Radiation Oncology Metrics

[medgator]

Feel bad for breast patients following with surgery and med onc having to come see me, and take ANOTHER day off work and pay ANOTHER co-pay for me to glance at their skin.

Some of my partners do that. The income from lots of fu pts is not insignificant but morally questionable in some cases when patients have trouble with finding the time, copay money etc

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[evilbooyaa]

In regards to optimal follow-up:

As a bright-eyed resident my goal is to follow all my cases treated for curative intent for at least 5 years. Even if I was 'just' the adjuvant breast RT or 'just' the neoadjuvant chemoRT for rectal cancer. It can be every 3 months or every 6 months or yearly, but I don't plan to discharge them from my practice. All definitive cases (anal, H&N, esophagus, lung, etc.) I will plan to follow religiously for 5 years or until metastatic progression where they are in-touch with med-onc.

Same for SRS for metastatic disease patients.

Palliative RT patients can get a one-time visit at 3 months and then back to med-onc.

Whether all of these lofty goals can be achieved in a busy clinical practice is to be determined. I agree that the first people to get removed from the follow-up schedule (assuming a generalist practice) will be the cases where the patient had surgery (breast, rectal, pancreas, gastric, etc.) and is having routine follow-up with their surgeon/med-onc. If there's at least 2 other physicians evaluating a patient I'm OK taking a step back.

 

[scarbrtj]

Right - consults / sims are a better number of productivity, but they don’t correlate to monetary value. wRVUs do.

Welllll... technically of course consults/sims correlate to productivity. EVERY physician has an average wRVU per patient if taken on a long timeline. Patients are the remunerative quanta of oncology (wRVU a sub-quantum?). So there's a correlation per physician, but of course one doc may see less patients and have more wRVU vs another who sees more patients/year but has less wRVU/year.

Regarding followups... heck, most breast cancer patients don't even have to follow with an oncologist much less a radiation oncologist. But to each his own. I know rad oncs that do a thorough cranial nerve exam on all prostate patients e.g.; some things we do are either laudable or silly, just all depends on a person's preferences. I think extensive followup of every single patient you treat is a form of virtue signalling

 

[deleted1002574]

In regards to optimal follow-up:

As a bright-eyed resident my goal is to follow all my cases treated for curative intent for at least 5 years. Even if I was 'just' the adjuvant breast RT or 'just' the neoadjuvant chemoRT for rectal cancer. It can be every 3 months or every 6 months or yearly, but I don't plan to discharge them from my practice. All definitive cases (anal, H&N, esophagus, lung, etc.) I will plan to follow religiously for 5 years or until metastatic progression where they are in-touch with med-onc.

Same for SRS for metastatic disease patients.

Palliative RT patients can get a one-time visit at 3 months and then back to med-onc.

Whether all of these lofty goals can be achieved in a busy clinical practice is to be determined. I agree that the first people to get removed from the follow-up schedule (assuming a generalist practice) will be the cases where the patient had surgery (breast, rectal, pancreas, gastric, etc.) and is having routine follow-up with their surgeon/med-onc. If there's at least 2 other physicians evaluating a patient I'm OK taking a step back.

It's one way to do it... and pretty much exactly how I started out in practice.

To do that to breast patients and prostate patients ... the co-pays, the time off (especially if you're at a far away center or a busy place that makes people wait a long time for their visit). If med onc has to see them for Tam/AI every so many months, I'm not sure seeing a rad onc that many times, as well is "value based care".

Keep us updated in 5 years!!

 

[scarbrtj]

It's one way to do it... and pretty much exactly how I started out in practice.

To do that to breast patients and prostate patients ... the co-pays, the time off (especially if you're at a far away center or a busy place that makes people wait a long time for their visit). If med onc has to see them for Tam/AI every so many months, I'm not sure seeing a rad onc that many times, as well is "value based care".

Keep us updated in 5 years!!

SCENE: Tumor board in a small American town; two rad oncs, one 5 years out and the other a recent grad, sit apart from each other listening to the cases presented...
OLDER RAD ONC: "Thank you for asking. All radiation therapy patients treated for curative intent must be followed religiously for 5 years."
BABY RAD ONC (internal monologue): "How shocking. Old fool. These LC curves don't plateau at 5 years. Once patients and referring physicians learn that I follow all my patients for 6-8 years, they'll transfer all their care to me..."

 

[deleted1002574]

I wonder IRL if the scarb is a dashing raconteur or a snooze inducing windbag. In my imagination it’s the former.

 

[deleted941485]

SCENE: Tumor board in a small American town; two rad oncs, one 5 years out and the other a recent grad, sit apart from each other listening to the cases presented...
OLDER RAD ONC: "Thank you for asking. All radiation therapy patients treated for curative intent must be followed religiously for 5 years."
BABY RAD ONC (internal monologue): "How shocking. Old fool. These LC curves don't plateau at 5 years. Once patients and referring physicians learn that I follow all my patients for 6-8 years, they'll transfer all their care to me..."

I guess it’s funny because they’re both wrong?

 

[deleted1002574]

I guess it’s funny because they’re both wrong?

Yes that’s the point. It is hard to make sense of the Scarb, but the point is trying to make is the older one thought they were “right” and the younger one thought they were “righter”, but neither one of them is... one year and out, guys, for breast. Not saving any lives here with extended follow up.

 

[radiaterMike]

While it is certainly fine to punt follow-up to PCPs, many (particularly in family medicine) won’t feel comfortable doing that. Obviously those PCPs participating in a RCT don’t fit that mold. Primary care docs are managing patients with endless problem lists, poorly controlled diabetes and hypertension, back pain, etc. such that cancer follow up will be an a added burden. And many in family medicine will have receive little oncology training. If a patient is getting AI then Med Onc should be following regularly.

 

[Krukenberg]

How many of you give instructions to PCP to send the patient back if they develop late effects? My observation has been that many patients are instead referred to other specialties when they develop late effects.

 

[deleted1002574]

Fair point.

I had a recurrent post op prostate cancer not come back to me until PSA was above 4, as normal range was between 0-4.

 

[Mandelin Rain]

Fair point.

I had a recurrent post op prostate cancer not come back to me until PSA was above 4, as normal range was between 0-4.

Been there. Done that. Not fun.

 

[scarbrtj]

many (particularly in family medicine) won’t feel comfortable doing that.

How many?

Obviously those PCPs participating in a RCT don’t fit that mold.

the only way we get close to answering these questions (must a specialist do f/u?) is trials; again, the trials suggest PCPs do adequate followup:
Traditionally, the majority of routine follow-up for cancer survivors has been performed by medical, radiation, and/or surgical oncologists, resulting in many patients receiving specialized care despite being well. This is not cost effective and may negatively impact the ability of cancer clinics, already overwhelmed by a shortage of health care resources, to respond to patients who require urgent attention. Primary care physicians (PCPs) who conventionally play a key role in providing continuous and comprehensive care for most chronic diseases could similarly assume the role of providing routine follow-up care to cancer survivors. This is supported by evidence from randomized controlled trials and a retrospective cohort study of well patients with breast and colorectal cancer that have shown no significant differences in adverse outcomes of patients observed by primary care as compared with follow-up care provided by outpatient oncology clinics.

Primary care docs are managing patients with endless problem lists, poorly controlled diabetes and hypertension

Sounds complicated. Are we sure PCPs can handle such complexity

such that cancer follow up will be an a added burden

PCPs handling patients with "endless" problem lists can't handle cancer f/u? Which is simple and quite guideline based in most instances?

And many in family medicine will have receive little oncology training.

What kind of training do they need... e.g. an early stage breast cancer patient just needs some ongoing yearly mammograms (PCP can order), a chit-chat and examination every so often. No "tests," (Doc, Shouldn’t We Be Getting Some Tests?), no scans, etc. PCPs do good chit-chat & physical exams: this is the majority of cancer f/u. And cancer screening (chest CT, Pap, mammo, genetic, PSA, etc.) almost always starts at the PCP level: they have to know a little.

If a patient is getting AI then Med Onc should be following regularly.

Why? PCPs handle binders full of women taking estrogens (for post-menopausal symptoms) e.g., which ostensibly can cause breast cancer. They can't handle women on anti-estrogens given to prevent cancer??? We have to be open to the possibility that PCP followup instead of specialist followup improves survival in certain settings. It's difficult to be super dogmatic re: specialist followup one way or the other.

 

[KHE88]

Been there. Done that. Not fun.

I've got one of these patients too. Well, two actually. One at 4 and one at 1.5.

It doesn't help that the field of family medicine has pushed this garbage idea on trainees that PSA is a worthless test based on sketchy, at best, data.

 

[seper]

PSA is not a good screening test to improve population health.

 

[scarbrtj]

PSA is not a good screening test to improve population health.

PSA plus MRI a bit better

 

[seper]

Knew a 71 y/o who has had 7 benign prostate biopsies.

PSA plus MRI a bit better

 

[radiaterMike]

In response to scarbrtj ... interesting articles. I wonder how much of this is regional. My experience (with PCPs calling me with anything remotely related to the patients cancer or treatment) is similar to this paper from UPMC ...

Primary Care Providers' Knowledge, Attitudes, Beliefs, and Practices Regarding Their Preparedness to Provide Cancer Survivorship Care. - PubMed - NCBI

“PCPs appear willing to assume an enhanced role in cancer survivorship care but feel unprepared to do so.”

It’s no mystery (and reported on this forum) that PCPs are often cramming in a target # of patients an hour and are often overextended. since we are a procedural specialty, we are immune to this type of clinic expectation.

But I concede that in certain settings it might work for PCPs to assume survivorship care and it seem a lot has been written on it.

I know some academic institutions have punted followups to survivorship clinics.

As mentioned above punting followups to PCPs might result in referrals back to you that are too late, and also further the perception of the Radiation oncologist as a technician.

 

[Palex80]

Fair point.

I had a recurrent post op prostate cancer not come back to me until PSA was above 4, as normal range was between 0-4.

I have a recurrent post op prostate cancer patient who won't come back to me until his PSMA is positive. PSA is now 2.5 ng/ml and rising, two negative PSMAs so far...

 

[Krukenberg]

Would follow ups pay an NP’s salary?

 

[Neuronix]

Would follow ups pay an NP’s salary?

If you packed their schedule like any other physician's office with like 10-15 followups per day I would expect they would pay for themselves. This is the model in many non-procedural specialties like primary care. Exactly how many follow-ups per week they would need to see depends on the math based on collections in your market.

I always argue that if it frees up the MD to do more radiotherapy, support staff or midlevels are almost always worth it. That's how we get paid--to treat, not to see office visits. If an MD is bogged down doing follow ups, excessive notes, or record collecting when they could be treating patients, then they're losing money and support staff would make up that lost revenue and more.

 

[medgator]

If you packed their schedule like any other physician's office with like 10-15 followups per day I would expect they would pay for themselves. This is the model in many non-procedural specialties like primary care. Exactly how many follow-ups per week they would need to see depends on the math based on collections in your market.

I always argue that if it frees up the MD to do more radiotherapy, support staff or midlevels are almost always worth it. That's how we get paid--to treat, not to see office visits. If an MD is bogged down doing follow ups, excessive notes, or record collecting when they could be treating patients, then they're losing money and support staff would make up that lost revenue and more.

Honestly I've not a had a lot of issues seeing an excess amount of follow-ups, almost always there is another specialist, usually med onc or the referring specialist who is seeing them well after radiation is over.

I think it's easier to just let some of those fu pts go back after a set amount of time or after the first fu to check everything is well post treatment

 

[radoncgrad2019]

If you packed their schedule like any other physician's office with like 10-15 followups per day I would expect they would pay for themselves. This is the model in many non-procedural specialties like primary care. Exactly how many follow-ups per week they would need to see depends on the math based on collections in your market.

I always argue that if it frees up the MD to do more radiotherapy, support staff or midlevels are almost always worth it. That's how we get paid--to treat, not to see office visits. If an MD is bogged down doing follow ups, excessive notes, or record collecting when they could be treating patients, then they're losing money and support staff would make up that lost revenue and more.

Yep. None of us want to be technicians but the way the payment model is set up, it sets people in most fields to be proceduralists

 

[OTN]

If you packed their schedule like any other physician's office with like 10-15 followups per day I would expect they would pay for themselves. This is the model in many non-procedural specialties like primary care. Exactly how many follow-ups per week they would need to see depends on the math based on collections in your market.

I always argue that if it frees up the MD to do more radiotherapy, support staff or midlevels are almost always worth it. That's how we get paid--to treat, not to see office visits. If an MD is bogged down doing follow ups, excessive notes, or record collecting when they could be treating patients, then they're losing money and support staff would make up that lost revenue and more.

Agree very much with this. The way things are going in the field with respect to reimbursement, hypofractionation, increasing SBRT, etc, I'm pretty certain when my partner retires I won't hire another radonc, but instead will hire an NP so I can increase the number of consults I can see, the amount of time I have to spend in tx planning, etc.

 

[scarbrtj]

Agree very much with this. The way things are going in the field with respect to reimbursement, hypofractionation, increasing SBRT, etc, I'm pretty certain when my partner retires I won't hire another radonc, but instead will hire an NP so I can increase the number of consults I can see, the amount of time I have to spend in tx planning, etc.

Very approximately... with half the number fractions we can all see twice the number of patients.

I keep trying to tell people it's going to be one radiation oncologist for a million patients one day and nobody (except some crazy Italian) believes me.

 

[Burt Radnolds]

I'm sure most people do similar things but I have a spiel I give about late effects every time I discharge a patient, encouraging them to come see me if they or another provider ever feels they are having a delayed complication from treatment. I always document this conversation and cc the last note to the PCP and have heard feedback from several acknowledging they will comply. I have had a couple patients develop complications that I later found out about and I went out of my way to call the PCP and specialists involved to let them know that I would prefer to be in the loop in the future. Sometimes I crack a joke to the patient before discharge saying that I'd be happy to keep seeing them but I feel bad taking a copay just to talk about the weather, their golf game, or their latest trip. They usually laugh and thank me for saving them the time and money. Many get excited and see it as one more step towards normalcy as its one less reminder of their cancer diagnosis.

 

[medgator]

Agree very much with this. The way things are going in the field with respect to reimbursement, hypofractionation, increasing SBRT, etc, I'm pretty certain when my partner retires I won't hire another radonc, but instead will hire an NP so I can increase the number of consults I can see, the amount of time I have to spend in tx planning, etc.

You'll just need a linac babysitter from time to time for vacation coverage. We've been using retired rad oncs for this purpose and honestly it's a sweet gig for everyone involved. Best to avoid the locums companies when possible, as they take a huge cut from both parties as the middleman.

Like I have said previously, this field is untouchable at 190/year graduating when you literally have existing practitioners seeing more patients/year in consult and the conversation changes from hiring partners to hiring extenders....

 

[seper]

This guy's portfolio surely tanked lately, along with ViewRay stock.

Very approximately... with half the number fractions we can all see twice the number of patients.

I keep trying to tell people it's going to be one radiation oncologist for a million patients one day and nobody (except some crazy Italian) believes me.

 

[msuxrt]

For those of you who have groups that collect some portion of technical from the hospital what was your argument to do so? What % were you able to capture?

 

[Mandelin Rain]

For those of you who have groups that collect some portion of technical from the hospital what was your argument to do so? What % were you able to capture?

Typically it would be a hard to recruit to place and/or not carry a volume of patients where professional reimbursement would pay well enough to staff.

 

[Neuronix]

Typically it would be a hard to recruit to place and/or not carry a volume of patients where professional reimbursement would pay well enough to staff.

I don't understand your meaning.

 

[Mandelin Rain]

I don't understand your meaning.

The rationale for a global split/technical share from a hospital's perspective is if they can't get someone there for what they're offering. One way to offer more is to share the technical (increase the upside risk for the doc).

Not sure I've seen a technical share in any other scenario.

 

[Neuronix]

The rationale for a global split/technical share from a hospital's perspective is if they can't get someone there for what they're offering. One way to offer more is to share the technical (increase the upside risk for the doc).

That's what I thought you meant. It just doesn't jive with my experience. I've had my share of interviews in multiple areas of the country and never once been offered a piece of technicals. I know plenty of recent grads like myself in professional only settings or academic satellite jobs that are basically straight RVU (and consistent with professional only level salaries).

 

[medgator]

The rationale for a global split/technical share from a hospital's perspective is if they can't get someone there for what they're offering. One way to offer more is to share the technical (increase the upside risk for the doc).

Not sure I've seen a technical share in any other scenario.

Exactly how I've seen it

 

[medgator]

That's what I thought you meant. It just doesn't jive with my experience. I've had my share of interviews in multiple areas of the country and never once been offered a piece of technicals.

It would basically be done via a generous professional percentage of the global collections.

Of course with 200 grads/year hitting the market, any chance of those arrangements happening becomes smaller and smaller

 

[Mandelin Rain]

That's what I thought you meant. It just doesn't jive with my experience. I've had my share of interviews in multiple areas of the country and never once been offered a piece of technicals. I know plenty of recent grads like myself in professional only settings or academic satellite jobs that are basically straight RVU (and consistent with professional only level salaries).

You will NEVER be offered technical share/global split. That is part of negotiation.

Their job is to get you there as cheaply as possible. Your job is to get what you think you're worth.

 

[Neuronix]

You will NEVER be offered technical share/global split. That is part of negotiation.

Their job is to get you there as cheaply as possible. Your job is to get what you think you're worth.

Indeed. And when I walk they find another new/recent grad to fill the position or they just decide not to hire.

Been through this a few times now. I don't know if you've heard about the recent oversupply of residents.

 

[Mandelin Rain]

Indeed. And when I walk they find another new/recent grad to fill the position or they just decide not to hire.

Been through this a few times now. I don't know if you've heard about the recent oversupply of residents.

I get it. This is the type of bargaining power that our esteemed academic chairmen have stolen from us, but was relatively common in 15 years ago.

 

[medgator]

I get it. This is the type of bargaining power that our esteemed academic chairmen have stolen from us, but was relatively common in 15 years ago.

Which is why most of us in practice are stuck now geographically.

You literally can't find the same job anywhere else if you are even remotely happy/ok with it.

 

[Mandelin Rain]

Which is why most of us in practice are stuck now geographically.

You literally can't find the same job anywhere else if you are even remotely happy/ok with it.

Don't get me wrong, I really like my work and am fulfilled at my current salary, but a big reason why I went into rad onc as a broke med student was the financial upside present at the time I applied. I knew multiple docs making 800k-1 million in 2004ish dollars. Academic guys weren't pulling in anything close, which I think is where some of the animus against PP came from. But... those salaries were support by healthy global splits in the early days of technical reimbursement for IMRT. Neither of those things are available now. Heck, they weren't really available when I finished residency.

 

[Neuronix]

Their job is to get you there as cheaply as possible. Your job is to get what you think you're worth.

Very few people come out and say this, so I'm glad that you're honest.

I always assumed that in medicine other physicians would offer new grads the same track/deal that they got. We all hear about the evil administrators. But frankly, as a new grad in a bad market, everyone is out to get you. They should state that plainly at the ARRO jobs meeting nowadays.

Many private groups aren't offering the same partnership tracks they had, hospital department chairs don't offer the same salaries or revenue sharing they have, and academic chairs don't offer the same cushy jobs and startup packages they received when they were fresh out of residency.

I honestly was just surprised by the whole thing and still am. I don't believe in taking advantage of people. Why should people get paid differently for doing the same work? Maybe I'm naive. Then again the number of times I've heard that I'm a sucker for helping people for free on SDN makes me think I probably am just a fool.

This they're all out to get you situation includes some people posting on this forum. I can't get the same deal that they got. Either the deal has changed for anyone coming in now or they never hire. It's the common refrain of "I got my technicals before the job market got bad. Sucks for you." People you thought were your friends smack their lips looking to get you as a new or recent grad at a bargain rate.

I love the indignation that people give to me. That THEY were special somehow. That THEY did something I didn't do. That I should be HAPPY to be even getting a portion of professional collections or some % of AAMC salaries. Yeah ok bro.

I can't imagine how low things will go. It's all supply and demand, and there's a worsening mismatch.

 

[Mandelin Rain]

FWIW, our contract has never changed. Everyone has signed the same one and has received the same treatment for decades. No plan on ever changing.

Treating people fairly (or at least as you, yourself would [have] be treated) is a key to getting and retaining good people.

 

[radoncgrad2019]

if like Mandelin Rain you're expecting to make 800k-1 million in most settings, you WILL be disappointed, People still make that, but not common.

If you are okay making 500k and don't see that as worthless, then you will be happy in this field.

That's the bottom line.

Happiness is about expectations, so medical students, take note.

 

[Neuronix]

If you are okay making 500k and don't see that as worthless, then you will be happy in this field.

If you lower that to 300-400k I'll agree with you. 500k is around MGMA median and as I've written before I've never had a clear path to get there. Maybe at full professor or another late career setup I'll get there.

That's today. I'm worried what things will look like in another 5 years, but the future is always hard to predict. 30% or more of residency spots going unfilled is a good start to correct the situation, but I suspect that they'll just fill in the SOAP and in future years more FMGs will fill the spots.

 

[Mandelin Rain]

Yeah, I'd say "most" rad oncs won't be making 500k in the future.

That may be the 800k-1 million white whale of my medical school era. Manage expectations appropriately.


EDIT: Just to flesh this out a bit. Even if you assume that 500k is the actual current median, the APM as it stands today looks to lower reimbursement by (optimistically) 6-8%. That is 30-40k off the top right there. Additionally, as have been shown multiple times here, there is an overwhelming and accelerating trend toward employment models, specifically academic employment models which have always paid less historically. There is no sign of that trend reversing.

 

[radoncgrad2019]

At least for me in all the private offers I was considering when I graduated, 500k was about normal for what to expect as partner. This was not rare. my friends all had the same experience, including a few that are graduating this year. I don't feel like 500k is rare.

Academics is a different beast of course.

 

[Mandelin Rain]

At least for me in all the private offers I was considering when I graduated, 500k was about normal for what to expect as partner. This was not rare. my friends all had the same experience, including a few that are graduating this year. I don't feel like 500k is rare.

Academics is a different beast of course.

500k is not rare in mid career private practice today. The expectation to become a mid career private practitioner is becoming increasingly rare though. The "different beast" keeps eating them, and has a voracious appetite for more.

 

[medgator]

Many private groups aren't offering the same partnership tracks they had, hospital department chairs don't offer the same salaries or revenue sharing they have, and academic chairs don't offer the same cushy jobs and startup packages they received when they were fresh out of residency.

I honestly was just surprised by the whole thing and still am. I don't believe in taking advantage of people. Why should people get paid differently for doing the same work? Maybe I'm naive. Then again the number of times I've heard that I'm a sucker for helping people for free on SDN makes me think I probably am just a fool.

This they're all out to get you situation includes some people posting on this forum. I can't get the same deal that they got. Either the deal has changed for anyone coming in now or they never hire. It's the common refrain of "I got my technicals before the job market got bad. Sucks for you." People you thought were your friends smack their lips looking to get you as a new or recent grad at a bargain rate.

Honestly, what's better.... Churn and burn or only hire when there is an actual need for the practice?

I've seen a lot of the former, and would prefer the latter. Fwiw, after walking out of my first malignant practice, I got hired for a center in the most rural part of our region with the lowest volumes (8 under treatment the first day I started). I guess that's why I got hired for that place, and not sure I needed help for even double that volume which took years to build.

There are plenty of older docs who are happy to employ and churn and burn new grads every 1-3 years, and their actions are even easier now in the era of residency expansion. Think Irvine, Atlanta, Austin CC etc.

So it has come down to which you choose in many desirable locales... exploitative fellowship/Junior faculty position or indefinite employee at one of those private centers.

 

[radoncgrad2019]

500k is not rare in mid career private practice today. The expectation to become a mid career private practitioner is becoming increasingly rare though. The "different beast" keeps eating them, and has a voracious appetite for more.

fair point

 

[msuxrt]

At least for me in all the private offers I was considering when I graduated, 500k was about normal for what to expect as partner. This was not rare. my friends all had the same experience, including a few that are graduating this year. I don't feel like 500k is rare.

Academics is a different beast of course.

Based on current reimbursements there is no reason 500k shouldn't be the case as a partner. From what i've seen those that have been practicing for 20-30 years watched their salaries shrink and have decided to subsidize themselves with newer physicians.

For those of you who have bargained for a technical component what % did you ask for/get?