proton centers prevent problems with data bias?

Yes is it is true that having a few proton centers promotes a monopoly. but what is your point - you are okay with the number of centers that exist? You think we should have more?

I do not.

 

[w00tz]

Too many proton centers means the centers are more likely going to NEED to treat more prostate than pediatrics, because there are only so many kids that need radiation. They have to pay for that $50-100 million machine some how.

 

[2014XRT]

Too many proton centers means the centers are more likely going to NEED to treat more prostate than pediatrics, because there are only so many kids that need radiation.

exacrly.

 

[scarbrtj]

Forty-plus proton fractions as a common treatment for the PSA-generated ubiquity of prostate cancer was the only way proton center pro formas made sense. Certainly the only way it could generate financial backer interests. My hunch is hypofractionation is happening at a substantially lower rate in proton centers than XRT centers even given close case matching. Would love to know...

 

[OTN]

Yes is it is true that having a few proton centers promotes a monopoly. but what is your point - you are okay with the number of centers that exist? You think we should have more?

I do not.

It doesn't matter what I think about the number of proton centers, as we are not a centrally-planned economy.

 

[Chartreuse Wombat]

It doesn't matter what I think about the number of proton centers, as we are not a centrally-planned economy.

Not yet...

 

[scarbrtj]

Patient volumes down by about a third
Average revenue loss: 20-30%
One in five freestanding centers predicting 50% or more revenue losses

ASTRO survey: Fewer patients despite enhanced safety measures at radiation oncology clinics - American Society for Radiation Oncology (ASTRO) - American Society for Radiation Oncology (ASTRO)

Initial results of a national survey on COVID-19 and radiation oncology from the American Society for Radiation Oncology (ASTRO)

www.astro.org

 

[deleted573262]

Patient volumes down by about a third
Average revenue loss: 20-30%
One in five freestanding centers predicting 50% or more revenue losses

ASTRO survey: Fewer patients despite enhanced safety measures at radiation oncology clinics - American Society for Radiation Oncology (ASTRO) - American Society for Radiation Oncology (ASTRO)

Initial results of a national survey on COVID-19 and radiation oncology from the American Society for Radiation Oncology (ASTRO)

www.astro.org

Good opportunity for residency contraction.

 

[w00tz]

Good opportunity for residency contraction.

Yes, was also good opportunity when Chirag Shah voiced his concerns about residency expansive 5+ years ago.

But I would imagine as a hospital admin/department chair, this would be an opportunity to get rid of the expensive rad oncs, keep the cheap residents, and hire more mid-levels.

 

[RadOncDoc21]

Yes, was also good opportunity when Chirag Shah voiced his concerns about residency expansive 5+ years ago.

But I would imagine as a hospital admin/department chair, this would be an opportunity to get rid of the expensive rad oncs, keep the cheap residents, and hire more mid-levels.

Just have a rad onc cover the LINAC remotely. Use the COVID pandemic rules and keep them around for convenience. Maybe have a nurse serve as general supervision or one of the residents.

I don’t think anybody died from radiation over the past 3 months with the recent changes in place.

 

[deleted941485]

Good opportunity for residency contraction.

Lol there’s always a need for cheap labor

 

[thecarbonionangle]

Lol there’s always a need for cheap labor

ain’t nothing more a chairman loves more than cheap labour, they love it more than martinis and tortured baby cow steaks at the country club.

 

[evilbooyaa]

Good opportunity for residency contraction.

But we need more data!!111

 

[scarbrtj]

Cleveland Clinic: "A truly scary statistic, though, is that our new patient consults are down by over 40 percent."

Finding, and Curing, Cancers May Be Another Casualty of Coronavirus (Published 2020)

As the death tolls rise to the coronavirus pandemic, those of us who specialize in oncology are bracing for another wave of victims: People not yet diagnosed with cancer.

www.nytimes.com

 

[seper]

I used to work at a charity-type hospital RadOnc in Midwest, and one year only 55% of my new patient visits converted to treatments... So there is a slack there in large institutions.

 

[scarbrtj]

Already murmurs of complaints at hospitals who are now "robbed" of facility fees for in-person outpatient office visits. Up next is probably lowering of provider fees over time with telehealth. And the inevitable loosening of supervision requirements across all disciplines not just rad onc.

‘I can’t imagine going back’: Medicare leader calls for expanded telehealth access after Covid-19

COVID-19's Impact on Radiation Oncology: Initial Results of a Nationwide Physician Survey, 5/20/20

 

[seper]

I hate facility fees. They make free post-op visits actually not free.

 

[Haybrant]

Hospitals Got Bailouts and Furloughed Thousands While Paying C.E.O.s Millions (Published 2020)

Dozens of top recipients of government aid have laid off, furloughed or cut the pay of tens of thousands of employees.

www.nytimes.com

Fun times, I mean if you just become a hospital exec you won’t have to worry about furloughs

 

[scarbrtj]

Hospitals Got Bailouts and Furloughed Thousands While Paying C.E.O.s Millions (Published 2020)

Dozens of top recipients of government aid have laid off, furloughed or cut the pay of tens of thousands of employees.

www.nytimes.com

Fun times, I mean if you just become a hospital exec you won’t have to worry about furloughs

"Do not imagine, comrades, that leadership is a pleasure! On the contrary, it is a deep and heavy responsibility. No one believes more firmly than C.E.O. Napoleon that doctors and staff and C.E.O.'s are equal. He would be only too happy to let you make your decisions for yourselves. But sometimes you might make the wrong decisions, comrades, and then where should we be?" - Animal Hospital, George Orwell

 

[RadOncMegatron]

Only if I were 15 years older and was a urologist who owned 3 LINACs, I could be planning my retirement right now. Instead of a Maui resort home, maybe would've had to settle for Miami b/c of what's going on.

Truly, was there a better deal in medicine than a urologist owning multiple LINACs? 79.2 Gy in 44 fractions all day every day FTW!

 

[medgator]

Only if I were 15 years older and was a urologist who owned 3 LINACs, I could be planning my retirement right now. Instead of a Maui resort home, maybe would've had to settle for Miami b/c of what's going on.

Truly, was there a better deal in medicine than a urologist owning multiple LINACs? 79.2 Gy in 44 fractions all day every day FTW!

Don't forget the lupron paying 4-figures for each shot. Handed that stuff out like candy

https://www.nejm.org/doi/full/10.1056/NEJMsa0910784

P.S. i kid you not, we started administering ADT in our practice when some of the local independent urologists told us there was not much money in it anymore and not worth it for them to give in the office

 

[scarbrtj]

Don't forget the lupron paying 4-figures for each shot. Handed that stuff out like candy

https://www.nejm.org/doi/full/10.1056/NEJMsa0910784

P.S. i kid you not, we started administering ADT in our practice when some of the local independent urologists told us there was not much money in it anymore and not worth it for them to give in the office

I had to "resort to Lupron" too lol... the only "chemo" I give in my office

 

[medgator]

I had to "resort to Lupron" too lol... the only "chemo" I give in my office

That's about the time that HIFU in the Caribbean and Mexico started taking off so i guess they moved on to greener pastures there (flying out to treat their cash patients with it since it was not FDA approved/covered by CMS).

 

[Mandelin Rain]

That's about the time that HIFU in the Caribbean and Mexico started taking off so i guess they moved on to greener pastures there (flying out to treat their cash patients with it since it was not FDA approved/covered by CMS).

So.... you must practice in Florida (yes, I see the “gator” in his name).

 

[Mandelin Rain]

Seriously though, I too had to start giving the lhrh meds once it became unprofitable.

At least that way someone is monitoring their bone density and whatnot.

 

[Carotenoid]

"Three months of COVID-19 may mean 80,000 missed cancer diagnoses... Screening and monitoring tests for breast, prostate, colorectal, cervical, and lung cancer were down 39%-90% in early April." There are about ~500-600,000 new dx XRT patients/year in the U.S. to put the 80,000 number in context. (also see here.)

If we multiply the effects of:
1) A spate of new rad oncs now entering the workforce
2) Massive, significant decrease in routine cases being treated per day due to hypofx
3) Significant decrease in cancer diagnosis rate due to COVID

We are maybe talking an apocalypse. Stay tuned.

Sad and true

 

[cpants]

I wasn't around in the golden age of Lupron, but I'll admit I have little interest in managing ADT. It's time consuming, there is significant liability and monitoring required, and very minimal reimbursement at this point. I am trying to turf it to med onc as much as possible because I feel like they do a better job and are more up on all the castrate resistant drugs, when to give chemo, etc. which changes on an almost monthly basis. I mostly am only giving ADT as adjuvant to XRT at this point. Metastatic patients go to med onc.

 

[BobbyHeenan]

I wasn't around in the golden age of Lupron, but I'll admit I have little interest in managing ADT. It's time consuming, there is significant liability and monitoring required, and very minimal reimbursement at this point. I am trying to turf it to med onc as much as possible because I feel like they do a better job and are more up on all the castrate resistant drugs, when to give chemo, etc. which changes on an almost monthly basis. I mostly am only giving ADT as adjuvant to XRT at this point. Metastatic patients go to med onc.

As it relates to this, are you all getting DEXA scans on all men that need ADT > 6 months?

Typically urologists in my neck of woods still do ADT. If they don't want to, I do it.

 

[OTN]

Just learned about a radonc in a large academically-affiliated health system who was let go- he graduated residency more than 10 years ago. His wife is a physician, so he's going back to get his MBA. He's not even going to bother looking for another radonc job. Cuts in the health system were made due to Covid. I'm in a Top 10ish metro.

 

[medgator]

As it relates to this, are you all getting DEXA scans on all men that need ADT > 6 months?

Typically urologists in my neck of woods still do ADT. If they don't want to, I do it.

I'll do it at 1-2 years. Only give ADT with xrt, i turf pts to med onc when i can, if pt needs long term ADT, med onc can give drugs like prolia to improve bone health etc as do for some high-risk breast pts on long term AI therapy

 

[radoncgrad2019]

You don’t want to deal with the jaw necrosis caused by the prolia either Trust me

 

[RadOncMegatron]

Just learned about a radonc in a large academically-affiliated health system who was let go- he graduated residency more than 10 years ago. His wife is a physician, so he's going back to get his MBA. He's not even going to bother looking for another radonc job. Cuts in the health system were made due to Covid. I'm in a Top 10ish metro.

WOW

 

[scarbrtj]

Just learned about a radonc in a large academically-affiliated health system who was let go- he graduated residency more than 10 years ago. His wife is a physician, so he's going back to get his MBA. He's not even going to bother looking for another radonc job. Cuts in the health system were made due to Covid. I'm in a Top 10ish metro.

the only people I know who're hiring are doing so in ~1 year... and I think that's optimistic...
Recently found out about some departures from academic-affiliated health system in my neck of woods too...
Academic or academic-affil rad onc, aka biggest employer of rad oncs in the USA, where job turnover is big and only increasing (if I could put a blinking red WARNING light on that I would).

 

[cpants]

As it relates to this, are you all getting DEXA scans on all men that need ADT > 6 months?

Typically urologists in my neck of woods still do ADT. If they don't want to, I do it.

Long term guys I do after a year or 2.

 

[Mandelin Rain]

Start them on Vit D and Calcium. Get a baseline dexa. If osteoporosis, send to med onc for continuation of adt and prolia. I ain’t got time for all that.

 

[thecarbonionangle]

the only people I know who're hiring are doing so in ~1 year... and I think that's optimistic...
Recently found out about some departures from academic-affiliated health system in my neck of woods too...
Academic or academic-affil rad onc, aka biggest employer of rad oncs in the USA, where job turnover is big and only increasing (if I could put a blinking red WARNING light on that I would).

we will hear more and more of these stories. Covid is peaking and will continue over the fall and winter and likely longer. Hiring freezes will be extended, more lay offs, more fellowships. Breadlines? Perhaps. We’ll see what happens!

 

[medgator]

COVID-19 has flipped the physician job search to a seller's market, recruiters say

Job opportunities for doctors have dried up quite a bit in wake of the COVID-19 pandemic, at least in the short term, according to an annual report from physician search firm Merritt Hawkins. | Job opportunities for doctors have dried up quite a bit in wake of the COVID-19 pandemic, at least in...

www.fiercehealthcare.com

In its 27th annual 2020 Review of Physician and Advanced Practitioner Recruiting Incentives, Merritt Hawkins found demand for physician recruitment dropped by more than 30% since March 31. In the 12 months period prior to March 31, physician and advanced practitioner recruiting searches had been up.

“Over our 33-year history, most physicians had little difficulty finding a job opportunity, with multiple offers to choose from,” said Travis Singleton, an executive vice president with Merritt Hawkins, which is part of AMN Healthcare, in a statement. “Today, we are seeing a growing number who are unemployed with a limited number of roles available. This is unprecedented. COVID-19 essentially flipped the physician job market in a matter of 60 days

 

[SneakyBooger]

His post is poorly worded because he's an old man

I believe he is posting exactly what he wants one to read...

 

[SneakyBooger]

Insurance companies are profiting:

"The country’s largest health insurer, UnitedHealth Group, reported its profits were $6.7bn in the second quarter of 2020 compared with $3.4bn in last year’s. Anthem’s profits rose to $2.3bn from $1.1bn for the same three-month period in 2019. Humana reported last week its earnings rose to $1.8bn, compared with $940m in 2019."

US health insurers doubled profits in second quarter amid pandemic

US’s largest health insurer, UnitedHealth Group, reported $6.7bn in profits compared with $3.4bn for the same quarter last year

www.theguardian.com