Race to the bottom

[Ray D. Ayshun]

Most evicore docs I've talked with have been reasonable, and basically have asked yes no questions to lead me to approval.

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[Lamount]

Seriously though, naming and shaming Evicore docs on social media, could be an effective tool.

Back in the day when they were rejecting IMRT for stage III lung, I considered asking those patients to go to the press with their concerns. Fortunately, Evicore reluctantly now considers IMRT for NSCLC 'medically necessary'

 

[Mandelin Rain]

Back in the day when they were rejecting IMRT for stage III lung, I considered asking those patients to go to the press with their concerns. Fortunately, Evicore reluctantly now considers IMRT for NSCLC 'medically necessary'

Not SCLC though.... which makes complete sense.

 

[medgator]

Back in the day when they were rejecting IMRT for stage III lung, I considered asking those patients to go to the press with their concerns. Fortunately, Evicore reluctantly now considers IMRT for NSCLC 'medically necessary'

Only took several years after the 0617 imrt analysis came out. Probably means sabr comet data will be incorporated by 2025 perfect timing for apm

 

[taserlaser]

Only took several years after the 0617 imrt analysis came out. Probably means sabr comet data will be incorporated by 2025 perfect timing for apm

By then we’ll have the phase 3 comet data. Can’t wait

 

[ramsesthenice]

Rather than bellyaching about Evicore--who we know is bad and is literally hurting people--why don't we DO something about it. Options?

Seriously though, naming and shaming Evicore docs on social media, could be an effective tool.

Evicore is a symptom, not a disease. Our pricing system is so broken I don't even know how to realistically implement the changes that are needed but increasing transparency and reducing complexity would be great places to start. If I want to buy I car I have a lot of resources (MSRPs, Blue Book etc) to know what it should cost me. If someone tries to charge me double what it is worth I laugh in their face and move on. The biggest hurdle I see to fixing anything in healthcare pricing is that too many people benefit from keeping the system broken. In theory, the major payors could just say look, we are reimbursing $X for a course of pelvic IMRT. You charge what you want, this is what you are going to get. But, of course they benefit too much from selective inflation to do that. Which, in turn, ramps up the need for "price control." Enter Evicore.

 

[Neuronix]

If you're making <$250k working 40 hours a week, then that's on you. MGMA says you're in the bottom 5-10th percentile. Either you're not working very hard or you have a terrible job and have to start looking elsewhere. A doc who can't contour a lytic bone lesion and has terrible haliotosis was offered the Salinas position earning far more than that.

This is the sort of starting number that gets thrown around in academics (including satellites) around major northeast and west coast cities. This can often be the only option for a new grad that needs to be in a certain city or region.

$300-350k is more common, especially outside tier 1 cities. Some of the exploitative midwest groups don't pay much different than this, and are primarily looking for FMGs to take advantage of.

Evicore has a great benefit of WFH 100%.
For many people that is important.
Pandemic highlighted that benefit.

Even before the pandemic, Evicore has filled a niche for people looking at an intolerable job or loss of job and no other jobs in the area. Some people can't just pick up and move their family a long distance away.

One thing I've always found interesting is that when I'm doing peer-to-peer for imaging studies or other procedures, it's almost never a specialist I'm speaking with--usually an FP or IM doc. With rad onc it's the opposite, always a rad onc. It just tells me that other specialists have better things to be doing than peer-to-peers.

 

[RickyScott]

Even before the pandemic, Evicore has filled a niche for people looking at an intolerable job or loss of job and no other jobs in the area. Some people can't just pick up and move their family a long distance away.

Certainly should not shame them anymore than shaming Docs who charge 150k for prostate protons. Job market is not fault of Evercore docs- If anything it is likely the fault of those same large instituitions charging 150k for prostate xrt.,

 

[Gfunk6]

Once APM is rolled out nation-wide and adopted by private insurers, EvilCore will no longer be necessary. People will be fighting at that point to give the least expensive treatment option.

 

[seper]

Once APM is rolled out nation-wide and adopted by private insurers, EvilCore will no longer be necessary. People will be fighting at that point to give the least expensive treatment option.

I doubt it. Besides direct reimbursement, I see other pressures to give more expensive RadOnc treatments. For example, need to document the use of newly installed equipment (like new immobilization setup or surface tracking).

 

[communitydoc13]

The docs at Evicore are a diverse bunch. I had an academic radonc from a well known place on the line one time. They are in general reasonable but I consider the Peer to Peer process to be farcical and I have had some nasty conversations over the past year.

Peer to Peer should clearly be to establish the "clinical reasonableness" of a test or intervention that may not be explicitly defined in guidelines or considered payable at first glance per review of "approved interventions" by the payor. This is not how it is approached, but rather as a personal communication of their rigid guidelines.

I have had 15 fraction IMRT lung denied for ultracentral lung lesions in very compromised patients. (The most conservative arm in the SUNSET trial and a reasonable option for the patient who will not tolerate any bronchial stenosis in my opinion.)

I have had IMRT for inoperable pancreas denied.

I routinely have restaging imaging denied. Classics include restaging PET for anal ca (Not in NCCN but the most valuable one time restaging modality in my opinion and justified by good data) and systemic restaging for locally advanced oral cavity cancers at 3 months post-treatment.

I'm guessing that the P2P reviewers are incentivized to deny?

 

[medgator]

The docs at Evicore are a diverse bunch. I had an academic radonc from a well known place on the line one time. They are in general reasonable but I consider the Peer to Peer process to be farcical and I have had some nasty conversations over the past year.

Peer to Peer should clearly be to establish the "clinical reasonableness" of a test or intervention that may not be explicitly defined in guidelines or considered payable at first glance per review of "approved interventions" by the payor. This is not how it is approached, but rather as a personal communication of their rigid guidelines.

I have had 15 fraction IMRT lung denied for ultracentral lung lesions in very compromised patients. (The most conservative arm in the SUNSET trial and a reasonable option for the patient who will not tolerate any bronchial stenosis in my opinion.)

I have had IMRT for inoperable pancreas denied.

I routinely have restaging imaging denied. Classics include restaging PET for anal ca (Not in NCCN but the most valuable one time restaging modality in my opinion and justified by good data) and systemic restaging for locally advanced oral cavity cancers at 3 months post-treatment.

I'm guessing that the P2P reviewers are incentivized to deny?

Can't get paid for doing nothing unless you do something

 

[Ray D. Ayshun]

 

[RadOncDoc21]

The docs at Evicore are a diverse bunch. I had an academic radonc from a well known place on the line one time. They are in general reasonable but I consider the Peer to Peer process to be farcical and I have had some nasty conversations over the past year.

Peer to Peer should clearly be to establish the "clinical reasonableness" of a test or intervention that may not be explicitly defined in guidelines or considered payable at first glance per review of "approved interventions" by the payor. This is not how it is approached, but rather as a personal communication of their rigid guidelines.

I have had 15 fraction IMRT lung denied for ultracentral lung lesions in very compromised patients. (The most conservative arm in the SUNSET trial and a reasonable option for the patient who will not tolerate any bronchial stenosis in my opinion.)

I have had IMRT for inoperable pancreas denied.

I routinely have restaging imaging denied. Classics include restaging PET for anal ca (Not in NCCN but the most valuable one time restaging modality in my opinion and justified by good data) and systemic restaging for locally advanced oral cavity cancers at 3 months post-treatment.

I'm guessing that the P2P reviewers are incentivized to deny?

Extremely rigid, I had one subtract one fraction for a follicular lymphoma. I guess he had a quota to make or something.

 

[Burt Radnolds]

I used to think I could win them over with persuasive logic and data but that was a losing effort. Now before each case review I pull up their guidelines and figure out how I can twist them to use against them, far more likely to be successful.

 

[Ray D. Ayshun]

I'm sort of interested in working for evicore on the side and approving everything that's even moderately reasonable until they fire me.

 

[ramsesthenice]

I'm sort of interested in working for evicore on the side and approving everything that's even moderately reasonable until they fire me.

Wasn't there a short lived "reality" show where people got jobs and then intentionally tried to get fired on hidden camera? I imagine that your tenure with Evicore would be similarly short.

As people eluded to before, Evicore reviewers have essentially no leeway to deviate from their algorithms. I don't honestly know how they get the degree of reviewer compliance that they do. I hope its through incentivized payments but the thought has crossed my mind a few times after completing one of our mind numbing interactions that maybe they randomly text the reviewers pictures of their family members out and about to gently remind them "we know where you live."

 

[TheWallnerus]

Have you ever been in tumor board and wished you could tell that other dumb rad onc how to treat his or her patients? At Evicore, we get to do that every day all day long!

 

[seper]

I'm sort of interested in working for evicore on the side and approving everything that's even moderately reasonable until they fire me.

Pretty soon you gonna run into a request for 25 fx IMRT for a bone met.

 

[Ray D. Ayshun]

Pretty soon you gonna run into a request for 25 fx IMRT for a bone met.

I said moderately reasonable. We could get a few of us to try this and sort of make a dead pool list where whoever makes it the longest gets all the after tax money from everyone else.

 

[Radonc90]

Replying to the original post.

Forget about 5 fractions...
How about one fraction...

Disclaimer: I don't use SBRT for prostate.


Apparently, this one fraction prostate SBRT got the urologist "excited" lol...

 

[Ray D. Ayshun]

Replying to the original post.

Forget about 5 fractions...
How about one fraction...

Disclaimer: I don't use SBRT for prostate.


Apparently, this one fraction prostate SBRT got the urologist "excited" lol...

In all honesty, removing "of virtual prostatectomy with" would make this paper seem serious. I can understand why urologists would be bothered by that idiotic term.

 

[TheWallnerus]

FIVE FRACTION BREAST.

FOR EVERYONE.

NOW.

Or else.

Five-fraction Radiotherapy for Breast Cancer: FAST-Forward to Implementation

The phase 3 FAST-Forward trial reported outcomes for 26 and 27 Gy schedules delivered in 5 fractions over 1 week versus 40 Gy in 15 fractions over 3 w…

www.sciencedirect.com

 

[Church of Radiontology]

This is the sort of starting number that gets thrown around in academics (including satellites) around major northeast and west coast cities. This can often be the only option for a new grad that needs to be in a certain city or region.

$300-350k is more common, especially outside tier 1 cities. Some of the exploitative midwest groups don't pay much different than this, and are primarily looking for FMGs to take advantage of.



Even before the pandemic, Evicore has filled a niche for people looking at an intolerable job or loss of job and no other jobs in the area. Some people can't just pick up and move their family a long distance away.

One thing I've always found interesting is that when I'm doing peer-to-peer for imaging studies or other procedures, it's almost never a specialist I'm speaking with--usually an FP or IM doc. With rad onc it's the opposite, always a rad onc. It just tells me that other specialists have better things to be doing than peer-to-peers.

Not my experience with hired-gun physician obfuscators.

I was told by a pediatric psychiatrist that a PET scan was not indicated to assess indeterminate lymphadenopathy.

The last Evicore rad onc I spoke to lost his medical license for fraudulent billing (continuing to run an aesthetic derm practice on the side without physician supervision despite previous discipline by the state board for this). I make a point of obtaining the full name of "Peer-to-peer" physicians before engaging in a conversation with them. A few minutes' research before our conversation is useful. When denied, I've told them I'm including their name and medical licensure status in my records because they are directing the patient's care by countermanding mine. This usually results in a "reassessment."

That being said, some of the physicians are quite reasonable. I only can imagine how soul-sucking it is to be in their situation. In my experience, insurance companies' pet doctors fall into one of two clear categories: either they are in financial straits (After working all day taking care of sick people, they spend nights and weekends interfering with other MDs' ability to do so from perceived necessity.), or they are incapable of functioning as a physician, either from inability or being prohibited from doing so. The first group often tries to do right by my patients--the second are owned individuals who do as they're told.

 

[Church of Radiontology]

I'm sort of interested in working for evicore on the side and approving everything that's even moderately reasonable until they fire me.

A friend in residency got "fired from fat camp" because he refused to write amphetamine prescriptions for low-BMI coeds who wanted them--or for high-BMI patients already on them who weren't losing weight after six months of tachycardia. When he started moonlighting with the clinic, they were so desperate that they tolerated him following the FDA guidelines, but once they found more compliant physicians they let him go--with professional honor and personal integrity intact.

 

[DireMoose]

Replying to the original post.

Forget about 5 fractions...
How about one fraction...

Disclaimer: I don't use SBRT for prostate.


Apparently, this one fraction prostate SBRT got the urologist "excited" lol...

Virtual prostatectomy = "Word abuse" .... Almost like an "emulated clinical trial."

 

[Ray D. Ayshun]

Virtual prostatectomy = "Word abuse" .... Almost like an "emulated clinical trial."

I was thinking either "prostatendectomy" or "pretendostatectomy" would've been better.

 

[RickyScott]

Not my experience with hired-gun physician obfuscators.

I was told by a pediatric psychiatrist that a PET scan was not indicated to assess indeterminate lymphadenopathy.

The last Evicore rad onc I spoke to lost his medical license for fraudulent billing (continuing to run an aesthetic derm practice on the side without physician supervision despite previous discipline by the state board for this). I make a point of obtaining the full name of "Peer-to-peer" physicians before engaging in a conversation with them. A few minutes' research before our conversation is useful. When denied, I've told them I'm including their name and medical licensure status in my records because they are directing the patient's care by countermanding mine. This usually results in a "reassessment."

That being said, some of the physicians are quite reasonable. I only can imagine how soul-sucking it is to be in their situation. In my experience, insurance companies' pet doctors fall into one of two clear categories: either they are in financial straits (After working all day taking care of sick people, they spend nights and weekends interfering with other MDs' ability to do so from perceived necessity.), or they are incapable of functioning as a physician, either from inability or being prohibited from doing so. The first group often tries to do right by my patients--the second are owned individuals who do as they're told.

In fields with a strong job market, more likely to select for problem docs for these type of positions. That is not the case in radonc. I know of one forced into evercore becausel just can’t find work where they live.

 

[Neuronix]

In fields with a strong job market, more likely to select for problem docs for these type of positions. That is not the case in radonc. I know of one forced into evercore becausel just can’t find work where they live.

I've personally known 4 in that position, all 4 in large cities.

 

[Lamount]

Virtual prostatectomy = "Word abuse" .... Almost like an "emulated clinical trial."

My first thought with 'virtual prostatectomy' was that the surgery was performed over zoom... maybe remote control of a Da Vinci haha

 

[TheWallnerus]

I've personally known 4 in that position, all 4 in large cities.

Wish there were some way to track this, the number of ROs not practicing RO but wish they could.

 

[GI_RadOnc]

FIVE FRACTION BREAST.

FOR EVERYONE.

NOW.

Or else.

Five-fraction Radiotherapy for Breast Cancer: FAST-Forward to Implementation

The phase 3 FAST-Forward trial reported outcomes for 26 and 27 Gy schedules delivered in 5 fractions over 1 week versus 40 Gy in 15 fractions over 3 w…

www.sciencedirect.com

I'm definitely going to recommend this; in large part because I want to be able to use the word 'fortnite' outside of talking to my kids' friends.

"FAST-Forward offers a good example in that breast erythema was less intense and also settled a fortnight earlier after five-fraction than 15-fraction schedules"

 

[medgator]

I'm definitely going to recommend this; in large part because I want to be able to use the word 'fortnight' in the consultation.

"FAST-Forward offers a good example in that breast erythema was less intense and also settled a fortnight earlier after five-fraction than 15-fraction schedules"

You spelled it wrong

 

[BobbyHeenan]

Wish there were some way to track this, the number of ROs not practicing RO but wish they could.

What's that ?Nelson Mandela ? quote - something like “no one is born a racist.”

No one went into rad onc to work for evicore.

 

[Radonc90]

Race to 5...
Make sure you guys/girls register for the 5x5 symposium to hear what the Swiss and Brits have to say...