And thus begins our end game. It will be very complex as it will pit private practice vs universities, Insurance companies against hospitals, Med Onc’s, surgeons, and Rad Oncs against each other by specialties and groups. The Bundled payment will get extremely complicated as he who controls the payment wins.... period.
Oncology is far and away the most complicated field in medicine to bundle.... bar none as it also involves pathology, radiology, and all oncology fields including subspecialists ( urology, ENT, GYN, CT surgeons, GI, Neurosurg, and more) but will be tried because of the possible savings involved. I believe insurance companies have the upper hand ( Kaiser, WellPoint, etc) followed by hospitals, and next Med Onc’s. Surgeons and Rad Oncs will be weaker so alliances are important . Few practices are buying new equipment( unless you have a foundation) and hiring is getting cautious.
Why do you think Walmart, Berkshire Hathaway, Amazon, Big Banks( JP Morgan) are all trying to get involved with HealthCare? Trump added a trillion dollars to defense and is looking where he can save money.... Medicare is the obvious target! That is also why McKesson bought US Oncology and Vantage. To ensure it’s own survival of supply chain.
Patrick Soon-Shiong of biotech and pharmacy fame has now bought 6 hospitals in both northern and Southern California . His focus is cancer.....
The big centers: MDA, MSK, Penn, Ohio St, City of Hope, USC and a few others negotiated a sweetheart deal to get paid about 3x more than anyone else
I used to do a lot of permanent seed prostate brachytherapy. It was great with regards to cost , complications and effectiveness. But it died years ago because Medicare stopped paying for seeds and it is little used except in a few places( Seattle....)
The bundled payment if it happens will bring insanity to our field especially if it is manditory. All private practices will be forced to join big groups, hospitals or insurances. Good night to all our autonomy.
The only good thing I see is that oncology is so complex, that bundling will take a few years to actually work, but I don’t believe it will stop the momentum from the government from trying. Just as current Academics don’t care much about the future problems of our young cub rad Onc’s or private practice; they will be more concerned about saving their own necks than they will saving our field. But,meantime we have little hope but to rely on them to give us some voice at the table. To use the Star Wars analogy, we are the rebel fleet as the Death Star approaches . May the rag tag Crew of SDN continue to fight for what is fair and ultimately good for our patients which also our best hope! May the Force be with us all
Long time lurker/rare poster, but hoping I can be of some help by chiming in now. It seemed most relevant to categorize my reply to this post while touching on some of the earlier and later ones. At risk of identifying myself, here are some points, not necessarily replying to Old rad onc:
- Capitation does not equal bundled payments. Capitation is where, for example, a PCP receives $75/mo per patient under his/her service and is responsible for the fees associated with most medical care for his/her patients. A "bundled payment" can be for any set of services and may or may not have significant financial risk built in for the provider. Highly specialized providers like radoncs don't fit a capitated model, and I'd bet large sums of money that we won't receive capitated payments for patients in my lifetime. More to follow.
- The proposed ASTRO RO-APM, currently not approved (though it's likely heading that way), is to deliver a per-patient bundled payment for radiation oncology services for the most common patient types we see. Patient comes for consult, needs (and is going to get) radiation, you receive part of the payment upfront and part on the back end, when the work is done. If you're interested, a description of it is available for free online, via a Google search. We once feared that we'd be receiving bundled payments for cancer patients (e.g. a payment to the center/group of centers to cover a breast cancer patient, and the med/rad/surg oncs have to figure out who gets what), but there is
no sign that we're heading that direction for the vast majority of markets. Contracted centers like ACOs may be able to experiment with this in the not so distant future, but IMHO, independent centers/groups will never be forced into that. It is too big of a logistical mess.
- The Oncology Care Model does not cover radiation oncology services. The bundled payments there are for the med oncs' work
- The RO-APM is meant to play nice with the OCM, so that if a patient (sticking to same example, early stage breast cancer patient) needs adjuvant radiation, the med onc or other referring provider is not financially liable for the radiation services.
- The RO-APM works off the prior two years of payments for patients of the given types, for your center/group. Looking back to the usual-and-customary care days from before fee-for-service, I can't imagine there won't be some regional averaging (i.e. it wouldn't make sense to pay different amounts to centers in the same town), and it is my understanding that the historical data part of the RO-APM is how they are planning to maintain the geographic modifier-type system.
- If you get a bundled payment, it will be up to you as to how to treat the patient. Protons? If you're into that. Brachy? Up to you. Frequency of imaging for setup? You'll get the same bundled payment. There will likely be some high-level/superficial surveillance to make sure providers aren't delivering inappropriate care, but I haven't seen that spelled out.
- IMHO, bundled payments will be an exciting era to cut waste at your site. I wouldn't believe anyone who told me they have no waste to cut from their processes. Sure, we won't have the ability to do more and get paid more like fee-for-service, but it'll force people to be more efficient or struggle to succeed.
At risk of being chased with pitch forks, for the future applicants and junior residents reading this:
- I thought the job market was pretty good this year. I targeted 5 desirable cities, and there was at least one job available in 4 of them. A job in the 5th appeared after I signed. I networked early and often. I followed up on cold calls/cold emails regularly, and I found everything I could about docs' personal and professional backgrounds online to establish some commonality with them. No, I did not say "I have to be in [x] city," and I agree with the others that you will likely be disappointed if you put that much pressure on your job search. That said, I am heading to a fantastic location and truly believe I got 3 out of 3 on location, salary, and lifestyle. Best of luck.
