To unionize or not to unionize-resident edition

[Purplethread]

Based on some of the information that was brought up in my previous thread, I feel that it might be better to address unionization for residents and employed rad oncs separately.

First, I would like to share an article regarding the experience of residents unionizing at the University of New Mexico School of Medicine (pubmed: 21646972. the full article is attached)

Second, I would like to share the link for the Committee of Interns and Residents, the largest union for house-staff, which represents 15,000 housestaff

( I still can't post links, but type in cirseiu. followed by org in your browser)

Current concerns being voiced on this forum for residents and new graduates regarding the number of radiation residency spots and the market glut for radiation oncologists, all together with trends pointing towards hypofractionation, corporations and academic centers buying up private practices, and declining indications for radiation in general, ever increasing workloads on residents among many others have created a negative spiral of emotions. Many feel here feel that there is nothing that any of us can do to prevent that.

It's important to understand why the field is trending in that direction. With the current profitability and huge margins radiation oncology departments at academic institutions enjoy, coupled with availability of residents as cheap/free labor, leadership at academic centers have a large incentive to get more and more residents instead of hiring PAs/NPs to help with the scut work, or actually hire graduated radiation oncology residents (It's likely that some programs actually get funds for "training" and adding new residents, as funding comes from federal government/medicare. In fact, most programs take out a chunk of the funds allocated by medicare for residents as payment to cover “costs” for training residents. The salary we end up getting is back a fraction of what the federal government gives them for those residency spots)

So how can residents push back against this? That is the question, and I believe that the answer lies in organization and collective bargaining. Federal law, under the National Labor Relations Act, allows residents to unionize. The union can take many shapes or forms. One possibility, which I believe is the best option for radiation oncology residents, is a single union representing rad onc residents in hopefully most/all of the radiation oncology programs in the country. The union can then engage in collective bargaining on behalf of all the residents with each institution separately

With collective bargaining, many strategies could be employed to improve conditions for residents and new graduates. Among the ones I came up with are:
- Pushing for significant wage increases, which hopefully will change the calculus for the bean counters, with theaim of driving them to hire more support staff instead of adding more residency spots.
-directly negotiating with programs regarding the number of spots they have
-Some small programs have been creating new residencies, and others have been increasing the number of residents, however I imagine that the training they provide may not be as robust, as the residents may not get sufficient exposure to less common cancers and learn about specialized techniques; ACGME requirements include only small amount of brachy procedures, SRS, SBRT...etc. If pressure can be put on the ACGME to change those requirements, with more emphasis on actually getting enough cases to become comfortable with those techniques, that would be a way to cut down on residency spots that might end up training rad oncs with deficiencies ( I find it shocking the most residents don't feel comfortable with gyn brachytherapy even though we spend 4 years in rad onc training). The change can be done gradually, to not harm residents that already joined these programs
-Push for more support, including dictation software, money for quality improvement and things to improve resident productivity, more research time and a push to invest in research to increase the indications for RT. I personally believe that it's truly underutilized in the treatment of cancer and especially under utilized in the treatment of benign conditions

I also believe that by merely forming such a union, organizations like ASTRO will be forced to re-examine their mandate, or risk being sidelined

Take control of your destiny! if we don't fight back no one else will fight on our behalf.

Those are some of the thoughts I had regarding this topic. Please feel free to chime in

---

Members don't see this ad.

 

[imhopeful432]

Its just not realistic for all rad onc residents nationally to unionize. I was a member of CIR as an intern - its a great organization. But it works because it represents all of the residents in the hospitals its active in - not just a single specialty.

To your points:
- Resident salaries are generally set by the GME office of the institution - not the department. Departments certainly have wiggle room (paying for conferences, academic fund, etc) but its generally pretty fixed. And no GME office is going to deal with a national specialty specific union that covers maybe 2-5% of the residents in the entire hospital
- How will you get every resident to join? If a new department got ACGME approval for a new residency program, they would recruit new residents and that's that. There would be no way for a rad onc union to use their leverage to stop this from happening. And they have no power over the ACGME because its against federal anti-trust laws etc for the ACGME to consider supply/demand when considering an application to expand a program or approve a new program

Having spoken to multiple leaders in ADROP/SCAROP, a lot of folks in ASTRO leadership have actually come around on this topic (big change since 5-6 years ago) and the majority of the leadership do believe in the job mal-distribution/oversupply problem and the uselessness generally of fellowships or "clinical instructor" positions. But, for any individual PD/Chair, there are still often strong incentives to expand their program (for all the reasons that have been previously stated). In the 1990s, SCAROP wrote an article stating that limiting the number of residents is "part of the solution" as well as broadening rad onc education. Rad onc residency also increased from 3 to 4 years and the number of programs shrunk considerably.

I don't know what the solution is now other than "shaming" programs that expand/critically evaluating programs where a lot of residents land fellowships instead of jobs, but for all the hate thrown at ASTRO on this issue, I just haven't heard any realistic (and legal) solutions on the topic that ASTRO or others could take.

 

[Haybrant]

You guys need to figure out a way to get the boomers and the old people out of their jobs. Tons of private practices are run or staffed by washed up 55-60+ year olds who will plan to work to their mid 70s. We all know they are washed up and we just tolerate them. Some aren’t even board certified but they are allowed to continue practicing through some grandfather rule (pretty sure that old bag wallner was involved in that too). It’s scandalous, really. To top it off they all made enough money already. I don’t know the answer, it may just be they won’t leave until pay declines even further. But it’s the saddest thing, graduating residents are top of their class, amazing researchers and would make amazing colleagues, compassionate people, and they are completely shut out bc of these old bags.

 

[RadOncDoc21]

You guys need to figure out a way to get the boomers and the old people out of their jobs. Tons of private practices are run or staffed by washed up 55-60+ year olds who will plan to work to their mid 70s. We all know they are washed up and we just tolerate them. Some aren’t even board certified but they are allowed to continue practicing through some grandfather rule (pretty sure that old bag wallner was involved in that too). It’s scandalous, really. To top it off they all made enough money already. I don’t know the answer, it may just be they won’t leave until pay declines even further. But it’s the saddest thing, graduating residents are top of their class, amazing researchers and would make amazing colleagues, compassionate people, and they are completely shut out bc of these old bags.

I see this in other fields as well where old surgeon’s are still doing hack jobs (wedges for all lungs or mediastinoscopy for staging, full axillary lymph node dissections in breasts, radical prostatectomies, upfront surgery for all GI cancers, sarcomas, etc), yet they have all the power and pull of their respected institutions. Most of them are either not board ceritified, were grandfathered in or do not have to maintain certification status.

Let’s face it, we got into medicine at the wrong time. These millenials on the other hand, have it way too easy...

 

[radiaterMike]

I don't get all of the spewed hatred at Wallner. Maybe I am missing something (my only interactions with him have been his spiel to examinees at the oral boards and listening to his ASTRO talks on MOC).

While it is true that his certificate is grandfathered, he (by his own doing) is required to maintain certification (as are all ABR volunteers and physician leadership).

Under his leadership he has in FACT eliminated indefinite board eligibility - which I know for a FACT has caused some rad. oncs. to retire. Also under his leadership, the MOC requirements are less onerous.

On this board people have knocked him for being a baby boomer, being old, being a bag, and being a DO (as was the first moderator of this forum). I guess this type of bashing is acceptable on an anonymous forum.

 

[radiaterMike]

Also - many of those “old bags” started or bought their own practices. You want to bump them out ? Come up with a business plan, lawyer and banker and make them an offer.

You guys need to figure out a way to get the boomers and the old people out of their jobs. Tons of private practices are run or staffed by washed up 55-60+ year olds who will plan to work to their mid 70s. We all know they are washed up and we just tolerate them. Some aren’t even board certified but they are allowed to continue practicing through some grandfather rule (pretty sure that old bag wallner was involved in that too). It’s scandalous, really. To top it off they all made enough money already. I don’t know the answer, it may just be they won’t leave until pay declines even further. But it’s the saddest thing, graduating residents are top of their class, amazing researchers and would make amazing colleagues, compassionate people, and they are completely shut out bc of these old bags.

 

[Haybrant]

Also - many of those “old bags” started or bought their own practices. You want to bump them out ? Come up with a business plan, lawyer and banker and make them an offer.

That’s like telling an independent bookstore to just go and take on amazon, go ahead make them an offer. There are a lot of people that feel, oh well times have changed the independent bookstore didn’t adapt they should go out of business. I’m not saying that’s not ok. But if one day amazon drove out all independent bookstores and then decides its just going to sell books that were written before the year 2000 and nothing else, would it be wrong for people to speak up about this. You simply can’t use pure economic arguments when it comes to clinical medicine - it’s a system level issue

But yes going into rad onc right now is like opening up an independent bookstore. Ya it’s fun, it’s a good field but it’s just not worth the investment

 

[medgator]

Also - many of those “old bags” started or bought their own practices. You want to bump them out ? Come up with a business plan, lawyer and banker and make them an offer.

That's pretty much how outfits like 21C, vantage oncology etc would acquire practices.

And imo it has been the lesser of two evils vs straight up selling to a hospital and having current and future RO physicians become employed.

That’s like telling an independent bookstore to just go and take on amazon, go ahead make them an offer. There are a lot of people that feel, oh well times have changed the independent bookstore didn’t adapt they should go out of business.

I don't quite get this analogy. Jeff bezos left his cush I-banking gig and started up Amazon as a bookseller and took a big risk to start it up. I think that's what radiatermike was getting at with the original founders of many of these practices.

Considering the current and last several years of cuts on the freestanding side in RO, I especially don't think I would have had the guts to build a practice from scratch starting today

 

[Reaganite]

You guys need to figure out a way to get the boomers and the old people out of their jobs. Tons of private practices are run or staffed by washed up 55-60+ year olds who will plan to work to their mid 70s. We all know they are washed up and we just tolerate them. Some aren’t even board certified but they are allowed to continue practicing through some grandfather rule (pretty sure that old bag wallner was involved in that too). It’s scandalous, really. To top it off they all made enough money already. I don’t know the answer, it may just be they won’t leave until pay declines even further. But it’s the saddest thing, graduating residents are top of their class, amazing researchers and would make amazing colleagues, compassionate people, and they are completely shut out bc of these old bags.

While I agree many of the "old bags" are behind the times, I begrudgingly admit I'd still prefer to hire a middle-age doc to linac babysit one of my practices than have a new grad take the reigns...and I'm a young guy myself. The new grads I have interviewed for PP positions recently are shockingly entitled and would have very little chance at excelling in private practice. We may be graduating residents at the top of their class, but frankly, there are few I would want anywhere near the offices I worked my ass off and took significant financial risks to build. I know may of the old bags feel the same way.

 

[radiaterMike]

I agree. But you might have the guts to work with an existing practice and develop a plan to buy them out. You won’t take on 21c (or amazon) but even some recent grads have taken over some small practices (more akin to the small book store). You and Reaganite have posted many times on this forum on how a practice is built. I agree that in the era when many of these practices have already been sold to universities and non-university hospitals, these opportunities are more limited. But the ‘old bags’ are not going to just step aside and hand everything they’ve worked for over to the new grads just because they were tops in their class, have record board scores, AOA ... and entered the field when it was highly competitive.

That's pretty much how outfits like 21C, vantage oncology etc would acquire practices.

And imo it has been the lesser of two evils vs straight up selling to a hospital and having current and future RO physicians become employed.



I don't quite get this analogy. Jeff bezos left his cush I-banking gig and started up Amazon as a bookseller and took a big risk to start it up. I think that's what radiatermike was getting at with the original founders of many of these practices.

Considering the current and last several years of cuts on the freestanding side in RO, I especially don't think I would have had the guts to build a practice from scratch starting today

 

[Phantom1]

Man, residents are employees but they are also trainees at the same time. Yes there are some residency groups which have unionized, but what is your recourse if you dont get what you want? Your going to go on strike? This could negativly impact training. Ultimately progression year to year through residency training is conditional and subject to GME and/or departmental/program director rules. What then.. you going to sue for discrimination if you dont advance based upon federal non-disrimination laws while in a training program? Good luck getting a job then..

I dont think a rad onc resident union has any legs. Didn’t supreme court strike down mandatory union fees? So your going to be left with a small group of disgruntled residents trying to negociate union demands with individual institutions on behalf of 3-4 residents at that institution???

I think efforts would be much better spent lobbying and campainging for a cap, moratorium on expansion, or overall better control on the number of residency positions through national organizations and generation of additional hard data and publications documenting the decline in faculty position availabilities, job placement/satisfaction etc. This is a very important issue for the field, but I dont think unionizing is the right answer...

 

[medgator]

. Ultimately progression year to year through residency training is conditional and subject to GME and/or departmental/program director rules. What then.. you going to sue for discrimination if you dont advance based upon federal non-disrimination laws while in a training program? Good luck getting a job then..

Yup. Reminds me of a real life horror story that happened in one dept of urology....

Allegations of the 1960s: A Throwback Surgeon? | Physician's Weekly

Former Resident Represented by Wilson & Wilson Co., L.P.A. Files Lawsuit against The Ohio State University Alleging Abuses at Wexner Medical Center

 

[Neuronix]

While I agree many of the "old bags" are behind the times, I begrudgingly admit I'd still prefer to hire a middle-age doc to linac babysit one of my practices than have a new grad take the reigns...and I'm a young guy myself. The new grads I have interviewed for PP positions recently are shockingly entitled and would have very little chance at excelling in private practice. We may be graduating residents at the top of their class, but frankly, there are few I would want anywhere near the offices I worked my ass off and took significant financial risks to build. I know may of the old bags feel the same way.

I think your sentiment goes both ways for new grads. I don't know if I was considered one of these "shockingly entitled" new grads a few years ago when I finished. I knew the private practice world fairly well around my residency program because I used to moonlight, and none of those guys were interested in hiring partnership track positions--only employed rad oncs that made the same if not less than the academic center in the area.

I interviewed in multiple PP settings in my residency area and in other parts of the country, and I specifically asked every time about partnership opportunities. All of the people I interviewed with (except the most junior) were partners in their practices. Yet those same people and practices had either done away with partnership track or had "restructured" it in some nebulous, less advantageous way for the new grad without further details. The same opportunities available even five years before were no longer available.

I always declared that a partnership track was my goal, noted that I am very a hard worker that would do whatever is necessary to make that happen, declaring that I would build with financial risk... I was never offered a real technical partnership opportunity regardless. All the groups seemed to get uncomfortable even discussing the topic. I didn't find one that had a developed track that I was offered. Some gave vague nebulous statements that wouldn't get written into a contract. Others straight up said that they weren't hiring for partnership track. Or even better, they had "professional" partnership tracks, which meant your salary might go up from assistant prof level in academics to associate prof level around the same time as it would in academics, assuming you could write.

So for me my only options were employed rad onc, whether that was private or academic. Given the choice, I stayed academic, but I just felt like a fish in a shark tank no matter which direction I went and I still do.

 

[RickyScott]

I think your sentiment goes both ways for new grads. I don't know if I was considered one of these "shockingly entitled" new grads a few years ago when I finished. I knew the private practice world fairly well around my residency program because I used to moonlight, and none of those guys were interested in hiring partnership track positions--only employed rad oncs that made the same if not less than the academic center in the area.

I interviewed in multiple PP settings in my residency area and in other parts of the country, and I specifically asked every time about partnership opportunities. All of the people I interviewed with (except the most junior) were partners in their practices. Yet those same people and practices had either done away with partnership track or had "restructured" it in some nebulous, less advantageous way for the new grad without further details. The same opportunities available even five years before were no longer available.

I always declared that a partnership track was my goal, noted that I am very a hard worker that would do whatever is necessary to make that happen, declaring that I would build with financial risk... I was never offered a real technical partnership opportunity regardless. All the groups seemed to get uncomfortable even discussing the topic. I didn't find one that had a developed track that I was offered. Some gave vague nebulous statements that wouldn't get written into a contract. Others straight up said that they weren't hiring for partnership track. Or even better, they had "professional" partnership tracks, which meant your salary might go up from assistant prof level in academics to associate prof level around the same time as it would in academics, assuming you could write.

So for me my only options were employed rad onc, whether that was private or academic. Given the choice, I stayed academic, but I just felt like a fish in a shark tank no matter which direction I went and I still do.

Agreed, the job market makes advancement prospects very difficult... At a basic level, many of us are like you, desire a shot at professional advancement. In academics, we know what that means; In private practice that would mean partnership...

Also wanted to add, how many of those private practices that dont have partnership tracks are hypofractionating breast- the point i am trying to make it that the tight job market also encourages overutilization

 

[Reaganite]

I think your sentiment goes both ways for new grads. I don't know if I was considered one of these "shockingly entitled" new grads a few years ago when I finished. I knew the private practice world fairly well around my residency program because I used to moonlight, and none of those guys were interested in hiring partnership track positions--only employed rad oncs that made the same if not less than the academic center in the area.

I interviewed in multiple PP settings in my residency area and in other parts of the country, and I specifically asked every time about partnership opportunities. All of the people I interviewed with (except the most junior) were partners in their practices. Yet those same people and practices had either done away with partnership track or had "restructured" it in some nebulous, less advantageous way for the new grad without further details. The same opportunities available even five years before were no longer available.

I always declared that a partnership track was my goal, noted that I am very a hard worker that would do whatever is necessary to make that happen, declaring that I would build with financial risk... I was never offered a real technical partnership opportunity regardless. All the groups seemed to get uncomfortable even discussing the topic. I didn't find one that had a developed track that I was offered. Some gave vague nebulous statements that wouldn't get written into a contract. Others straight up said that they weren't hiring for partnership track. Or even better, they had "professional" partnership tracks, which meant your salary might go up from assistant prof level in academics to associate prof level around the same time as it would in academics, assuming you could write.

So for me my only options were employed rad onc, whether that was private or academic. Given the choice, I stayed academic, but I just felt like a fish in a shark tank no matter which direction I went and I still do.

I've had bad luck with interviews recently. I'm sure there are great PP candidates out there I just don't have the opportunity to meet. Part of that is my own fault--I never advertise my positions. I don't want to draw attention to my practice honestly. If I put out an ad, competitors assume all sorts of things...I must be the reason their clinics are slow...I'm paying referring docs...I'm working underhanded deals with insurance companies, etc. It's crazy. Then suddenly I'm the victim of fake online reviews, ****-talking to referring docs, etc. (All of this comes from first-hand experience). For this reason, I always prefer to hire a known commodity...which usually means somebody in the area. I try as early as I can to reach out to the local residency programs and offer their residents locums opportunities. Gives me a chance to get really know them rather than just relying on a short interview. If I can stress anything to new grads looking for PP practice work, it would be:

1. Make connections. Do locums work as early as you can in the area you want to work. Even if you have to accept a **** rate, at least you get your foot in the door. I used to offer probably 50% of the prevailing locum rate as a resident just to make these contacts.
2. Be careful bringing up partnership, vacation, etc. during your initial interview. FWIW, I don't personally know anyone in PP today who is offering partnership track (not saying others aren't, but nobody in my sphere is). Also, what does partnership even mean? When a new grad asks me about "partnership," I always throw it back to them. What does partnership mean to you? The kind of guy I'm looking for is someone who comes to my office ready to learn from me...somebody who doesn't expect partnership to be handed to him but is eager to learn how I built my practice(s) and wants to utilize that knowledge to create new business/open a new center for us...then he becomes my de facto partner.
3. Don't voluntarily bring up hypofractionation. Contrary to what you think, many of us hypofractionate breast and prostate in PP. Many insurance companies have shifted to case-rate payments so we are actually incentivized to hypo-fx. What I don't want to see during an interview, though, is some holier-than-thou new grad trashing docs for "over-treatment" without understanding the nuances of PP. As an example, I have some referring docs who don't want me to hypofx breast because they (and the patients) hate the delayed skin reaction. Also, if a referring doc has already told some prostate patient his treatment is gonna be 9 weeks and the patient has read online the treatment is 9 weeks...I'm going to think twice about proposing a hypo-fx course of treatment. It creates doubt in patients' minds, and they start questioning their docs, seeking second opinions...then I get a call from my angry referring doc asking why I threw him under the bus...

 

[Neuronix]

wants to utilize that knowledge to create new business/open a new center for us...then he becomes my de facto partner.

So... "De facto partner" means they build a practice for you and you take all the profit? Sounds like a great deal--for you.

 

[medgator]

So... "De facto partner" means they build a practice for you and you take all the profit? Sounds like a great deal--for you.

Not really, if they are collecting their own professional fees. Which is what I got out of that statement.

Heck if the risk is that great, I imagine reaganite might even allow said individual to BUY shares in the technical revenue stream, in addition to collecting his/her pro fees, given that that individual is likely responsible for keeping said center profitable from a technical standpoint. That will further incentivize this successful individual and give them even more skin in the game.

Imagine if reaganite didn't do that and said individual bailed on said successful practice? Prob wouldn't look good to patients and referrings, now would it? How long do you think it would take to build this practice back up again? And do you think reaganite can do that on his own with other centers to be physically present at and keep successful?

The corollary is if said individual is a warm body who simply treats what comes through the door from 830-430...well they might be looking for a new job after the 2-3 year employment agreement, since such an individual would easily be replaced... might be better off working in a VAMC situation or something that.

 

[Reaganite]

So... "De facto partner" means they build a practice for you and you take all the profit? Sounds like a great deal--for you.

Lol..not at all...but the usual response. It means I want partners who think like me and want to expand the practice...not people who expect to have a piece of what I already created. Its easy to find cheap rad onc labor in desirable areas. I can employ a middle aged guy for <200k no problem. I dont need "good" radoncs from top 10s. Most of the new grads I meet are fully competent. But a guy who, for example, comes to me with a plan about where he thinks we can build a center...thats the guy I partner with and equitably split the technical shares with. My whole point in all of this is you shouldnt blindly ask about partnership in an interview...you should tell them what you want to do to become a partner. They dont need you as much as you need them in desirable locations at least.

 

[nkmiami]

opening new centers is not a reality in most parts of the country. So given a choice between employment by a nonprofit/large organization vs someone who sees every dollar going to me as coming out of their own pocket, better applicant will always work for an organization, which is more stable.
In the end many of these type of practices will get sold to the local hospital system/21c etc. heard of quite a few radoncs screwed this way

Lol..not at all...but the usual response. It means I want partners who think like me and want to expand the practice...not people who expect to have a piece of what I already created. Its easy to find cheap rad onc labor in desirable areas. I can employ a middle aged guy for <200k no problem. I dont need "good" radoncs from top 10s. Most of the new grads I meet are fully competent. But a guy who, for example, comes to me with a plan about where he thinks we can build a center...thats the guy I partner with and equitably split the technical shares with. My whole point in all of this is you shouldnt blindly ask about partnership in an interview...you should tell them what you want to do to become a partner. They dont need you as much as you need them in desirable locations at least.

Lol..not at all...but the usual response. It means I want partners who think like me and want to expand the practice...not people who expect to have a piece of what I already created. Its easy to find cheap rad onc labor in desirable areas. I can employ a middle aged guy for <200k no problem. I dont need "good" radoncs from top 10s. Most of the new grads I meet are fully competent. But a guy who, for example, comes to me with a plan about where he thinks we can build a center...thats the guy I partner with and equitably split the technical shares with. My whole point in all of this is you shouldnt blindly ask about partnership in an interview...you should tell them what you want to do to become a partner. They dont need you as much as you need them in desirable locations at least.

 

[Fpg1245]

opening new centers is not a reality in most parts of the country. So given a choice between employment by a nonprofit/large organization vs someone who sees every dollar going to me as coming out of their own pocket, better applicant will always work for an organization, which is more stable.
In the end many of these type of practices will get sold to the local hospital system/21c etc. heard of quite a few radoncs screwed this way

PP is pretty much non existent in any area with a giant hospital system which is virtually every area that Ian desirable. The hospitals systems are treated more favorably and honestly They’re really aren’t enough patients to go around for everyone to succeed. If someone threw the question back at me if I asked about a partnership then it just means they’ve run out of ideas for how to grow they’re own bussiness. The reality is you need patients and referrals to succeed and if you cant get them because the entire medical profession works for 1 or two major hospitals in the area then guess whatWeather or not you are familiar with the area or how great you were in residency isn’t going to change the structural issues. Partnership is fantasy unless you like the boonies and even then it really isn’t that great a deal.

 

[medgator]

PP is pretty much non existent in any area with a giant hospital system which is virtually every area that Ian desirable. The hospitals systems are treated more favorably and honestly They’re really aren’t enough patients to go around for everyone to succeed.

You can't generalize any of that to all over the country. In fact I bet that's the exception rather than the rule

In the areas where PP/freestanding centers still exist, many of the insurers are looking to them to preferentially contract with rather than the more expensive hospital system. And those centers are actually thriving because of that.

Moreover, not every hospital system has an in-house oncology service line, so the pp med onc and rad onc groups will take care of the patients there.

And ALL of the above is true in several metros, including many desirable ones.

 

[Fpg1245]

You can't generalize any of that to all over the country.

In the areas where PP/freestanding centers still exist, many of the insurers are looking to them to preferentially contract with rather than the more expensive hospital system. And those centers are actually thriving because of that.

Moreover, not every hospital system has an in-house oncology service line, so the pp med onc and rad onc groups will take care of the patients there.

And ALL of the above is true in several metros, including many desirable ones.

Give it time, they’ll all fall in line even the Professional component only groups. Cost of these new systemic agents is ridiculous and honestly the allowed markup on those drugs is how pp med oncs keep the doors open. Freestanding RT facilities need TC to keep the doors open. However, the preferential treatment of hospital based programs and the pretty much mandatory payment cuts by CMS on the PC and the TC side mean it’s only a matter of time before the practices fold. Even if they don’t fold, how will they attract new grads? They will have very little to offer them. Insurers may like you more but the big health system has the money and political clout to pretty much nullify that preference. And if the price is right, they could buy you out. I’m sorry but in the ACA era The deck is stacked against pp in the zero sum game if payors, patients, and providers. Thanks for playing. I can’t wait for the real bloodbath in oncology once single payor finally comes to town making this whole discussion moot.

 

[medgator]

. However, the preferential treatment of hospital based programs and the pretty much mandatory payment cuts by CMS on the PC and the TC side mean it’s only a matter of time before the practices fold.

That preferential treatment by Medicare may soon come to an end when site neutral payments come to fruition. Why should Medicare pay hospital-based RO facilities more for the same service?

Along the same line, case based/bundled reimbursement will also hurt the hospitals more than the freestanding centers, which have actually been pushing for this for a long time (much to chagrin of ASTRO, until very recently).

. Insurers may like you more but the big health system has the money and political clout to pretty much nullify that preference.

There are lawsuits going on now against monopolistic health systems which buy up practices and jack up prices as a result. This is creating a backlash against these systems

Here’s why Carolinas HealthCare could settle federal lawsuit

California sues hospital giant Sutter Health, where study found prices 25% higher

The Sutter Health lawsuit could guide other states that aim to break up highly concentrated markets.

 

[RickyScott]

Give it time, they’ll all fall in line even the Professional component only groups. Cost of these new systemic agents is ridiculous and honestly the allowed markup on those drugs is how pp med oncs keep the doors open. Freestanding RT facilities need TC to keep the doors open. However, the preferential treatment of hospital based programs and the pretty much mandatory payment cuts by CMS on the PC and the TC side mean it’s only a matter of time before the practices fold. Even if they don’t fold, how will they attract new grads? They will have very little to offer them. Insurers may like you more but the big health system has the money and political clout to pretty much nullify that preference. And if the price is right, they could buy you out. I’m sorry but in the ACA era The deck is stacked against pp in the zero sum game if payors, patients, and providers. Thanks for playing.

Ultimately, prices are not sustainable no matter how big and powerful regional health systems get. With the oversupply of residents, yes, many will be forced into exploitative private practices. (and most of us would rather be "exploited" by a nonprofit) Hospitals consolidations, as you point out, is another limitation on the demand for new docs, in addition to hypofractionation, and changes in disease management. The oversupply of docs benefits anyone who owns a machine, whether that be ASTRO leadership/chairman or private practioners.

Yes, the private practioner who enriches himself by exploiting new grads, and overutilization, provokes gut level emotional disgust in all of us, but in the macroeconomic picture, it is still the prices, stupid! of the large monopolistic/ASTRO systems that is the problem in the economic literature. And, these are the systems that are pumping out residents to fill satellites.

"Translating Discovery to Cure"

 

[Reaganite]

That preferential treatment by Medicare may soon come to an end when site neutral payments come to fruition. Why should Medicare pay hospital-based RO facilities more for the same service?

Along the same line, case based/bundled reimbursement will also hurt the hospitals more than the freestanding centers, which have actually been pushing for this for a long time (much to chagrin of ASTRO, until very recently).



There are lawsuits going on now against monopolistic health systems which buy up practices and jack up prices as a result. This is creating a backlash against these systems

Here’s why Carolinas HealthCare could settle federal lawsuit

California sues hospital giant Sutter Health, where study found prices 25% higher

The Sutter Health lawsuit could guide other states that aim to break up highly concentrated markets.

Absolutely agree. Do you think the Blues, United, etc. (all multi-billion dollar corps with as much money and lobbying power as anyone) are going to sit back and let big hospital systems consolidate and rape them in the a**? I actually think the tide is turning in some markets. I know where I practice the big academic centers are absolutely on local IPA and insurance hit lists. The PPOs in my area have started to develop limited networks that exclude academic centers, and IPAs that refuse to contract with academic centers are gobbling up millions of lives. United has even started buying up large medical groups. Granted, there are geographies where you have a near monopoly like Sutter health, but as you can see even there they are pursuing aggressive litigation.

 

[RickyScott]

I think the only way to fix this is for "collective voices" from the specialty to advocate for sustainable prices. ie. prostate radiation should be below 30,000$ If insurance cos takes notice, it will dissuade large academic centers from expanding satellites and residency spots to fill these giant departments. Because of the fixed cost nature of radiation, and the high prices that these systems can charge, there is a strong incentive to build satellites and fill them with recent grads.

Here is a recent example of 10X fee differentials in trauma:

A baby was treated with a nap and a bottle of formula. His parents received an $18,000 bill.

"Comprehensive data from the Health Care Cost Institute shows that the average price that health insurers paid hospitals for trauma response (which is often lower than what the hospital charges) was $3,968 in 2016. But hospitals in the lowest 10 percent of prices received an average of $725 — while hospitals in the most expensive 10 percent were paid $13,525. Data from Amino Health, a health cost transparency company, shows the same trend. On average, Medicare pays just $957.50 for the fee."

The large hospital systems associated with ASTRO leadership, you can bet they are in the top 10% in our field, and with a fixed cost business, radiation provides a powerful incentive for satellites and residency expansion...(while falsely focusing on utilization-choose wisely- than prices)

."Translating Discovery to Cure"

 

[Haybrant]

That's pretty much how outfits like 21C, vantage oncology etc would acquire practices.

And imo it has been the lesser of two evils vs straight up selling to a hospital and having current and future RO physicians become employed.



I don't quite get this analogy. Jeff bezos left his cush I-banking gig and started up Amazon as a bookseller and took a big risk to start it up. I think that's what radiatermike was getting at with the original founders of many of these practices.

Considering the current and last several years of cuts on the freestanding side in RO, I especially don't think I would have had the guts to build a practice from scratch starting today

It’s fun to run with the tech analogy a bit. Travis kalanick also started a behemoth from nothing, Uber. He saw a problem and tried to fix it and innovate. By your argument Uber and kalanick should be immune from any criticism or responsibility and all other should just say tough luck. That would be a minority opinion at this point. Boomers undermined medicine by pulling the crap that they pulled and have continued to pull. They deliver inferior treatment and accept overtreatment in their own department and of referrings. But you’re right, just bc we criticize doesn’t mean anything will happen, it won’t. Someone needs to innovate a solution possibly tech based. Those of us that are early career are very interested

 

[medgator]

It’s fun to run with the tech analogy a bit. Travis kalanick also started a behemoth from nothing, Uber. He saw a problem and tried to fix it and innovate. By your argument Uber and kalanick should be immune from any criticism or responsibility and all other should just say tough luck. That would be a minority opinion at this point. Boomers undermined medicine by pulling the crap that they pulled and have continued to pull. They deliver inferior treatment and accept overtreatment in their own department and of referrings. But you’re right, just bc we criticize doesn’t mean anything will happen, it won’t. Someone needs to innovate a solution possibly tech based. Those of us that are early career are very interested

I think the pendulum will swing back to freestanding RO in the next decade just because of the sheer (increasing) costs of everything, once the elephant in the room is acknowledged, namely cost transparency. That is the single biggest thing anyone from either side of the aisle in Congress could fix, yet it never happens. I am hopeful something will get done there soon, which will be a great equalizer.

If someone is responsible for 20% of their co-pay for Tx, and they knew the freestanding center offered equivalent care at a fraction of the price, where would they go with their healthcare $$? Ditto for everything else, like chemo, MRIs, PETs, etc. which all have the same issue. I've had patients tell where they want their follow up scans done, because they've done their homework (because they are responsible for a % of the bill!)

Regardless of where the pendulum goes, newer grads are going to continue to face a rough job market as long as current trends in residency expansion and hypo-fractionation hold.

 

[nkmiami]

I think the pendulum will swing back to freestanding RO in the next decade just because of the sheer (increasing) costs of everything, once the elephant in the room is acknowledged, namely cost transparency. That is the single biggest thing anyone from either side of the aisle in Congress could fix, yet it never happens. I am hopeful something will get done there soon, which will be a great equalizer.

If someone is responsible for 20% of their co-pay for Tx, and they knew the freestanding center offered equivalent care at a fraction of the price, where would they go with their healthcare $$? Ditto for everything else, like chemo, MRIs, PETs, etc. which all have the same issue. I've had patients tell where they want their follow up scans done, because they've done their homework (because they are responsible for a % of the bill!)

Regardless of where the pendulum goes, newer grads are going to continue to face a rough job market as long as current trends in residency expansion and hypo-fractionation hold.

Based on previous post I called Health Care Cost Institute: HCCI | Health Care Cost Institute
they have data on what insurances are actually paying for the different cpt codes, but you need to be an academic partner to have access
Academic Research Partnerships | Health Care Cost Institute (HCCI)