- Joined
- Oct 19, 2004
- Messages
- 536
- Reaction score
- 833
The Enemy
- Thread starter SneakyBooger
- Start date
- Joined
- Feb 7, 2019
- Messages
- 258
- Reaction score
- 804
UnitedHealth Group's 5 highest-paid executives
UnitedHealth Group CEO Andrew Witty was paid $20.9 million in total compensation in 2022.
- Joined
- Apr 28, 2005
- Messages
- 1,201
- Reaction score
- 3,466
UnitedHealth Group's 5 highest-paid executives
UnitedHealth Group CEO Andrew Witty was paid $20.9 million in total compensation in 2022.www.beckerspayer.com
That is only 2/5 of what Joe Burrow makes in a year.
- Joined
- Aug 23, 2014
- Messages
- 3,274
- Reaction score
- 6,646
The grifters at UH/optum, Aetna/CVS and other leeches are perpetually exsanguinating our healthcare system. “Academic” institutions in our field are just learning from them, charging 3-5x CMS rates, and promoting the oversupply to continue to have fresh batches of cheap blood for their daily operations. These “nonprofits” are ravaging/ransacking the system!
Last edited:
D
deleted1111261
It’s fascinating that we all know many physicians that overdo it - we all talk about it, we all see it. I’m seeing it as a person doing PA all the time.
Amongst our phone calls and chats and group messages we know that some of our colleagues are milking the system. Not one of us would disagree (I think). From the 15-20 fx bone Mets, to the academic centers doing 44 fx protons for prostate, etc.
Yet, it’s always the “grifters” fault.
I have not reviewed one case that there wouldn’t be controversy over. Every single case there is a legit issue. There is one I’m steaming about right now - it is incredibly wasteful spending.
If all of you spent 1 week in my seat, I think your view of who is the grifter would become much more fluid.
Amongst our phone calls and chats and group messages we know that some of our colleagues are milking the system. Not one of us would disagree (I think). From the 15-20 fx bone Mets, to the academic centers doing 44 fx protons for prostate, etc.
Yet, it’s always the “grifters” fault.
I have not reviewed one case that there wouldn’t be controversy over. Every single case there is a legit issue. There is one I’m steaming about right now - it is incredibly wasteful spending.
If all of you spent 1 week in my seat, I think your view of who is the grifter would become much more fluid.
- Joined
- Nov 2, 2019
- Messages
- 3,506
- Reaction score
- 14,554
The question is always "intent".
Corporations exist solely for revenue. More revenue, less expenses: higher profit. That is their sole purpose on the Earth.
I know very few RadOncs who have a clear and blatant pattern of milking the system. They ABSOLUTELY EXIST. I can point to some of them. I can call them on the phone.
But...while I personally would never give 20 fractions for a "simple" bone met, I absolutely know older docs who would out of genuine fear of bigger fraction size. The increased reimbursement could also come into their minds, and probably does, but it's not exclusively the reason.
On balance, who has more negative impact on "the system"?
It's not even a contest.
This gets incredibly complicated very quickly, especially when you take reimbursement into account. Who is more of the bad guy: someone in private practice treating prostate in 44 or 28 fractions with unfavorable reimbursement rates, or someone at a PPS exempt center treating yet another bone met/oligoprogressive disease with SBRT?
Does the intent of the individual matter if the system as a whole is being hurt?
- Joined
- Jul 14, 2020
- Messages
- 1,376
- Reaction score
- 4,164
IGRT for abdominal mets or long field bone mets? I have to P2P this fairly often.
Also, hippocampal sparing WBRT a few years ago. Hasn't come up recently.
But most docs are reasonable. (Both practitioners and reviewers). The big grifters are corporate leadership. If one aspires to this, you're not getting my respect.
~20M annual compensation? for what? to prioritize shareholders. It's a stupid club. It's not really saving anybody any money except for health plans (who don't need savings).
Case based compensation is roughly correct. Without carve outs. I'll support single payor any day.
Insurance is a racket. UHC is 11th largest company globally by revenue. What is their great innovation?
The problem is... it's not even a question of individual morality, but rather a question of institutional ethics. The leadership of a public healthcare company feels a greater moral obligation to its shareholders than its "customers". This is the compelling argument to get capitalism out of health insurance.
- Joined
- Jul 14, 2020
- Messages
- 1,376
- Reaction score
- 4,164
...but the Glaucomflecken script here sucks. Very elitist and schmucky.
JHH filled with some morally ambivalent institutionalists (often winners). Also some great doctors, nurses and staff. Just like every other institution.
MDACC the GOAT at not doing evidence based care.
Let's get things straight.
JHH filled with some morally ambivalent institutionalists (often winners). Also some great doctors, nurses and staff. Just like every other institution.
MDACC the GOAT at not doing evidence based care.
Let's get things straight.
- Joined
- Oct 4, 2017
- Messages
- 5,027
- Reaction score
- 9,813
The enemy are the hospitals. Insurances do not earn most their profits from “insurance”, but rather as a middlemen overseeing payments from employers to hospitals. Their “commissions” increase with higher hospital prices.
Globally, overutilization has not been shown to be a problem in the us health system! Sure, some are milking it, but that is just a distraction.
Globally, overutilization has not been shown to be a problem in the us health system! Sure, some are milking it, but that is just a distraction.
Last edited:
- Joined
- Jul 14, 2020
- Messages
- 1,376
- Reaction score
- 4,164
Did you see the data on Medicare spending stabilization!
A Huge Threat to the U.S. Budget Has Receded. And No One Is Sure Why.
Instead of growing and growing, as it always had, spending per Medicare beneficiary has nearly leveled off over more than a decade.
D
deleted1111261
The prostate fraction war is over, I believe. 5-44 should be okay for all patients. You certainly won't lose an appeal. And always appeal.
Oligo is really challenging - I don't know the answer to that.
What I'm talking about is nonsense. I don't want to frame it as community vs academic, b/c they do it in different ways. Protons protons protons from the big guys and these are very high ticket. The community guys with protons are far more EBM than the big academic centers. The egregious proton stuff comes from places and people you have all heard of, not the single gantry joint in some suburb. Community guys do 33 fx for stage I breast and DCIS. You'd better believe we knock those down, but pure Medicare and some commercial do not. Something like 40% of patients that should get hypo don't. And we know hypo is better, so this is just bad behavior. Making a patient come in for >2 weeks for bone mets is evil. This is not seen from academic centers, but routinely from FL/TX. Derms do the daily IGRT and daily 77280 for skin cancer. They are never academic.
Thanks for sharing your experience. I think it should be obvious to everyone that the docs Simul is speaking of are what created the need for prior auth in the first place. If everyone was practicing SOC medicine then I don’t think prior auth would exist (or it would at least be fairly automatic)
D
deleted1111261
IGRT for anything should be allowed. I am getting to the stage where I think it really should be bundled for most things. If you're not doing IGRT, you're doing it wrong. I've never once said no to non superficial IGRT.
HS-WBRT - should be fine. I'd be annoyed if I had to do P2P with a doctor requesting - that would mean my training failed. But, who's really checking if the doctor is doing HS WBRT? I'm guessing more than a few are billing it without doing it properly.
We have such a mess that it simply cannot be fixed with "reform". Would need total burn down and then go Singapore-ish model. That's the only one I see working with the American system. So much skin in the game. Market regulation. Limit moral hazard. Tiers of comfort based on what you want to pay. Private options for wealthier/pickier types. But, main thing is ... skin in the game.
- Joined
- Mar 20, 2013
- Messages
- 1,916
- Reaction score
- 3,525
Like everything else in life a small number can ruin it for everyone (I'm looking at you 20 fx bone met, R sided breast protons, etc).
What is ?unique? or a stand out for our field is that many of the institutions that are bad actors are also behind the steering wheel on policy decisions. Seems like a bad recipe. It's one thing to be doing excessive hip replacements or extra radiation fractions out in a rural community...it's another to be doing some questionable things in the clinic and also writing policy that favors it.
What is ?unique? or a stand out for our field is that many of the institutions that are bad actors are also behind the steering wheel on policy decisions. Seems like a bad recipe. It's one thing to be doing excessive hip replacements or extra radiation fractions out in a rural community...it's another to be doing some questionable things in the clinic and also writing policy that favors it.
- Joined
- Aug 4, 2020
- Messages
- 1,967
- Reaction score
- 3,354
Are there any reasons why standard fraction might be better than hypo? For the record, I use hypo in about 90% of my patients..
e.g. prior radiation or sensitivity to radiation exposure
postoperative complications (swelling)
unusual anatomy either natural or from implants
pacemaker proximity
- Joined
- Jun 21, 2022
- Messages
- 951
- Reaction score
- 3,322
The data suggests that a very high rate of RO denials are overturned and approved.
Are there "docs" that create a need for prior auth or is it purely a mechanism to maximize profit shrouded in a myth of quality improvement?
I think it's the latter. How many things do we do to "prevent" "bad" doctors? How many of those conveniently drive revenue and profit for companies? How many times a year do we hear about those bad doctors that slip through and cause a bunch of harm?
MOC? Certification? Prior Auth? Practice Accreditation?
- Joined
- Aug 4, 2020
- Messages
- 1,967
- Reaction score
- 3,354
Yes, the "damage" that bad docs do to milk the system is not ok, but the damage done by heavy handed profit driven PA and regulatory capture is far far greater, orders of magnitude greater.
If we snapped our fingers and eliminated PA, the worst case scenario, maybe the cost would go up 10%. But patients, and doctors, would be better.. even if an occasionally unnecessary study is done, it would seem.
Discuss.
If we snapped our fingers and eliminated PA, the worst case scenario, maybe the cost would go up 10%. But patients, and doctors, would be better.. even if an occasionally unnecessary study is done, it would seem.
Discuss.
D
deleted1111261
Prior RT - BCS contra-indication. Would suggest mastectomy.
For the rest - total dose is lower with HF and all studies show equal or less toxicity.
Postop complication - boomer reason; not real. No change noted in any study or from high volume center. Would have same or worse problem with CF.
Unusual anatomy / implant reasons - boomer reason; I can make an allowance for implant with huge eye roll, b/c data shows its fine. In addition you can do partial breast 26-30/5 or 40/15.
Pacemaker proximity - boomer reason; nothing to do with HF. If you can do CF, you can do HF
What else did I hear from 2010 - now from people?
- DCIS
- They got chemo
- They are triple negative
- They are high grade
- They are large breasted
D
deleted1111261
To me, we are the ones who gave the oath. I don't compare myself to corporate charlatans or private equity people.
Don't compare to them. Compare to ourselves. If you had 500 radoncs and randomized them to PA or no PA, the difference in costs would be dramatic. I can see it with my own eyes how people practice.
There is a "natural" way to see this. Look at hypo breast for pure Medicare vs MA plans. It is a staggering difference.
D
deleted1111261
The data suggests that a very high rate of RO denials are overturned and approved.
Are there "docs" that create a need for prior auth or is it purely a mechanism to maximize profit shrouded in a myth of quality improvement?
I think it's the latter. How many things do we do to "prevent" "bad" doctors? How many of those conveniently drive revenue and profit for companies? How many times a year do we hear about those bad doctors that slip through and cause a bunch of harm?
MOC? Certification? Prior Auth? Practice Accreditation?
NotMatt, I'll let you field my calls for a week, let's see if you feel the same way!
I've had 3 docs send me VMAT plans that doubled or tripled the heart dose compared to 3D plan. One still justified it b/c "well the lung dose". We aren't exactly seeing patients get pneumonitis and dying. There is a lot of literature on this. Save the heart. Try to save the lung, but save the heart. And, smart board certified docs are twisting themselves into knots to justify treating with IMRT. And I like IMRT. I just don't like it used stupidly.
I've not had Evicore promote any "peer review" or quality. But, several of my callers have been happy with my comments. I had a guy add 5 fractions last week. How many prior auth reviewers do that??
- Joined
- Aug 4, 2020
- Messages
- 1,967
- Reaction score
- 3,354
You sound.. I believe there is a word for it.. obnoxious.
Noninferiority trials and extracting subgroups from trials and saying "look, those patients were in there, and thus they all do the same" isn't the same as a randomized trial with careful endpoints looking at cosmesis/fibrosis. "would have the same" isn't the same as "had the same, or better/worse."
As always: Anyone who does PA has a profit motive to reduce spend, increase the 3rd party's profit/position with the insurer, and generate bonuses for itself.
BURN IT DOWN
I chortle whenever I recall an aspiring, brilliant medical student exclaim he/she is going into academic medicine to create change from within the system. That path is just incrementalism at best
Anyways, non sequitur aside, for PA, I rarely do any. One per year?
I’m evidence based and I’ll hypofrac liberally to save patients from driving long distances. 5 fx apbi, 15-16 fx, omit boost for low risk dz, omit scar boost for majority of pmrt patients, 3dcrt for vast majority of whole breast, rni patients. I had to listen to a boomer rad onc “educate” me recently about imrt breast and his amazing heart mean doses of 4 Gy.
That being said, I dgaf about saving insurance companies money or saving money for the US taxpayer. I take great pleasure when I can justifiably use IMRT, or use more fractions for a disease site or presentation in which 3D is standard. Why? It probably has something to do with payments getting cut every year, regulations favoring consolidation and centralization of power within hands of administrators, ppse institutions playing with cheat codes. I’ve said it before, the “system” whether it’s gov’t regulators, insurers, academia and their job market satisfaction surveys, they are not your friend.
Last edited:
- Joined
- Aug 4, 2020
- Messages
- 1,967
- Reaction score
- 3,354
The only friend we had was fractions and technology. We cranked on fractions, and got by. But now the pendulum has swung the other way, and we are destroying radonc by racing to 0 fractions.
That plus oversupply of residents and carve outs for PPT/academia/protons have sounded the death knell.
I'm lucky to # it but many of my colleagues who did not experience the golden era will suffer greatly. Here's what it currently looks like in academia however (the force being protons naturally):
ps. ROCR Is a gambit to shift care to academic centers, make no mistake. The "rural apocalypse" is well underway... SCAROP might as well be Mr. Burns..
That plus oversupply of residents and carve outs for PPT/academia/protons have sounded the death knell.
I'm lucky to # it but many of my colleagues who did not experience the golden era will suffer greatly. Here's what it currently looks like in academia however (the force being protons naturally):
ps. ROCR Is a gambit to shift care to academic centers, make no mistake. The "rural apocalypse" is well underway... SCAROP might as well be Mr. Burns..
D
deleted1111261
You can hold on to this til the end and call me names.. maybe even a racist one
but anyone below a certain age and trained in modern era knows that HF is better for patients. Every single sub group has been argued, and everyone still is better off with hypo.
- Joined
- Mar 31, 2008
- Messages
- 1,396
- Reaction score
- 2,042
Srs our income only makes up 10% of healthcare expenses.
D
deleted1111261
our salary if pro only in RadOnc is 1/4 of the payment bc of this absurd tech prof ratio.
So it’s not trying to cut our ever smaller salaries, it’s hacking away at these hospital costs. And doc salaries are collateral damage, I presume.
- Joined
- Jun 21, 2022
- Messages
- 951
- Reaction score
- 3,322
I would feel the same way because I am not arguing that bad doctors dont exist or that you are doing a bad job.
I think if UHC said the truth: "Our goal is to make as much profit as possible and prior auth helps us reach this goal"... people would be upset.
So we say it helps quality.
We can argue about whether it helps or not for years and UHC will continue to "improve quality" at staggering YoY rates
- Joined
- Aug 4, 2020
- Messages
- 1,967
- Reaction score
- 3,354
Pulling the race card bro? Seriously? Anyone can be obnoxious ...as you have just demonstrated. And nothing is more arrogant than the new found knowledge of youth. Or, as my teenagers like to say "I know everything I need to know."
Arguing sub groups is like arguing about who had the best dish at Thanksgiving. Its fun, but meaningless.
I don't think "everyone is better off with hypo" but just for fun, whats your stance on doing it with RNI? Yes, I know there is some data from overseas with good results and decent follow up. The problem with breast, which is the worst, is that some late complications are ..late.
Arguing sub groups is like arguing about who had the best dish at Thanksgiving. Its fun, but meaningless.
I don't think "everyone is better off with hypo" but just for fun, whats your stance on doing it with RNI? Yes, I know there is some data from overseas with good results and decent follow up. The problem with breast, which is the worst, is that some late complications are ..late.
D
deleted1111261
I did forget to say welcome back from forum vacation. Sorry about that!
It’s okay to see the world pass you by. It’s going to happen to me, too, and I’ll probably be not graceful about it. For stage 1, there is never going to be a subgroup that benefits from historic fractionation of 1.8-2.0.
For RNI, we all know the prospective data that we use as rationale for PMRT had mostly HF. Somehow, we can extrapolate in that direction but not the other. But, I did hypo during pandemic. Way better tolerated. I don’t see a lot of breast now.
The guidelines don’t state a preference. So, I allow the most expansive reading.
- Joined
- Aug 4, 2020
- Messages
- 1,967
- Reaction score
- 3,354
Thanks for the (quite false) welcome back. They say your character really comes through when the pressure is on, and yours certainly does. Obnoxious may have been too gentle a descriptor... I'm leaning towards schmuck.
You aren't graceful now, so I have little hope for you in the future. But maybe, just maybe, with time and wisdom, you'll learn to be temperate.
We shall see.
Your comment "I'll allow" for any case... is subject to overturn, and often is on appeal. Maybe my appeal on your personality will be upheld too.
You aren't graceful now, so I have little hope for you in the future. But maybe, just maybe, with time and wisdom, you'll learn to be temperate.
We shall see.
Your comment "I'll allow" for any case... is subject to overturn, and often is on appeal. Maybe my appeal on your personality will be upheld too.
- Joined
- Apr 3, 2019
- Messages
- 4,273
- Reaction score
- 9,988
Five fraction for breast will be the worldwide standard for stage 0-3 by 2035.
- Joined
- Jan 26, 2017
- Messages
- 87
- Reaction score
- 218
Fixed it
- Joined
- Oct 24, 2010
- Messages
- 3,518
- Reaction score
- 6,384
I’m going under 1 fx for everything in 5 years. Leaning towards zero in 10 unless we right this course.
- Joined
- Jun 21, 2022
- Messages
- 951
- Reaction score
- 3,322
Maybe we will get case based payments of some form. I'd bet on it. Then we will all be caught up to the world.
Maybe people will then finally admit that FFS did influence their practices? I wouldn't bet on it.
Maybe.
Wait but, hey girl, hey! Hot off the press from the ASTRO Presidential-Elected Department, a timely article informing breast cancer irradiation:
And, a remarkable "interpretation":
"After a median follow-up of 39·3 months, non-inferiority of the hypofractionation group could not be established. However, given similar tolerability, hypofractionated proton PMRT appears to be worthy of further study in patients with and without immediate reconstruction."
Well there you have it. Even in the face of a prospective trial that they designed (quite permissive IMO!), the investigators believe that hypofractionated proton therapy is not not inferiorly toxic, but only a little, or $omething.
With regard to evidence based clinical reasoning, I love to quote one of my favorite scientists of all time:
"Life... uh, finds a way"
- Joined
- Oct 19, 2004
- Messages
- 536
- Reaction score
- 833
Zero fraction...
A_DeMichele
Full Member
- Joined
- Jul 9, 2022
- Messages
- 159
- Reaction score
- 229
RadOnc is unlucky; it somehow came to incentivize prolonged fractionation in the US. Also whoever argued for CPT 77014 level back in the day did a major disservice
- Joined
- Aug 23, 2014
- Messages
- 3,274
- Reaction score
- 6,646
The best radiation is zero radiation per “leaders”.
- Joined
- Apr 16, 2004
- Messages
- 4,663
- Reaction score
- 5,086
If the “leaders” could include zero fractions or hospice referral as legitimate options to get the case rate . . . that would be pretty sweet
D
deleted1111261
That pmrt/implant result is not one of those that fully answers a question. 12 Vs 2% complication rate .. maybe not statistically significant, but enough to give me pause, if treating with protons. I doubt the rate would be that high with photons, but CHARM will give us a data point.
From a payor perspective, it does not justify protons. They should have made the control arm photons.
From a payor perspective, it does not justify protons. They should have made the control arm photons.
- Joined
- Oct 4, 2017
- Messages
- 5,027
- Reaction score
- 9,813
It is totally false that PA is always profit motivated. I work for a self insured hospital and have treated a number of staff, and sometimes have to deal with the PA. The insurance company is deploying PA as a performative gesture to employers.the hospital is paying the bill.
It is actually in the insurance company’s financial interest that the bill/radiation services are priced as high as possibe since the employer (hospital) is the one actually paying the bill and United is just taking a percentage.
It is amazing how many docs don’t understand the differing “insurances” out there. The majority of Americans recieve insurance through self insured employers. Why is this so hard to understand?
It is actually in the insurance company’s financial interest that the bill/radiation services are priced as high as possibe since the employer (hospital) is the one actually paying the bill and United is just taking a percentage.
It is amazing how many docs don’t understand the differing “insurances” out there. The majority of Americans recieve insurance through self insured employers. Why is this so hard to understand?
Last edited:
- Joined
- Aug 4, 2020
- Messages
- 1,967
- Reaction score
- 3,354
Yes some PA is service contract based. PA gets a small fixed rate.
But the fat stacks happen when PA "buys" the insured risk and ratchets down the cost.
Does PA actuarial look forwards win most of time?
You better believe son..
- Joined
- Oct 4, 2017
- Messages
- 5,027
- Reaction score
- 9,813
Yes, this is true, but most Americans still obtain insurance through self funded employers,
For Medicare advantage plans, the PA is totally profit motivated.
- Joined
- Apr 3, 2019
- Messages
- 4,273
- Reaction score
- 9,988
Surprised more haven’t been commenting how icky this study isMaybe we will get case based payments of some form. I'd bet on it. Then we will all be caught up to the world.
Maybe people will then finally admit that FFS did influence their practices? I wouldn't bet on it.
Maybe.
Wait but, hey girl, hey! Hot off the press from the ASTRO Presidential-Elected Department, a timely article informing breast cancer irradiation:
And, a remarkable "interpretation":
"After a median follow-up of 39·3 months, non-inferiority of the hypofractionation group could not be established. However, given similar tolerability, hypofractionated proton PMRT appears to be worthy of further study in patients with and without immediate reconstruction."
Well there you have it. Even in the face of a prospective trial that they designed (quite permissive IMO!), the investigators believe that hypofractionated proton therapy is not not inferiorly toxic, but only a little, or $omething.
With regard to evidence based clinical reasoning, I love to quote one of my favorite scientists of all time:
"Life... uh, finds a way"
- Joined
- May 7, 2014
- Messages
- 1,657
- Reaction score
- 3,473
This is truly embarrassing that this woefully underpowered study is published in Lancet OncologyMaybe we will get case based payments of some form. I'd bet on it. Then we will all be caught up to the world.
Maybe people will then finally admit that FFS did influence their practices? I wouldn't bet on it.
Maybe.
Wait but, hey girl, hey! Hot off the press from the ASTRO Presidential-Elected Department, a timely article informing breast cancer irradiation:
And, a remarkable "interpretation":
"After a median follow-up of 39·3 months, non-inferiority of the hypofractionation group could not be established. However, given similar tolerability, hypofractionated proton PMRT appears to be worthy of further study in patients with and without immediate reconstruction."
Well there you have it. Even in the face of a prospective trial that they designed (quite permissive IMO!), the investigators believe that hypofractionated proton therapy is not not inferiorly toxic, but only a little, or $omething.
With regard to evidence based clinical reasoning, I love to quote one of my favorite scientists of all time:
"Life... uh, finds a way"
A_DeMichele
Full Member
- Joined
- Jul 9, 2022
- Messages
- 159
- Reaction score
- 229
I suppose people should be doing 5-6 weeks of proton PMRT instead of 3 based on this?
- Joined
- Oct 4, 2017
- Messages
- 5,027
- Reaction score
- 9,813
I have real concerns abt bed and Bragg peak effects w/protons and that hypofract won’t translate.
- Joined
- May 7, 2014
- Messages
- 1,657
- Reaction score
- 3,473
Sorry to perseverate but the non-inferiority margin was 10%. Control arm expected to be 10% they would accept a doubling of complications (20%) and conclude non-inferiority. WTF?
- Joined
- Jul 14, 2020
- Messages
- 1,376
- Reaction score
- 4,164
Setting yourself up to win....and then losing....and then claiming victory.
When the investment is this large....