p2p uptick

[medgator]

I believe i saw a quadshot a few weeks ago on an editorial about ORN proton paper. They went back and identified that most of those patients had older techniques. Maybe Im mistaken but i thought i saw this.

The protonists have a losing scenario. The same people who claim they want to see the data, are the same people who will claim that the cost is not worth it for such a mild improvement (“clinically insignificant”) with whatever endpoint is shown.
This is because they don’t have protons and never will so there is a COI there. Likewise, places that have this tech have a conflict of interest as well. Bottomline, i doubt the skeptics would ever be satisfied because it threatens their bottom line. i would imagine practices who did not have IMRT also said at some point it was not needed and not worth it!

It ain't the same as imrt, hun and never will be. The cost differential is so great plus you never saw such bad data coming out of IMRT compared to 3D vs IMRT/protons now. And it's not like the protonistas haven't had several years to start pumping out the prospective, comparative data right?

In the end though, data won't matter:

---

Members don't see this ad.

 

[CaesarRO]

It ain't the same as imrt, hun and never will be. The cost differential is so great plus you never saw such bad data coming out of IMRT compared to 3D vs IMRT/protons now. And it's not like the protonistas haven't had several years to start pumping out the prospective, comparative data right?

In the end though, data won't matter:

For the record something that #grindsmygears is frequently seeing this quote framed as though Nancy Lee implies she will ignore data, but from the context of the slide, it's clear she's pointing to this as a concern facing the field and proton centers.

She is sounding the alarm, not cheerleading the mindset of "treat no matter what"

 

[Fpg1245]

For the record something that #grindsmygears is frequently seeing this quote framed as though Nancy Lee implies she will ignore data, but from the context of the slide, it's clear she's pointing to this as a concern facing the field and proton centers.

She is sounding the alarm, not cheerleading the mindset of "treat no matter what"

Based on what I’ve seen at other academic centers, actions speak louder than words. If you have a PC then you will be expected to use it. And if the numbers are too low,expect to have your chair “have a one on one” with you to discuss which patients “should” be on the machine.

You might not be ignoring the data. But you sure won’t be practicing EBM…that is if you want to keep your job.

 

[thecarbonionangle]

It ain't the same as imrt, hun and never will be. The cost differential is so great plus you never saw such bad data coming out of IMRT compared to 3D vs IMRT/protons now. And it's not like the protonistas haven't had several years to start pumping out the prospective, comparative data right?

In the end though, data won't matter:

I have seen people on this board say they do not discuss protons with esophagus patients because it is “not needed” and the study is “impossible to understand”. Similarly, have seen people on this board admit they treat peds and do not refer out.
When NRG GI006 reports, and lets assume it is a positive study for some endpoint, will the data matter to these folks or will they continue business as usual moving the meat?

 

[thecarbonionangle]

Based on what I’ve seen at other academic centers, actions speak louder than words. If you have a PC then you will be expected to use it. And if the numbers are too low,expect to have your chair “have a one on one” with you to discuss which patients “should” be on the machine.

You might not be ignoring the data. But you sure won’t be practicing EBM…that is if you want to keep your job.

This is true but isn't this the case in a lot of places and not just with protons? Medicine is business and yeah “numbers” are closely watched in academics and pp even though numbers is a growingly outdated boomer/gen x metric

 

[medgator]

I have seen people on this board say they do not discuss protons with esophagus patients because it is “not needed” and the study is “impossible to understand”. Similarly, have seen people on this board admit they treat peds and do not refer out.
When NRG GI006 reports, and lets assume it is a positive study for some endpoint, will the data matter to these folks or will they continue business as usual moving the meat?

I send out proton referrals several times a year. The ebm conclusions (based on prospective data) will never put photons out of business, you betcha

 

[sirspamalot]

business as usual moving the meat?

This sounds like something my wife would say.

 

[thecarbonionangle]

This sounds like something my wife would say.

Women are very smart beings. Always listen to your wife.

 

[sirspamalot]

She's pretty.. and pretty funny too. I do listen... but its the agreeing part that is sometimes a challenge.

 

[thecarbonionangle]

She's pretty.. and pretty funny too. I do listen... but its the agreeing part that is sometimes a challenge.

Pick your battles carefully brotha!

 

[sirspamalot]

We duke it out she's a tough little lady. Making up is fun. After a decade.. We both have gotten better at handling each other. Marriage isn't today's battle...its a lifelong war.

 

[radiaterMike]

already published data out of MDACC showing that protons reduce the risk of Gtubes and hospitalization

This paper compared proton therapy from ~2011-2014 vs IMRT from 2010-2012. Any clue if there was any attempt to spare the pharyngeal constrictors with IMRT (which was not routinely done until somewhat recently) ? The paper certainly does not divulge that. Comparing proton therapy to suboptimal IMRT seems to be the way to go with published papers and insurance appeals.

 

[communitydoc13]

I believe that the human data supporting protons relative to IMRT is already more robust, in my opinion.

In terms of human data, how about this? How many docs with protons would insist on having them when looking for a new job? How many docs from proton having academic centers actually feel that they are providing substandard care after moving on to a photon only facility?

My impression (I'm a lifelong photon only user) is that the intuitive, many variable calculation that most docs who have used protons for years have made is that they are of marginal if any benefit over photons...…and that they take exorbitant resources.

Am I wrong?

They do bill however, and they do improve market share.

 

[sirspamalot]

For those who are tired of p2p I wonder if recording and dumping the calls (stripped of ID) into a repository would be useful. Certainly the press would enjoy seeing the circus.

Ape together strong?

 

[evilbooyaa]

I believe i saw a quadshot a few weeks ago on an editorial about ORN proton paper. They went back and identified that most of those patients had older techniques. Maybe Im mistaken but i thought i saw this.

The protonists have a losing scenario. The same people who claim they want to see the data, are the same people who will claim that the cost is not worth it for such a mild improvement (“clinically insignificant”) with whatever endpoint is shown.
This is because they don’t have protons and never will so there is a COI there. Likewise, places that have this tech have a conflict of interest as well. Bottomline, i doubt the skeptics would ever be satisfied because it threatens their bottom line. i would imagine practices who did not have IMRT also said at some point it was not needed and not worth it!

Yes and now if you can't do IMRT properly you should probably not exist as a center and definitely shouldn't (doesn't mean they're not out there in rural areas) practice as a radiation oncologist.

I do not think the same will be said of proton radiation in 20-30 years from now.

 

[sirspamalot]

Im in a rural area and on the menu today is yet ANOTHER postop head and neck with bilateral neck dissections, + styloid margin and on and on. Those are fun to contour.

Anyone miss opposed laterals with electron blocks for the cord from the 1990's? Lol.

 

[seper]

Im in a rural area and on the menu today is yet ANOTHER postop head and neck with bilateral neck dissections, + styloid margin and on and on. Those are fun to contour.

Anyone miss opposed laterals with electron blocks for the cord from the 1990's? Lol.

there are data of course showing that 3D is better in postop HN )

 

[deleted1111261]

there are data of course showing that 3D is better in postop HN )

Randomized ?

 

[seper]

Randomized ?

Fox Chase. Of course retrospective, thus outcomes are operator-dependent

 

[deleted1111261]

Fox Chase. Of course retrospective, thus outcomes are operator-dependent

Hmm.

I’m surprised that you would quote something like that with multiple positive HNC IMRT studies.

 

[seper]

Hmm.

I’m surprised that you would quote something like that with multiple positive HNC IMRT studies.

IMRT is better than 3D for tumor control? I don't know any solid data on that either

 

[deleted1111261]

IMRT is a form of 3D.
If the volumes are the same
I would not expect any change in local control or cure, except in nasopharynx because of improved coverage in those hard to reach spots.
IMRT is used for reduction in toxicity.

 

[Mandelin Rain]

"too conformal"

 

[BobbyHeenan]

had a new one for me today.
p16+ vaginal cancer s/p chemo xrt. NED in pelvis.
new solitary small lung met;
was planning SBRT (gyn onc sent). maybe post SBRT chemo.

P2P said "due to vaginal cancer" there is not randomized data for this.

I said "can you name any randomized data PERIOD in vaginal cancer?"
He said no. But he just read their policy statement.

SO now appealing back to insurance but they told me "may take 3 monhts"

wow.

 

[radiaterMike]

"too conformal" = appropriately conformal ≠ missing target

 

[OTN]

had a new one for me today.
p16+ vaginal cancer s/p chemo xrt. NED in pelvis.
new solitary small lung met;
was planning SBRT (gyn onc sent). maybe post SBRT chemo.

P2P said "due to vaginal cancer" there is not randomized data for this.

I said "can you name any randomized data PERIOD in vaginal cancer?"
He said no. But he just read their policy statement.

SO now appealing back to insurance but they told me "may take 3 monhts"

wow.

Just keep pushing up the p2p chain, they will approve eventually

 

[sirspamalot]

Just keep pushing up the p2p chain, they will approve eventually

Yup. Also, ask for expedited which forces them by law to respond within 3 bizdays.

Continue to ask for expedited.

Also ask for same specialty, which you can use for appeals documentation if they don't cough one up.

 

[evilbooyaa]

there are data of course showing that 3D is better in postop HN )

Link?

 

[seper]

Link?

Increased recurrences using intensity-modulated radiation therapy in the postoperative setting - PubMed

Local, regional failures were more common following PORT related to an increased risk of marginal failures.

pubmed.ncbi.nlm.nih.gov

 

[IonsAreOurFuture]

Increased recurrences using intensity-modulated radiation therapy in the postoperative setting - PubMed

Local, regional failures were more common following PORT related to an increased risk of marginal failures.

pubmed.ncbi.nlm.nih.gov

That is really interesting. I remember that being one of the theorized concerns against IMRT in the early 2000s, that there would be all these geographic misses from being "too conformal" or having too steep of a dose falloff.

I wonder how much of it relates to user error, basically, not knowing to contour in the whole operative bed, or not giving adequate skin dose and then seeing subcutaneous nodules pop up.

The proton world has a related concern over range uncertainty and getting "too tight." Almost the exact same arguments that IMRT had against it 15 years ago.

 

[dieABRdie]

had a new one for me today.
p16+ vaginal cancer s/p chemo xrt. NED in pelvis.
new solitary small lung met;
was planning SBRT (gyn onc sent). maybe post SBRT chemo.

P2P said "due to vaginal cancer" there is not randomized data for this.

I said "can you name any randomized data PERIOD in vaginal cancer?"
He said no. But he just read their policy statement.

SO now appealing back to insurance but they told me "may take 3 monhts"

wow.

Please record the P2P.
And inform the patient their cancer treatment is being held by insurance.

So far I have at least three board certified rad oncs on record saying "I totally agree... its just that United/Evicore/Optum etc. will not let me change it!"

 

[thesauce]

Anyone dealt with Medical Review Institute of America? They seem just as bad as Evicore.

 

[medgator]

Anyone dealt with Medical Review Institute of America? They seem just as bad as Evicore.

Worst for me so far has been AIM specialty health (now owned by carelon). Not sure if their rad oncs are even board certified and they make you call the main number for a p2p rather than the customary call to you. Worst part is when your call in, there's often no physician available to review the case. It's total BS

 

[seper]

Worst for me so far has been AIM specialty health (now owned by carelon). Not sure if their rad oncs are even board certified and they make you call the main number for a p2p rather than the customary call to you. Worst part is when your call in, there's often no physician available to review the case. It's total BS

There are many benefits of having good insurance. You can go to a good hospital / MD of your choice. And your RadOnc benefit manager will be someone from a reputable company

 

[evilbooyaa]

Increased recurrences using intensity-modulated radiation therapy in the postoperative setting - PubMed

Local, regional failures were more common following PORT related to an increased risk of marginal failures.

pubmed.ncbi.nlm.nih.gov

The paper shows that post-operative H&N patients do worse than definitive H&N patients. All patients were treated with IMRT (even the definitive ones). 3 of 12 failures were considered marginal, and were all in oral tongue patients.

Oral tongue cancer (which generally gets surgery) is more likely to recur than things treated with definitive intent, like oropharynx, nasopharynx, and larynx.

I'm not sure how this supports your point of 3D is better than IMRT for post-op H&N. I think it says oral tongue cancer patients have ****ty oncologic outcomes compared to things treated with definitive intent, like oropharynx and nasopharynx.

Perhaps a paper using some weird inverse planning process... or the fact that only 20% of the PORT patients received concurrent chemotherapy.

You see that the 3 marginal recurrences (Table 6) show that a Rt oral tongue tumor failed in the Rt BoT. A Lt oral tongue tumor failed in the R oral tongue. A Rt oral tongue failed in the Lt oral tongue. I think what this tells you is that if you want to avoid marginal miss, to draw volumes perhaps like Nancy Lee does - an oral tongue tumor resected means remainder of oral tongue and ipsilateral BoT gets RT. Perhaps a component of their contournig could've been improved given that this was likely 'early' IMRT between 2001 and 2008.

To say that PORT shouldn't be done with IMRT due to high recurrence rates when you're comparing oral cavity patients getting PORT to more favorable primary sites is.... questionable at best.

 

[Tigerstang]

One way to interpret this, there is a continuing uptick of RadOncs trying to extract every possible charge. Right-sided DIBH, postop SBRT for cord compression, IMRT lumpectomy boost…

Tell me you work doing insurance review without telling me you do insurance review.

 

[sirspamalot]

Its true: there are a small percentage of physicians who "Game" the system. But the vast majority do not. There is some minor "Wiggle" room where folks could agree to disagree - and would cost less to simply approve that then build out another huge for profit UM review entity - but here we are.

This isn't limited to Radiation Oncology: imaging abuse (particularly by those who own the machines) was all the rage back in the day. Not so much today. The egregious 5% should be scrutinized heavily. The other 95% should be "Gold carded" and left alone to do their job.

But physicians can't organize and protest very well, and hospitals make most of their cash from inpatient care, even if it is lower margin then they'd like it to be.. their success depends on market dominance ensuring better negotiating terms that are visible (pay above the medicare line) and not so visible (better behind closed doors negotiating with laxity on approvals for key items in the outpatient setting).

There are some bills coming forward in various states to bring forth "Gold Carding" by law. We shall see.

 

[Tigerstang]

There are many benefits of having good insurance. You can go to a good hospital / MD of your choice. And your RadOnc benefit manager will be someone from a reputable company

like yours? HA!

 

[deleted1111261]

Increased recurrences using intensity-modulated radiation therapy in the postoperative setting - PubMed

Local, regional failures were more common following PORT related to an increased risk of marginal failures.

pubmed.ncbi.nlm.nih.gov

I don't understand how this compares 3D and IMRT?

16% post op recurrence rate is not terribly high. 25% in RTOG 9501 post op RT vs CRT trial. (22-28% depending on arm).

Marginal miss with IMRT means your volumes were likely too small.

Let's not blame the hammer when you are using your ear to operate it.

 

[TheWallnerus]

Its true: there are a small percentage of physicians who "Game" the system. But the vast majority do not.

 

[sirspamalot]

Uh wut? It happens. What % are abusive is open to debate.

 

[thesauce]

Well the definition is “abuse” is not entirely clear either.

10 fractions for palliation?? Why not 1?? You are giving TEN TIMES the radiation!!!

 

[TheWallnerus]

Uh wut? It happens. What % are abusive is open to debate.

Gaming the system, and abuse… Every proton center in America treats a lot of breast and prostate, for starters.

But the gamer is you. The gamer is me!

When I treat a 5 fraction breast, I will consult on Monday for example. If treatment starts Thursday, I see her again on Friday to “check on her side effects and see how radiation is going.” Or I could consult a bone met patient Wednesday and see the person again the next day, less than 24h later, for their one fraction treatment… and get a charge for both visits. I mean sure it’s nice to talk to people and give them a little update on things. But getting paid several hundred bucks for that few minute social visit? Rad oncs might be the only docs in America who can see a patient two times in one week with absolutely no medical reason to do so. But I do it, every time. We all do.

The system games us. So we have to game the system at least a little, or you’d not even be able to game. By adopting a thoroughly altruistic and charge-as-little-as-possible behavior, no rad onc center would stay open. GenesisCare started something called SkinViva for basal/squamous skin cancer, which was basically just IMRT as best as I can tell. A “verbal gaming” like calling a garbage man a sanitation engineer. And now America’s largest rad onc employer is closing up shop despite that and other gaming. They didn’t game enough.

Now… all that said… there are about 5000 rad oncs in the Part B Medicare rolls. Each year, more than half of them are reimbursed $200K or less per year… while about 200 get $1M or more from Medicare.

 

[Fpg1245]

Gaming the system, and abuse… Every proton center in America treats a lot of breast and prostate, for starters.

But the gamer is you. The gamer is me!

When I treat a 5 fraction breast, I will consult on Monday for example. If treatment starts Thursday, I see her again on Friday to “check on her side effects and see how radiation is going.” Or I could consult a bone met patient Wednesday and see the person again the next day, less than 24h later, for their one fraction treatment… and get a charge for both visits. I mean sure it’s nice to talk to people and give them a little update on things. But getting paid several hundred bucks for that few minute social visit? Rad oncs might be the only docs in America who can see a patient two times in one week with absolutely no medical reason to do so. But I do it, every time. We all do.

The system games us. So we have to game the system at least a little, or you’d not even be able to game. By adopting a thoroughly altruistic and charge-as-little-as-possible behavior, no rad onc center would stay open. GenesisCare started something called SkinViva for basal/squamous skin cancer, which was basically just IMRT as best as I can tell. A “verbal gaming” like calling a garbage man a sanitation engineer. And now America’s largest rad onc employer is closing up shop despite that and other gaming. They didn’t game enough.

Now… all that said… there are about 5000 rad oncs in the Part B Medicare rolls. Each year, more than half of them are reimbursed $200K or less per year… while about 200 get $1M or more from Medicare.

You can’t survive as a physician if you aren’t gaming the system. The system has no problem gaming you.

 

[thecarbonionangle]

You can’t survive as a physician if you aren’t gaming the system. The system has no problem gaming you.

Simple rule of nature is eat or be eaten

 

[Fpg1245]

Simple rule of nature is eat or be eaten

Something that a lot MDs seem to forget.

 

[sirspamalot]

Game me once.. shame on me.. Game me twice.. won't get gamed.. wait.. will always game again...

The only real question is: how much gaming are you willing to do before it becomes incompatible with your soul?

We have been doing 30/10 for a very long time in many patients who could do 8/1. I've been asking this question for almost a quarter century.

It is what it is..

 

[IonsAreOurFuture]

Gaming the system, and abuse… Every proton center in America treats a lot of breast and prostate, for starters.

But the gamer is you. The gamer is me!

When I treat a 5 fraction breast, I will consult on Monday for example. If treatment starts Thursday, I see her again on Friday to “check on her side effects and see how radiation is going.” Or I could consult a bone met patient Wednesday and see the person again the next day, less than 24h later, for their one fraction treatment… and get a charge for both visits. I mean sure it’s nice to talk to people and give them a little update on things. But getting paid several hundred bucks for that few minute social visit? Rad oncs might be the only docs in America who can see a patient two times in one week with absolutely no medical reason to do so. But I do it, every time. We all do.

The system games us. So we have to game the system at least a little, or you’d not even be able to game. By adopting a thoroughly altruistic and charge-as-little-as-possible behavior, no rad onc center would stay open. GenesisCare started something called SkinViva for basal/squamous skin cancer, which was basically just IMRT as best as I can tell. A “verbal gaming” like calling a garbage man a sanitation engineer. And now America’s largest rad onc employer is closing up shop despite that and other gaming. They didn’t game enough.

Now… all that said… there are about 5000 rad oncs in the Part B Medicare rolls. Each year, more than half of them are reimbursed $200K or less per year… while about 200 get $1M or more from Medicare.

Just to set the record straight, not every proton center in America treats a lot of breast and prostate patients, some treat very few.

When I was a fellow at Beaumont's proton center we were routinely turning prostate patients away from protons or encouraging them to have HDR with or without external beam. They have a very strong prostate HDR program with a really high volume, and we simply didn't have surplus capacity in the single room proton center. The dept chair was very adamant about protons not being a "prostate mill."

Most of the breast patients were on the Radcomp trial during my time there. It seems like UAB's center is mostly treating Head and Neck, and the University of Utah is pretty full with just peds and CNS from what I understand.

There is a big culture difference between single room universities and multi-room private centers

 

[CaesarRO]

When I treat a 5 fraction breast, I will consult on Monday for example. If treatment starts Thursday, I see her again on Friday to “check on her side effects and see how radiation is going.” Or I could consult a bone met patient Wednesday and see the person again the next day, less than 24h later, for their one fraction treatment… and get a charge for both visits. I mean sure it’s nice to talk to people and give them a little update on things. But getting paid several hundred bucks for that few minute social visit? Rad oncs might be the only docs in America who can see a patient two times in one week with absolutely no medical reason to do so. But I do it, every time. We all do.

What?

I'm confused how this works.

You see a consult Monday, pt starts Thursday, you get your 1 OTV --- ooohh. Your just saying that some OTVs are nonsense.

Yeah okay, I guess that's fair.

I'd argue anything less than 5 fx they should just bundle the OTV charge with the rest and spare everyone the charade.

On the other hand, I think not seeing the patient with current rules is leaving money on the table. The way we are paid there is a lot of weight in those OTVs.

 

[TheWallnerus]

Just to set the record straight, not every proton center in America treats a lot of breast and prostate patients, some treat very few

I disagree that this straightens the record.

Breast is the number one indication for RT in America. Prostate is number two (a tie with lung more or less). Protons are radiation therapy. A proforma for ANY radiation center doesn’t work if you exclude the top two primary diagnoses which comprise 50% or more of RT utilization for radiotherapy. Proton centers that don’t treat a good share of the “RT Cancer Market” become closed or bankrupt. Published data has shown the most common indication/utilization for proton beam therapy is breast and prostate… which makes perfect sense statistically and mathematically.