The problems facing radiation oncology

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Gfunk6

And to think . . . I hesitated
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I subscribe to the Bridge Oncology email list and they typically send weekly updates. There was an excellent summary they just posted of the problems facing our field. Although none of this information is new, I though it was put together very well in a digestible format.

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Radiation Oncology in Perspective

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Understanding Supply and Demand in Radiation Oncology: A Misalignment with Operational Reality
The principles of supply and demand assume that the value of a product or service remains relatively stable. When that value fluctuates—particularly due to rising operational costs or declining reimbursement—the model begins to break down. This is precisely the challenge facing radiation oncology today.
In a traditional economic model, if demand for a service remains constant, and supply is stable, prices and margins should also remain relatively consistent. However, in radiation oncology, while demand remains steady or increases due to rising cancer incidence, the reimbursement per unit of care has steadily decreased. At the same time, the costs to operate—driven by staffing shortages, regulatory requirements, equipment upgrades, and maintenance—have risen significantly.

This creates a widening gap between cost and revenue. Unlike a typical market, radiation oncology departments cannot simply raise prices to compensate. Medicare and commercial payers set fixed rates, often decreasing year over year, regardless of inflation or cost escalation. As a result, maintaining the same margins requires one of three responses:
  • Increase patient volume, which may not be feasible due to workforce constraints or geographic limitations.
  • Decrease operational expenses, often difficult without compromising care quality, staffing, or compliance.
  • Generate halo revenues, by integrating radiation oncology into broader care pathways that capture downstream value (e.g., diagnostics, pharmacy, infusion, or hospital admissions).

It is a flawed assumption that just because a radiation oncology service line exists, it should be maintained at all costs. Financial sustainability must be part of the strategic equation—particularly as hospitals face broader margin pressure. Radiation oncology once carried many institutions by subsidizing other underperforming or mission-based service lines. But the reversal of that dynamic means it now needs intentional investment, performance monitoring, and business discipline to survive.

As reimbursement models evolve and operational challenges mount, health systems must recognize that preserving access to radiation oncology requires more than legacy thinking—it demands a recalibrated strategy rooted in economics, efficiency, and innovation.
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On the one hand, sure. On the other hand, remind me what is Bridge selling again? Is it in Brooklyn?
 
This is basically medicine as a whole outside of a few niche areas like elective plastics or cash pay Psych.
I don't think so. Rad Onc is very hardware dependent and relies on highly specialized and expensive staff. A typical IM/FP clinic and many medicine specialities for that matter can be run with a few MAs/front desk people and a PA/NP or two.
 
I wonder how high the cost of RTTs will go once everyone starts becoming an APRT and doesn't want to man the sim or non adaptive linac
 
I don't think so. Rad Onc is very hardware dependent and relies on highly specialized and expensive staff. A typical IM/FP clinic and many medicine specialities for that matter can be run with a few MAs/front desk people and a PA/NP or two.
I’d be open to hearing about how Rad Onc overhead is somehow uniquely an outlier in Medicine (which I doubt) but… you guys won’t let me in the business forum.
 
I’d be open to hearing about how Rad Onc overhead is somehow uniquely an outlier in Medicine (which I doubt) but… you guys won’t let me in the business forum.
LOL—it’s not rocket science, but it is physics, real estate, labor economics, and capital equipment amortization all rolled into one.

Here’s the reality of Radiation Oncology overhead:
  1. Machine Costs: Each linear accelerator (LINAC) costs $3–5 million, not including interest if financed. And they break down, so you must pay for a service contract—$200K+/year, escalating as the machine ages.
  2. Vault Construction: You need to build a shielded vault to house this machine so you don’t irradiate your staff, patients, or pedestrians. Vault cost: $1–2M, depending on specs and location. Bonus: it’s completely worthless real estate for any other use—unless you’re renting to the military or selling it as a luxury fallout shelter.
  3. Staffing Requirements:
    • 2–3 Radiation Therapists: Each costs >$100K fully loaded.
    • Dosimetrist: Still necessary for now. Plans cost ~$300 each (or salaried, same economics).
    • Medical Physicist: Legally required to perform daily/weekly QA on both plans and hardware. Typically $200K+ annually. Cannot be fully remote
  4. Software & Systems:
    • Oncology-specific EMRs (like MOSAIQ or Aria) are legally required for dose tracking and compliance. These are completely separate from Epic, Cerner, or IKnowMed.
    • You also need a Treatment Planning System (e.g. Eclipse, RayStation) and potentially fusion/contouring software like MIM or Brainlab. All of it is subscription/cloud-based, and the vendors raise fees annually with zero negotiation.
  5. Fixed Cost Trap: This is the crux—
    • Medical Oncology = Variable Cost Model (you buy drugs as needed).
    • Radiation Oncology = Fixed Cost Model. You pay all of the above—regardless of whether you have 1 patient or 100 on treatment.
  6. Don’t forget: You’ll still need front desk staff, MAs, RN, NP/PA support depending on your volume. All of that is on top of the physics/therapist core.
TL;DR:

Radiation Oncology overhead isn’t just high—it’s baked in and front-loaded, with no meaningful cost deferral lever. In a climate of:
  • Shrinking indications (prostate, breast, oligomets)
  • Declining reimbursement (especially freestanding)
  • A leadership vacuum in our societies
… the economics are brutal. Any specialty with $10M+ fixed infrastructure before you even treat a patient isn’t comparable to most of medicine.
 
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So Bridge’s innovation idea is to use their services as they’re cheaper operationally. Good for hospitals’ bottom line. Bad for rad oncs and probably patient care.
 
So Bridge’s innovation idea is to use their services as they’re cheaper operationally. Good for hospitals’ bottom line. Bad for rad oncs and probably patient care.
To be clear, I don’t use Bridge but their insights are still legitimate and they are free.
 
So Bridge’s innovation idea is to use their services as they’re cheaper operationally. Good for hospitals’ bottom line. Bad for rad oncs and probably patient care.

I do not know this first hand, but it appears their job is to do the job of hospital admins. just better. Educate them on how to run a cancer program, etc. Then somewhere in there it sounds like they facilitate remote supervision logistics too.

===

Agree with @Gfunk6 their insights are often correct. But any company built to siphon off revenue/"consult" I am generally skeptical of....especially if not physician owned/operated.

These companies exist because administrators have no clue what they're doing.
 
LOL—it’s not rocket science, but it is physics, real estate, labor economics, and capital equipment amortization all rolled into one.

Here’s the reality of Radiation Oncology overhead:
  1. Machine Costs: Each linear accelerator (LINAC) costs $3–5 million, not including interest if financed. And they break down, so you must pay for a service contract—$200K+/year, escalating as the machine ages.
  2. Vault Construction: You need to build a shielded vault to house this machine so you don’t irradiate your staff, patients, or pedestrians. Vault cost: $1–2M, depending on specs and location. Bonus: it’s completely worthless real estate for any other use—unless you’re renting to the military or selling it as a luxury fallout shelter.
  3. Staffing Requirements:
    • 2–3 Radiation Therapists: Each costs >$100K fully loaded.
    • Dosimetrist: Still necessary for now. Plans cost ~$300 each (or salaried, same economics).
    • Medical Physicist: Legally required to perform daily/weekly QA on both plans and hardware. Typically $200K+ annually. Cannot be fully remote
  4. Software & Systems:
    • Oncology-specific EMRs (like MOSAIQ or Aria) are legally required for dose tracking and compliance. These are completely separate from Epic, Cerner, or IKnowMed.
    • You also need a Treatment Planning System (e.g. Eclipse, RayStation) and potentially fusion/contouring software like MIM or Brainlab. All of it is subscription/cloud-based, and the vendors raise fees annually with zero negotiation.
  5. Fixed Cost Trap: This is the crux—
    • Medical Oncology = Variable Cost Model (you buy drugs as needed).
    • Radiation Oncology = Fixed Cost Model. You pay all of the above—regardless of whether you have 1 patient or 100 on treatment.
  6. Don’t forget: You’ll still need front desk staff, MAs, RN, NP/PA support depending on your volume. All of that is on top of the physics/therapist core.
TL;DR:

Radiation Oncology overhead isn’t just high—it’s baked in and front-loaded, with no meaningful cost deferral lever. In a climate of:
  • Shrinking indications (prostate, breast, oligomets)
  • Declining reimbursement (especially freestanding)
  • A leadership vacuum in our societies
… the economics are brutal. Any specialty with $10M+ fixed infrastructure before you even treat a patient isn’t comparable to most of medicine.

Extremely well stated. It is very hard to make it as a freestanding center nowadays. Overhead is crazy.
 
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