PPS Exempt? Cha-ching. MDACC? CHA-CHING!

[TheWallnerus]

(FWIW for price transparency, hospitals of 550 or more beds not complying in 2022 can face up to $5500/day fines instead of the $300/day max now)

Cancer Hospital Payment Adjustment

Since the inception of OPPS, Medicare has paid the 11 hospitals that meet the criteria for “cancer hospitals” under OPPS for covered outpatient hospital services to reflect their higher outpatient costs. CMS will continue to provide additional payments to cancer hospitals so that a cancer hospital’s payment-to-cost ratio (PCR) after the additional payments is equal to the weighted average PCR for the other OPPS hospitals using the most recently submitted or settled cost report data. However, the 21st Century Cures Act requires that this weighted average PCR be reduced by 1.0%. Based on the data and the required 1.0% reduction, CMS will use a target PCR of 0.89 to determine the CY 2022 cancer hospital payment adjustment to be paid at cost report settlement. That is, the payment adjustments will be the additional payments needed to result in a PCR equal to 0.89 for each cancer hospital.

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[RickyScott]

Still worth repeating until I am blue in the face, but absolutely amazing how these guys (Ben smith and Aileen Chen) have been so vocal about imrt and the financial motivations of other radoncs (who they outcharge by a factor of 5-10). And, the vast majority of us earn less than Bens 1 million dollar salary.

 

[jondunn]

King Koong must be getting boatloads of cash

 

[RickyScott]

King Koong must be getting boatloads of cash

I am sure he does well, but the vast majority of profit is used for building and hiring more administrators, increasing their baseline costs. It’s not like they can return the money to shareholders and there is a limit to how much cash they can accumulate as a nonprofit without reinvesting it. Would be nice If they treated poor/indigent texans with Medicaid as they are a tax payor supported state institution, but they are just too greedy. I can’t think of a worse use of philanthropy than donating to these types of centers. I think it can easily be argued that this type of philanthropy is harming the greater good.

 

[TheWallnerus]

Still worth repeating until I am blue in the face, but absolutely amazing how these guys (Ben smith and Aileen Chen) have been so vocal about imrt and the financial motivations of other radoncs (who they outcharge by a factor of 5-10). And, the vast majority of us earn less than Bens 1 million dollar salary.

A guy goes to the doctor’s office. “Doctor I have this horrible problem. I’m letting such stinky silent farts. They’re just so bad and stinky. Oh! There’s one just now. Pretty bad I know. Sorry. Just wondering what I can do. Oh! There’s another one. They are so silent but smell awful. What’s my problem doc?”

And the doc goes “Well first of all you’re goin’ deaf.”

Aileen and Ben went deaf a looong time ago.

 

[elementaryschooleconomics]

It's also worth noting that 3 of these 11 - namely, Sloan, Anderson, and DFCI - have some of the largest complements of Radiation Oncology residents and (unaccredited) fellows in the entire country.

The return on investment for these residents is staggering. At Anderson, for example, RadOnc residents get paid between $63k-$70k per year. While we all agree that a first year, first rotation resident might require enough assistance that they "slow their attending down", they soon thereafter can significantly facilitate RVU generation by doing nothing more than writing notes and handling standard patient issues. A senior resident (or a fellow who might have been a practicing attending in a different country) can be a significant power multiplier for whoever they work with.

Senior faculty at Anderson have salaries 14x-15x more than the PGY2s who work with them. As always, I am absolutely not saying these faculty don't deserve to earn that much or more. But this narrative that has been created, published, and sold regarding "greedy community doctors using too many fractions of IMRT" is absurd in the face of these numbers. Obviously, there are absolutely questionable characters in the community treating bone mets with 20 fractions of VMAT or whatever they can get away with. But they're not the ones receiving special treatment from CMS in both reimbursement and policy guidance.

Sometimes, I think about an Anderson PGY5 on a GU rotation seeing prostate patients for protons. Is that a thing that happens? I think only some of their faculty have residents only some of the time, so maybe not. But man, if that's something they do...hats off to Anderson for creating a system to arbitrage talent like that.

 

[jondunn]

The return on investment for these residents is staggering. At Anderson, for example, RadOnc residents get paid between $63k-$70k per year. While we all agree that a first year, first rotation resident might require enough assistance that they "slow their attending down", they soon thereafter can significantly facilitate RVU generation by doing nothing more than writing notes and handling standard patient issues. A senior resident (or a fellow who might have been a practicing attending in a different country) can be a significant power multiplier for whoever they work with.

will say that at least at MDACC, the residents don't have to do that much. I don't think they are being used for note labor, because frankly MDACC has PAs that they pay to do all of it. residents at MDACC see few OTVs, few follow-ups, often don't even have to go to the sims.

it is not only my opinion that some MDACC residents come out a little less than prepared for the real world

 

[elementaryschooleconomics]

will say that at least at MDACC, the residents don't have to do that much. I don't think they are being used for note labor, because frankly MDACC has PAs that they pay to do all of it. residents at MDACC see few OTVs, few follow-ups, often don't even have to go to the sims.

it is not only my opinion that some MDACC residents come out a little less than prepared for the real world

I have heard the same, but don't have direct experience to say either way.

Perhaps a better example is the kids doing the fellowship with Nancy Lee...

 

[RickyScott]

I have heard the same, but don't have direct experience to say either way.

Perhaps a better example is the kids doing the fellowship with Nancy Lee...

For such a rich institution I am amazed the scut that mskcc dumps on their residents. Hire an ma or nurse like mdacc to free up the resident to publish retrospective crap.

 

[temujim]

For such a rich institution I am amazed the scut that mskcc dumps on their residents. Hire an ma or nurse like mdacc to free up the resident to publish retrospective crap.

Word on the street is a bunch of MAs and RNs left mskcc bc of mandates. Severely understaffed. But CMS says not a problem. Not sure who to believe.

 

[TheWallnerus]

Word on the street is a bunch of MAs and RNs left mskcc bc of mandates. Severely understaffed. But CMS says not a problem. Not sure who to believe.

Speaking of staff, buried in this 1300-page rule is what Medicare deems appropriate labor cost for certain rad onc staff...

The table below lists the proposed updates to the clinical labor prices that are of interest to radiation oncology. The proposed cost per minute for the clinical staff type was derived by dividing the annual salary (converted to 2021 dollars using the Medicare Economic Index) by 2,080 (the number of hours in a typical work year) to arrive at the hourly wage rate and then again by 60 to arrive at the per minute cost. To account for the employers’ cost of providing fringe benefits, such as sick leave, CMS used the benefits multiplier of 1.296, which is an update from the multiplier of 1.366 used in CY 2002 and subsequent years until the new benefits multiplier takes effect in CY 2022.

This works out to annual salaries of:

$79,560/year for a therapist

$92,820/year for a basic dosimetrist

$157,794/year for a great dosimetrist

$222,768/year for a physicist

Nice work, physicists!

 

[temujim]

Speaking of staff, buried in this 1300-page rule is what Medicare deems appropriate labor cost for certain rad onc staff...

The table below lists the proposed updates to the clinical labor prices that are of interest to radiation oncology. The proposed cost per minute for the clinical staff type was derived by dividing the annual salary (converted to 2021 dollars using the Medicare Economic Index) by 2,080 (the number of hours in a typical work year) to arrive at the hourly wage rate and then again by 60 to arrive at the per minute cost. To account for the employers’ cost of providing fringe benefits, such as sick leave, CMS used the benefits multiplier of 1.296, which is an update from the multiplier of 1.366 used in CY 2002 and subsequent years until the new benefits multiplier takes effect in CY 2022.

This works out to annual salaries of:

$79,560/year for a therapist

$92,820/year for a basic dosimetrist

$157,794/year for a great dosimetrist

$222,768/year for a physicist

Nice work, physicists!

Physicists set the floor for rad onc salary. I love those guys.

 

[Palex80]

I am sure he does well, but the vast majority of profit is used for building and hiring more administrators, increasing their baseline costs. It’s not like they can return the money to shareholders and there is a limit to how much cash they can accumulate as a nonprofit without reinvesting it.

I thought I could by stock with that Chinese company?

 

[Mandelin Rain]

"Let them eat cake."

 

[Mandelin Rain]

Per QuadShot today

“Do any of us really know how much money is exchanged for medical services? The fact is, few (if any?) people in the entire country can truthfully say they understand our intentionally opaque payment system. Although CMS significantly decreased Medicare reimbursement for Gamma Knife radiosurgery in 2013 to equate it with linac-based radiosurgery, here’s an investigation into the list prices for private insurers for radiosurgery techniques across 58 NCI-designated cancer centers. And what a mess it is. First of all, the median price for Gamma Knife ($49,529) was significantly higher than for linac-based single-fraction ($22,915) and muli-fraction ($31,834) radiosurgery. What’s more the ranges were, let us say, wide, topping out at $111,298; $312,480; and $104,396 for the three aforementioned techniques, respectively. Patients might be interested to know, if they are charged >$300K for SRS at one center, they could get the same treatment for <$15K at another.”

 

[TheWallnerus]

Per QuadShot today

“Do any of us really know how much money is exchanged for medical services? The fact is, few (if any?) people in the entire country can truthfully say they understand our intentionally opaque payment system. Although CMS significantly decreased Medicare reimbursement for Gamma Knife radiosurgery in 2013 to equate it with linac-based radiosurgery, here’s an investigation into the list prices for private insurers for radiosurgery techniques across 58 NCI-designated cancer centers. And what a mess it is. First of all, the median price for Gamma Knife ($49,529) was significantly higher than for linac-based single-fraction ($22,915) and muli-fraction ($31,834) radiosurgery. What’s more the ranges were, let us say, wide, topping out at $111,298; $312,480; and $104,396 for the three aforementioned techniques, respectively. Patients might be interested to know, if they are charged >$300K for SRS at one center, they could get the same treatment for <$15K at another.”

Holy fouk

 

[RickyScott]

Holy fouk

“ Even after excluding outlier pricing, estimates from high-cost institutions are as much as 6 to 9 times higher than quotes from other high-volume academic institutions that are less expensively priced”
Mdacc is no doubt an outlier. Is it possible to determine from cms database how many Medicare proton treatments Ben smith and Aileen Chen are delivering?

 

[communitydoc13]

What is the relationship between prices/charges and actual payment?

Say MDACC charges 300K for something. Who pays this and what does everyone else pay?

Do rich foreign patients pay the sticker price with cash? (I'm guessing yes, usually?)

Have they negotiated these rates with certain private payors due to perverse incentives and they actually get paid this amount by U.S. insurance. (Find this hard to believe but maybe some real Cadillac plans out there?)

Do they insist on the balance to be paid regardless of payor status? (I'm guessing not?)

 

[RickyScott]

Part of business model of destination centers is to jack up sbrt/srt prices and have high pt througput. Zelefsky and mskcc gung ho on this. Someone at Cornell trying to differentiate themselves by starting 2 fraction trial with view ray.

 

[RickyScott]

What is the relationship between prices/charges and actual payment?

Say MDACC charges 300K for something. Who pays this and what does everyone else pay?

Do rich foreign patients pay the sticker price with cash? (I'm guessing yes, usually?)

Have they negotiated these rates with certain private payors due to perverse incentives and they actually get paid this amount by U.S. insurance. (Find this hard to believe but maybe some real Cadillac plans out there?)

Do they insist on the balance to be paid regardless of payor status? (I'm guessing not?)

I couldn’t tell if these are list prices or actual negotiated prices as required by the price transparency law. UPenn is the only top tier place that posted actual negotiated paid prices that I know of. Jordan Johnson has some proprietary data that he just pulblished with Fumiko chino. I didn’t read her paper but I would be shocked if they released data on speficic institutions.

 

[elementaryschooleconomics]

Patients might be interested to know, if they are charged >$300K for SRS at one center, they could get the same treatment for <$15K at another.”

This QuadShot is right on the money (pun intended).

Generally, I don't want to target specific faculty at Anderson or other institutions. Because QuadShot is right - who can really say, with 100% certainty, what the sum total of our actions in a given course of treatment will cost each patient? At my residency institution, an academic behemoth, I would barely know where to start. In my current setup, where I have basically complete control and access to all financial information, it is still impossible for me to accurately predict how much my treatments will cost someone. And believe me, I have tried, many times. @communitydoc13 is right - even if I could get a precise number ahead of time, can I even know what the patient will actually pay out-of-pocket?

But - it upsets me to read work from folks at Anderson and Sloan et al about financial toxicity, because really, "the call is coming from inside the house". However, did any of the authors of these studies negotiate any reimbursements? I would be surprised if even the most senior faculty at Anderson had the power (and desire) to influence reimbursements. Perhaps a select few, and even then, probably not much.

Not to sound like I belong on a hippie commune, but I increasingly feel like we're just C-suite puppets. At the PPS-exempt centers, I imagine most (all?) of reimbursements are negotiated by admin, behind the scenes, with some input with departmental Chairs. And here's the trick:

Part of business model of destination centers is to jack up sbrt/srt prices and have high pt througput. Zelefsky and mskcc gung ho on this. Someone at Cornell trying to differentiate themselves by starting 2 fraction trial with view ray.

...though I don't know if it was by accident or design. The faculty advance their careers through publications and reputation. The more "in vogue" your work is, the faster and higher you can climb. Financial toxicity, easing the burden on cancer patients (travel, financial, etc) - so hot right now. You know what's hard to understand? CMS reimbursements. You know what's easy to understand? "More fractions bad, less fractions good". In this example, everyone at Sloan wins. C-suite has the power to demand exorbitant reimbursements, to not only survive but also thrive in the SBRT era. Zelefsky et al come away looking awesome, careers advance.

So now what do we have? Community and small academic practices needing to adopt fewer fractions without being able to negotiate the same levels of reimbursement as the giants, leading to consolidation and diminished competition. Doctors argue amongst themselves in journals and on the internet, accusing each other of not caring about the cost they inflict to society. Residencies expand, more graduates are produced, driving individual salaries - and career opportunities - down. Meanwhile, the PPS-exempt Oligarchy rumbles on, with non-clinician admins taking huge salaries built on the fact that people get sick and doctors dedicate their entire lives learning how to care for them.

 

[TheWallnerus]

This QuadShot is right on the money (pun intended).

Generally, I don't want to target specific faculty at Anderson or other institutions. Because QuadShot is right - who can really say, with 100% certainty, what the sum total of our actions in a given course of treatment will cost each patient? At my residency institution, an academic behemoth, I would barely know where to start. In my current setup, where I have basically complete control and access to all financial information, it is still impossible for me to accurately predict how much my treatments will cost someone. And believe me, I have tried, many times. @communitydoc13 is right - even if I could get a precise number ahead of time, can I even know what the patient will actually pay out-of-pocket?

But - it upsets me to read work from folks at Anderson and Sloan et al about financial toxicity, because really, "the call is coming from inside the house". However, did any of the authors of these studies negotiate any reimbursements? I would be surprised if even the most senior faculty at Anderson had the power (and desire) to influence reimbursements. Perhaps a select few, and even then, probably not much.

Not to sound like I belong on a hippie commune, but I increasingly feel like we're just C-suite puppets. At the PPS-exempt centers, I imagine most (all?) of reimbursements are negotiated by admin, behind the scenes, with some input with departmental Chairs. And here's the trick:


...though I don't know if it was by accident or design. The faculty advance their careers through publications and reputation. The more "in vogue" your work is, the faster and higher you can climb. Financial toxicity, easing the burden on cancer patients (travel, financial, etc) - so hot right now. You know what's hard to understand? CMS reimbursements. You know what's easy to understand? "More fractions bad, less fractions good". In this example, everyone at Sloan wins. C-suite has the power to demand exorbitant reimbursements, to not only survive but also thrive in the SBRT era. Zelefsky et al come away looking awesome, careers advance.

So now what do we have? Community and small academic practices needing to adopt fewer fractions without being able to negotiate the same levels of reimbursement as the giants, leading to consolidation and diminished competition. Doctors argue amongst themselves in journals and on the internet, accusing each other of not caring about the cost they inflict to society. Residencies expand, more graduates are produced, driving individual salaries - and career opportunities - down. Meanwhile, the PPS-exempt Oligarchy rumbles on, with non-clinician admins taking huge salaries built on the fact that people get sick and doctors dedicate their entire lives learning how to care for them.

View attachment 345611

Man I wish I had your brain!

 

[RickyScott]

This QuadShot is right on the money (pun intended).

Generally, I don't want to target specific faculty at Anderson or other institutions. Because QuadShot is right - who can really say, with 100% certainty, what the sum total of our actions in a given course of treatment will cost each patient? At my residency institution, an academic behemoth, I would barely know where to start. In my current setup, where I have basically complete control and access to all financial information, it is still impossible for me to accurately predict how much my treatments will cost someone. And believe me, I have tried, many times. @communitydoc13 is right - even if I could get a precise number ahead of time, can I even know what the patient will actually pay out-of-pocket?

But - it upsets me to read work from folks at Anderson and Sloan et al about financial toxicity, because really, "the call is coming from inside the house". However, did any of the authors of these studies negotiate any reimbursements? I would be surprised if even the most senior faculty at Anderson had the power (and desire) to influence reimbursements. Perhaps a select few, and even then, probably not much.

Not to sound like I belong on a hippie commune, but I increasingly feel like we're just C-suite puppets. At the PPS-exempt centers, I imagine most (all?) of reimbursements are negotiated by admin, behind the scenes, with some input with departmental Chairs. And here's the trick:


...though I don't know if it was by accident or design. The faculty advance their careers through publications and reputation. The more "in vogue" your work is, the faster and higher you can climb. Financial toxicity, easing the burden on cancer patients (travel, financial, etc) - so hot right now. You know what's hard to understand? CMS reimbursements. You know what's easy to understand? "More fractions bad, less fractions good". In this example, everyone at Sloan wins. C-suite has the power to demand exorbitant reimbursements, to not only survive but also thrive in the SBRT era. Zelefsky et al come away looking awesome, careers advance.

So now what do we have? Community and small academic practices needing to adopt fewer fractions without being able to negotiate the same levels of reimbursement as the giants, leading to consolidation and diminished competition. Doctors argue amongst themselves in journals and on the internet, accusing each other of not caring about the cost they inflict to society. Residencies expand, more graduates are produced, driving individual salaries - and career opportunities - down. Meanwhile, the PPS-exempt Oligarchy rumbles on, with non-clinician admins taking huge salaries built on the fact that people get sick and doctors dedicate their entire lives learning how to care for them.

View attachment 345611

I agree that faculty including chairs, have zero input regarding reimbursement. With respect to Ben smith, he has basically stated that the use of imrt for breast in the community is driven by greed, which I find highly offensive and hypocritical.

 

[Reaganite]

I couldn’t tell if these are list prices or actual negotiated prices as required by the price transparency law. UPenn is the only top tier place that posted actual negotiated paid prices that I know of. Jordan Johnson has some proprietary data that he just pulblished with Fumiko chino. I didn’t read her paper but I would be shocked if they released data on speficic institutions.

I think with a coordinated effort we could all work to get the actual negotiated rates. It would basically take people calling the finance departments of each institution and claiming to have a certain insurance and asking for a cost estimate for some service. Sometimes they will ask you for your insurance card information, but you can just say you are thinking of changing to a different insurer and you want an estimate. I've done this locally to figure out the cost of hospital and NCI competitors and it works.

 

[communitydoc13]

I've done this locally to figure out the cost of hospital and NCI competitors and it works.

Baller

 

[deleted1111261]

What if you do the digging and find out you’re the more expensive one ? People don’t really want to know …

 

[elementaryschooleconomics]

What if you do the digging and find out you’re the more expensive one ? People don’t really want to know …

Honestly, perhaps that's the best case scenario. "More expensive" is all relative, of course. It seems unlikely that your average hospital-employed RadOnc or small freestanding practice has negotiated $300,000+ rates per course of SRS, but stranger things have happened.

If I had to guess, there are very few non-academic places that command these types of rates (*cough* The Artist formerly known as 21C *cough*). It would probably take groups the size of SERO or TOPA to have that kind of negotiating power. Similarly, I can't imagine the smaller academic shops doing it either.

But in the academic bubble of institutions with a residency program, I don't know how deep of an understanding there is about this. I can only speak from my experience during my residency, where cost was definitely discussed, but not in a nuanced way like how much our institution charged vs another institution or local community practice. The ONLY thing I was taught was "more fractions bad, less fractions good", "IMRT is more expensive than 3D and people abuse that", on top of the attitude (either implied or, on several occasions, explicitly stated) that the care received in the community was unquestionably inferior to receiving treatment at our institution.

Prior to some legislative changes over the last couple of years, this data was difficult or impossible to find. It's still difficult, but not like it was. Maybe a holistic way to address financial toxicity also includes medical students and residents exploring their own institution's negotiated rates, and how it compares with other hospitals/centers in the region?

 

[deleted1111261]

Anyone familiar with Maryland’s payment system? I worked there, and they had some sort of cap for everything. It seemed to work well, as they were exempt from RO-APM. @elementaryschooleconomics - wanna do a deep dive us and learn us?

 

[BobbyHeenan]

Honestly, perhaps that's the best case scenario. "More expensive" is all relative, of course. It seems unlikely that your average hospital-employed RadOnc or small freestanding practice has negotiated $300,000+ rates per course of SRS, but stranger things have happened.

If I had to guess, there are very few non-academic places that command these types of rates (*cough* The Artist formerly known as 21C *cough*). It would probably take groups the size of SERO or TOPA to have that kind of negotiating power. Similarly, I can't imagine the smaller academic shops doing it either.

But in the academic bubble of institutions with a residency program, I don't know how deep of an understanding there is about this. I can only speak from my experience during my residency, where cost was definitely discussed, but not in a nuanced way like how much our institution charged vs another institution or local community practice. The ONLY thing I was taught was "more fractions bad, less fractions good", "IMRT is more expensive than 3D and people abuse that", on top of the attitude (either implied or, on several occasions, explicitly stated) that the care received in the community was unquestionably inferior to receiving treatment at our institution.

Prior to some legislative changes over the last couple of years, this data was difficult or impossible to find. It's still difficult, but not like it was. Maybe a holistic way to address financial toxicity also includes medical students and residents exploring their own institution's negotiated rates, and how it compares with other hospitals/centers in the region?

I've learned a lot about this over the years and my experience with "cost" and residency was just like this.

I have a quite a few prostate patients over the past few years (often engineers/scientists) that want a cost breakdown between IMRT, SBRT, and protons. My billers hate me for it, but I give them a print out sheet looking at that after I submit hypothetical codes. At the end of the day all they really care about is their out of pocket costs, but it's eye opening to see overall costs.

Even if it isn't coming out of your pocket, that 100K+ proton course is coming from somewhere.

 

[elementaryschooleconomics]

Anyone familiar with Maryland’s payment system? I worked there, and they had some sort of cap for everything. It seemed to work well, as they were exempt from RO-APM. @elementaryschooleconomics - wanna do a deep dive us and learn us?

Interesting question, I'm not familiar with that but what an irresistible rabbit hole...

In the mean time, putting my money where my mouth is, I tried comparing my costs using my hospital's charge list with my nearest PPS-exempt competitor. My community hospital's Excel file is far more detailed and user friendly than the nearest PPS-exempt place. A reasonable comparison could not be made. So I went to the next closest PPS-exempt center with the same outcome.

So, not to continue to bash Anderson, I went to their charge list (I really don't have anything against them in particular, Texas just makes them publish EVERYTHING).

Looking at the SRS charge as a surrogate endpoint, Anderson has a "Domestic Prompt Pay Discounted Charge Amount" column. GK-based SRS is $41,232.

My SRS is linac-based, and using the "uninsured out-of-pocket" number (which is as similar to this Anderson charge as I can get), I'm charging around $4,000.

So, unsurprisingly, Anderson is charging ten-times as much as me for a similar treatment. This isn't even their highest negotiated reimbursement amount, which isn't on this Excel sheet.

Check it out for yourself. See where you and your hospital stand compared to Anderson. Consider these numbers when they publish financial toxicity data about number of fractions.

 

[elementaryschooleconomics]

Ultra-basic comparison between prostate SBRT at Anderson vs 44 fractions prostate IMRT at my hospital:
(using the dollar amount from the "domestic prompt pay discount" for them and "uninsured out-of-pocket" for me)

Anderson:
Complex Sim - $1,595
IMRT treatment planning - $5,557
SBRT daily delivery - $10,681 per treatment, assuming five fractions = $53,405
Total = $60,557

Community hospital (rounded up for anonymity):
Complex Sim - $500
IMRT treatment planning - $3,000
IMRT daily delivery - $1,000 per treatment, assuming 44 fractions = $44,000
Total = $47,500

Again, I don't think Anderson is unique here, their Excel sheet is just the best I've found so far for the PPS-exempt centers.

Obviously, there are a lot more codes/charges associated with these treatments, but I would consider these charges the "major" ones, and adding in each and every code likely won't change the point I'm trying to make.

This is an incredibly imperfect comparison, for a multitude of reasons. I'm clearly not over here applying rigorous methodology during the lunch hour. However, I have long suspected that 5 fractions at one of these institutions is at least as costly as conventional IMRT in the community, and the hospital-published numbers seem to support that. Maybe someone will publish something down the line and prove me wrong, who knows.

If your hospital has one of these standard charges files (required by law), it's easy to find these numbers. Check for yourself.

 

[TheWallnerus]

let’s assume 50K for 45fx prostate. But if you treat that many weeks, and if you see just 4 new prostates a week, you’d have 36 daily treats on one machine and that machine would be all tied up. And ultimately you’d be making about $200K a week (and that’s maxing that one machine). With SBRT (and Andersonian reimbursement) and the same patient load, you would have just 4 on beam every day but be making $240K a week. Of course on that one machine you have the capacity for up to ~16 prostate SBRTs a day, and at that level you are making about $960K a week. This makes one $3m linac capable of producing close to $50m a year (at least in theory).

TL;DR with equal referral numbers and one machine you make more (and work less) with SBRT vs IMRT… with robust referrals you can make a LOT more with SBRT with that one machine.

 

[RickyScott]

Ultra-basic comparison between prostate SBRT at Anderson vs 44 fractions prostate IMRT at my hospital:
(using the dollar amount from the "domestic prompt pay discount" for them and "uninsured out-of-pocket" for me)

Anderson:
Complex Sim - $1,595
IMRT treatment planning - $5,557
SBRT daily delivery - $10,681 per treatment, assuming five fractions = $53,405
Total = $60,557

Community hospital (rounded up for anonymity):
Complex Sim - $500
IMRT treatment planning - $3,000
IMRT daily delivery - $1,000 per treatment, assuming 44 fractions = $44,000
Total = $47,500

Again, I don't think Anderson is unique here, their Excel sheet is just the best I've found so far for the PPS-exempt centers.

Obviously, there are a lot more codes/charges associated with these treatments, but I would consider these charges the "major" ones, and adding in each and every code likely won't change the point I'm trying to make.

This is an incredibly imperfect comparison, for a multitude of reasons. I'm clearly not over here applying rigorous methodology during the lunch hour. However, I have long suspected that 5 fractions at one of these institutions is at least as costly as conventional IMRT in the community, and the hospital-published numbers seem to support that. Maybe someone will publish something down the line and prove me wrong, who knows.

If your hospital has one of these standard charges files (required by law), it's easy to find these numbers. Check for yourself.

It is so absurd that a state supported nonprofit refuses to comply with both Texas and federal law and pay both fines for price transparency.

 

[DebtRising]

Medicare premiums to jump in part due to pricey Alzheimer’s drug

Seniors on Medicare will have to pay more than $20 more per month extra in premiums next year, a large increase that officials in part attributed to possible coverage of a pricey and controversial …

thehill.com

Doesn’t make sense to me to circling fire squad our own specialty on price when we in total are not even a drop in the bucket. Gotta love that pharma lobby

 

[medgator]

Medicare premiums to jump in part due to pricey Alzheimer’s drug

Seniors on Medicare will have to pay more than $20 more per month extra in premiums next year, a large increase that officials in part attributed to possible coverage of a pricey and controversial …

thehill.com

Doesn’t make sense to me to circling fire squad our own specialty on price when we in total are not even a drop in the bucket. Gotta love that pharma lobby

Problem is we eat our own like no other specialty does. ASTRO and co have done a good job of pitting academic vs PP rad onc, hospital vs freestanding. You just don't see that type of animosity and division in med onc imo

 

[RickyScott]

I agree that faculty including chairs, have zero input regarding reimbursement. With respect to Ben smith, he has basically stated that the use of imrt for breast in the community is driven by greed, which I find highly offensive and hypocritical.

“The Nuffield Council on Bioethics proposed the “intervention ladder” concept, which demonstrates different levels at which public health policy influences individual provider decision making when choosing treatment—ranging from the softest levels of intervention on the basis of information and enablement like Choosing Wisely, to more direct and even compulsory levels of intervention—incentivizing, disincentivizing, restricting, or eliminating specific treatment choices (12”

“Yet also over the last two decades, use of IMRT has represented one of the foundational drivers of increased health-care dollar spending in radiation oncology practice (6,7). Recent data demonstrate that use of IMRT, compared with 3D treatment strategies, is associated with up to twice the cost per radiation treatment course”


Read this editorial and savor the hypocrisy. In light of the apm, this may trump his 2013 paper -on need to increase radiation oncologists -as the most damaging garbage ever published in the history of the field.. It provides incite into how Aileen Chen may view the apm and advice given to cms. My understanding is that he is very opposed to imrt for breast cancer in most circumstances (including nodal treatment).There is certainly a public interest in uncovering the proton utilization rates of these docs

Sea Change: A Decade of Intensity-Modulated Radiation Therapy for Treatment of Breast Cancer

“Nothing of him that doth fadeBut doth suffer a sea-changeInto something rich and strange”

academic.oup.com

 

[TheWallnerus]

Ultra-basic comparison between prostate SBRT at Anderson vs 44 fractions prostate IMRT at my hospital:
(using the dollar amount from the "domestic prompt pay discount" for them and "uninsured out-of-pocket" for me)

Anderson:
Complex Sim - $1,595
IMRT treatment planning - $5,557
SBRT daily delivery - $10,681 per treatment, assuming five fractions = $53,405
Total = $60,557

Community hospital (rounded up for anonymity):
Complex Sim - $500
IMRT treatment planning - $3,000
IMRT daily delivery - $1,000 per treatment, assuming 44 fractions = $44,000
Total = $47,500

Again, I don't think Anderson is unique here, their Excel sheet is just the best I've found so far for the PPS-exempt centers.

Obviously, there are a lot more codes/charges associated with these treatments, but I would consider these charges the "major" ones, and adding in each and every code likely won't change the point I'm trying to make.

This is an incredibly imperfect comparison, for a multitude of reasons. I'm clearly not over here applying rigorous methodology during the lunch hour. However, I have long suspected that 5 fractions at one of these institutions is at least as costly as conventional IMRT in the community, and the hospital-published numbers seem to support that. Maybe someone will publish something down the line and prove me wrong, who knows.

If your hospital has one of these standard charges files (required by law), it's easy to find these numbers. Check for yourself.

let’s assume 50K for 45fx prostate. But if you treat that many weeks, and if you see just 4 new prostates a week, you’d have 36 daily treats on one machine and that machine would be all tied up. And ultimately you’d be making about $200K a week (and that’s maxing that one machine). With SBRT (and Andersonian reimbursement) and the same patient load, you would have just 4 on beam every day but be making $240K a week. Of course on that one machine you have the capacity for up to ~16 prostate SBRTs a day, and at that level you are making about $960K a week. This makes one $3m linac capable of producing close to $50m a year (at least in theory).

TL;DR with equal referral numbers and one machine you make more (and work less) with SBRT vs IMRT… with robust referrals you can make a LOT more with SBRT with that one machine.

The separating to me always confuses.

If everyone’s prices were the same, hypofractionation will save money. They are two components and do not have to be mutually exclusive.

That being said, hypoFX not be paid out so much less. If it’s an equivalent treatment to the conventional treatment, it should be paid out the same, or some amount more that isn’t enough to justify additional treatments (when the two treatments are equal).

Graphical followup. And it all dovetails. Data show that SBRT/SRS utilization have exploded the last ~5 years. I would add as far as I know no linac is producing ~$50m a year in revenue. But after thinking about this I imagine some of the very big centers (16 new prostate patients a week would be A LOT) are getting numbers, maybe, half that per linac? Economies of scale make SBRT a far more financially threatening menace than IMRT could have hoped to have been. The only thing in our favor is that the increased capacities via hypofractionation have been met with absolutely stagnant RT-as-frontline-tx utilization rates.

 

[medgator]

Graphical followup. And it all dovetails. Data show that SBRT/SRS utilization have exploded the last ~5 years.

That reimbursement is accurate for prostate SBRT vs IMRT?

 

[TheWallnerus]

That reimbursement is accurate for prostate SBRT vs IMRT?

It's accurate when it's accurate. It's going to be very accurate for some patients and wildly off in others. It makes doing very good calculations on this almost have mandatory error bars (but I don't have enough data for that).

 

[medgator]

It's accurate when it's accurate. It's going to be very accurate for some patients and wildly off in others. It makes doing very good calculations on this almost have mandatory error bars (but I don't have enough data for that).

Yeah, different sites of service... HOPPS vs PPS exempt. Hypofractionation has had the added benefit of stealing patients from the community and keeping them for treatment at large high cost PPS exempt centers. Overall cost to the system is still more financially toxic.

Freestanding center collecting less than $40k easy on conventional fx

 

[TheWallnerus]

“The Nuffield Council on Bioethics proposed the “intervention ladder” concept, which demonstrates different levels at which public health policy influences individual provider decision making when choosing treatment—ranging from the softest levels of intervention on the basis of information and enablement like Choosing Wisely, to more direct and even compulsory levels of intervention—incentivizing, disincentivizing, restricting, or eliminating specific treatment choices (12”

“Yet also over the last two decades, use of IMRT has represented one of the foundational drivers of increased health-care dollar spending in radiation oncology practice (6,7). Recent data demonstrate that use of IMRT, compared with 3D treatment strategies, is associated with up to twice the cost per radiation treatment course”


Read this editorial and savor the hypocrisy. In light of the apm, this may trump his 2013 paper -on need to increase radiation oncologists -as the most damaging garbage ever published in the history of the field.. It provides incite into how Aileen Chen may view the apm and advice given to cms. My understanding is that he is very opposed to imrt for breast cancer in most circumstances (including nodal treatment).There is certainly a public interest in uncovering the proton utilization rates of these docs

Sea Change: A Decade of Intensity-Modulated Radiation Therapy for Treatment of Breast Cancer

“Nothing of him that doth fadeBut doth suffer a sea-changeInto something rich and strange”

academic.oup.com

Let's not just call it hypocrisy. Let's pull a Dan Spratt and call it harmful and dangerous and causing bad patient care!

Ben Smith:

Not Ben Smith:

 

[TheWallnerus]

Yeah, different sites of service... HOPPS vs PPS exempt. Hypofractionation has had the added benefit of stealing patients from the community and keeping them for treatment at large high cost PPS exempt centers. Overall cost to the system is still more financially toxic.

Freestanding center collecting less than $40k easy on conventional fx

I get ~$35K max for long-course IMRT. In some PPS exempt places this would be called "chickenfeed."

 

[elementaryschooleconomics]

Yeah, different sites of service... HOPPS vs PPS exempt. Hypofractionation has had the added benefit of stealing patients from the community and keeping them for treatment at large high cost PPS exempt centers. Overall cost to the system is still more financially toxic.

Freestanding center collecting less than $40k easy on conventional fx

For me, that's really the point of posting these numbers and talking about this. Historically, in my personal experience at least, when cost was talked about, it was in the context of:

1) Number of fractions
2) Technology used

These are obviously incredibly important and do indeed drive a lot of cost of radiotherapy. However...they're also the easiest variables to study with common database methodology.

But, if you were to take the exact same patient with the exact same treatment, and compare the cost at every hospital in this country, I would honestly be surprised if the total treatment cost was the same at any hospital. Heck, I would be surprised if any of the sums were within $100 of each other.

Now, I'm certain that, in the circles of people who study healthcare costs, this is commonly discussed. But that is NOT what has trickled out to the rest of us, at least as I have perceived it. Through Choosing Wisely and various ASTRO White Papers, the primary messaging has been "you better use less fractions and the oldest technology, or you're a greedy doctor". Evicore and other benefit managers have heard this messaging loud and clear, and wrote their policies accordingly.

I don't think there's any grand scheme amongst the PPS-exempt centers to steal patients, I think that's a happy accident. It goes without saying that if you can get equivalent outcomes for 5 treatments compared to 45, you're picking the 5 fraction treatment, every time. I know I would.

It's just that, in the setting of 10+ years of being told "use fewer fractions to save people money", the logical train of thought is "well obviously 5 fractions is cheaper than 45". It's just not true. I'm not even sure if it's true the majority of the time.

I guess my point is that we should think about radiotherapy like real estate, and fractions like the number of bedrooms in a house. We all assume a condo in San Francisco is significantly more expensive than a 4-bedroom house in Arkansas, and 5-fraction SBRT at UCSF is probably more expensive than 45-fraction IMRT in Pine Bluff.

Maybe my perception about the emphasis on fractions is biased and unfair, so if anyone has felt like the general messaging has been different, I would be open to hearing about it!

 

[RickyScott]

I guess my point is that we should think about radiotherapy like real estate, and fractions like the number of bedrooms in a house. We all assume a condo in San Francisco is significantly more expensive than a 4-bedroom house in Arkansas, and 5-fraction SBRT at UCSF is probably more expensive than 45-fraction IMRT in Pine Bluff.

Spot on. From our administrators , fractionation and modality are important, but don’t drive cost of radiation. It is largely driven by negotiated rates of hospital systems.

 

[Mandelin Rain]

It's about the prices!!!!!

Always and forever.

 

[Irradi8or]

Recently had a patient come back to me after treatment at MDACC Houston. Said that they’re still doing telehealth routinely for on treatment visit OTVs even when treated at a regional center. That was really only supposed to be for circumstances due to PHE and not routinely - anyone else heard this? Almost every group I’ve talked to has been doing in person again and only telehealth for Otv when Covid related reasons arise and interfere.

 

[TheWallnerus]

That was really only supposed to be for circumstances due to PHE and not routinely

I know many people state this. But what is the official statement that this was just for PHE and not "routine." There was certainly an incisura in attitudes about all this around March 2020... it went from anathema to "hey this is great" in a nanosecond... but in the meantime CMS has held an open comment period (outcome TBD) for making virtual supervision permanent. And FWIW it has included 77427 as OK for telehealth (without comment or precaution, seemingly) in the final PFS which will last until 12/31/22. As much as some want to put the genie back in the bottle, I don't see it returning.

"The bottom line is that this study supports the use of telehealth as a permanent transformation of the healthcare landscape," commented Anne Chiang, MD, PhD, associate professor of medicine, Yale Cancer Center/Smilow Cancer Hospital, New Haven, Connecticut, and member of the National Comprehensive Cancer Network (NCCN) policy advisory group.

Many Patients With Cancer Consider Telemedicine Appointments Just as Effective as In-Office Visits

 

[DrZap]

Recently had a patient come back to me after treatment at MDACC Houston. Said that they’re still doing telehealth routinely for on treatment visit OTVs even when treated at a regional center. That was really only supposed to be for circumstances due to PHE and not routinely - anyone else heard this? Almost every group I’ve talked to has been doing in person again and only telehealth for Otv when Covid related reasons arise and interfere.

We are still in a PHE. And lots of patients aren't vaxed. This is not my practice but I can't find fault with it

 

[radoncopotamus]

Graphical followup. And it all dovetails. Data show that SBRT/SRS utilization have exploded the last ~5 years. I would add as far as I know no linac is producing ~$50m a year in revenue. But after thinking about this I imagine some of the very big centers (16 new prostate patients a week would be A LOT) are getting numbers, maybe, half that per linac? Economies of scale make SBRT a far more financially threatening menace than IMRT could have hoped to have been. The only thing in our favor is that the increased capacities via hypofractionation have been met with absolutely stagnant RT-as-frontline-tx utilization rates.

Who made this graphic? Its dumb as hell. Does SBRT quadruple the incidence of prostate cancer?

 

[Irradi8or]

I know many people state this. But what is the official statement that this was just for PHE and not "routine." There was certainly an incisura in attitudes about all this around March 2020... it went from anathema to "hey this is great" in a nanosecond... but in the meantime CMS has held an open comment period (outcome TBD) for making virtual supervision permanent. And FWIW it has included 77427 as OK for telehealth (without comment or precaution, seemingly) in the final PFS which will last until 12/31/22. As much as some want to put the genie back in the bottle, I don't see it returning.

"The bottom line is that this study supports the use of telehealth as a permanent transformation of the healthcare landscape," commented Anne Chiang, MD, PhD, associate professor of medicine, Yale Cancer Center/Smilow Cancer Hospital, New Haven, Connecticut, and member of the National Comprehensive Cancer Network (NCCN) policy advisory group.

Many Patients With Cancer Consider Telemedicine Appointments Just as Effective as In-Office Visits

Where did you get that information that final PFS put 77427 on the permanent list of telehealth services? It was only for PHE, not permanent. If you've got another link, would appreciate if you could send it over! Here's CMS' list:

List of Telehealth Services | CMS

List of services payable under the Medicare Physician Fee Schedule when furnished via telehealth.List of Telehealth Services for Calendar Year 2024 (ZIP) - Updated 11/13/2023

www.cms.gov