RO-APM Podcast Episode (from The Accelerators)

[elementaryschooleconomics]

I think those of us who frequent RadOnc Social Media are aware that Simul/Spraker/Laucis started a podcast recently called "The Accelerators".

They just released a beast of an episode, available on Spotify here.

I know for me, trying to learn about the APM has been very difficult and time consuming, even when I consider reading about RadOnc policy and economics to be basically my main hobby. They do an incredible job having a discussion about what the APM is, what it affects, and why it's important, and they do so by bringing in several guests who actually know what they're talking about (including Anne Hubbard and Dave Adler, the policy/advocacy leadership from ASTRO).

I would strongly encourage folks who aren't really sure about why some of us are very concerned about APM re: the future of the specialty to listen to this episode. I know I've spent a lot of time advocating for cutting residency spots because I think oversupply is a threat to the health of RadOnc, but the implications of APM, as it is currently written, threatens existing practices independent of any of the canonical SDN issues of oversupply, ABR board exams, etc.

I also really appreciate Spraker bringing up the PPS-exempt centers (which are exempt from APM as well), and the fact that CMS has chosen to bring on a Clinical Consultant from MD Anderson into what appears to be high-level decision making circles about APM. Hubbard side steps the issue by explaining the mechanics of why PPS-exempt centers are also APM-exempt, but not commenting further. I don't think any of us were confused about why they aren't included (they've exempted several types of geographies/designations because they're already not operating in the standard FFS fashion that most of the country uses).

I think we're more concerned that someone with zero skin in the game is being given a chance to advise on policy that will affect almost 1,000 practices/institutions, but not their own. Faculty and staff from the 11 PPS-exempt shouldn't be anywhere near having input on APM (at least in the "forced enrollment experimental stage"), or at least their presence should be balanced out by adding someone who, you know, will actually have to practice under this model. Again, this is definitely not a comment about that particular person or anyone from that institution, I just don't want anyone from those places creating the rules to a game they don't have to play.

Very relevant to me, as someone who will be forced to participate in APM, was the comment towards the end of the episode about the wish for CMS to collect their own data. A large part of the "experiment" of APM is that CMS wants to analyze practice patterns and assess the efficacy of their model in regards to cutting reimbursement to Radiation Oncology (because all that Keytruda and Herceptin ain't gonna reimburse itself).

The analogy was made that, if a patient enrolls on a clinical trial, do we ask the patient to record and report all of their own data and submit it to the PI? No, because that's obviously ridiculous - the team running the clinical trial will collect and analyze the data. Why, on God's green Earth, is CMS forcing non-consenting practices to participate in an experimental reimbursement model AND collect and submit their own data on it? Documentation requirements are already astronomical, and CMS is demanding more? Never mind that currently, about two months away from APM implementation, the only way to submit this data is through manually entering it into an Excel spreadsheet on the CMS website and submitting it through the portal. There are no vendor solutions for this. Well, I guess that's not entirely true - though not discussed in the podcast, one of my admins heard that Varian has created an $85,000 product to generate the APM data, and that product is evidently...not great. Also, CMS expects us to submit data on all of our patients, even the ones not covered by APM. That's right, they want data on your Anthem and Aetna patients, too. I'm not sure how that doesn't violate some sort of patient privacy rights, but perhaps smarter people than me already have that figured out.

But I digress - listen to the episode!

(@RealSimulD, I'll send you a link to my Venmo account for the advertising fee)

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[fiji128]

Entering the required data via an excel spreadsheet sounds like a level of hell.

Spend untold hours entering stuff into epic and then aria and now a government spreadsheet, yikes. Time to get a VA job I guess.

 

[elementaryschooleconomics]

Entering the required data via an excel spreadsheet sounds like a level of hell.

Spend untold hours entering stuff into epic and then aria and now a government spreadsheet, yikes. Time to get a VA job I guess.

Yeah, it's not clear to me what the truth is about how we can submit the CDE stuff. In meetings I've had over the last few weeks, we knew what the government wanted from us, available in this document.

Here's a screenshot of the elements:

My original plan was to write some code with our existing EHR software to automatically generate as much of this as possible in a single document (though a few items would still need manual adjustments).

However, IN A PEAK EXAMPLE OF HOW LAZY CMS IS, it appears we need to submit this data in the CMS-crafted Excel template, presumably because it assigns specific variables for each element SO IT'S EASIER FOR CMS TO ANALYZE IT LATER:

This is so appallingly lazy that I'm in disbelief.

I get what CMS is trying to do with this, I really do. But this model should not have been rolled out based on "random" geographic distribution with this level of requirement. It would be one thing if they "just" wanted to change how we're reimbursed. We'd still grumble (because their explicit goal is to take money away from RadOnc and give it to whoever the Astra Zeneca lobbyists tell them to), but it wouldn't significantly increase our workload. By slashing reimbursement as well as FORCING US TO DO THEIR ONEROUS DATA COLLECTION FOR THEM, they're (ironically) threatening the ability of small departments to provide quality patient care. Cutting reimbursements doesn't exactly facilitate a budget which allows small departments to hire additional staff to handle these requirements, meaning existing staff and doctors will have to do this if they want to, you know, get reimbursed for curing cancer. There are only 24 hours in a day. Filling out these forms for the government's little research project will require taking time and attention away from other pursuits...like patient care.

The writing on the wall, bundled payments are coming for everyone. I just hope there's an 11th-hour reprieve from some of the aspects of RO-APM because it is crystal clear that doing it like this will negatively impact patients in small and/or rural settings.

 

[Lamount]

The APM rollout is pretty dumb. Even for those at CMS who believe in the underlying principles of the APM, this could have been done better. There is a decent chance this will be an abject failure -that patient access will decrease significantly in the affected zips. If they made the cuts a little less draconian and had some small incentives, they might have gotten away with making enrollment voluntary and some places sick of having to bill for FFS would have signed on. This strikes me as just being pretentious and vindictive, and my gut is telling me that it will blow up in their faces

 

[TheWallnerus]

The APM rollout is pretty dumb. Even for those at CMS who believe in the underlying principles of the APM, this could have been done better. There is a decent chance this will be an abject failure -that patient access will decrease significantly in the affected zips. If they made the cuts a little less draconian and had some small incentives, they might have gotten away with making enrollment voluntary and some places sick of having to bill for FFS would have signed on. This strikes me as just being pretentious and vindictive, and my gut is telling me that it will blow up in their faces

What has the govt done which was pretentious and vindictive which has blown up in their faces in recent memory. I can think of nothing. Who watches the watchmen. No one is accountable. Nobody will lose a job at CMS.

What no one is mentioning, and from ASTRO on down, is there is another way that APM decreases access to care. Let's say you want to become a doctor. And then in medical school you think about becoming a rad onc. Look at the drama in this specialty. Who would want to join this mess. You'd have to have a screw loose if you're a top med student and chose rad onc with all its existential threats. It would be like being very rich and investing all your money in highly volatile penny stock. And even if APM gets cancelled one gets the feeling that it would not be an eternal reprieve. Long-term, the govt is causing rad onc to become not a great specialty because there's no way anyone smart... or who loves patients... would want rad onc.

 

[medgator]

What has the govt done which was pretentious and vindictive which has blown up in their faces in recent memory. I can think of nothing. Who watches the watchmen. No one is accountable. Nobody will lose a job at CMS.

What no one is mentioning, and from ASTRO on down, is there is another way that APM decreases access to care. Let's say you want to become a doctor. And then in medical school you think about becoming a rad onc. Look at the drama in this specialty. Who would want to join this mess. You'd have to have a screw loose if you're a top med student and chose rad onc with all its existential threats. It would be like being very rich and investing all your money in highly volatile penny stock. And even if APM gets cancelled one gets the feeling that it would not be an eternal reprieve. Long-term, the govt is causing rad onc to become not a great specialty because there's no way anyone smart... or who loves patients... would want rad onc.

Knowing what I know now, if I was a current MS3 I would do med onc 100000000% or rads over this dumpster fire of a specialty currently.

Rads was actually a good residency "buy" several years ago regarding job market concerns as they have totally gone the other way with new indications and studies forthcoming.

Hypofx, APM and supervision reg changes are snowballing together with residency expansion to absolutely obliterate the job market going forward

 

[RickyScott]

What has the govt done which was pretentious and vindictive which has blown up in their faces in recent memory. I can think of nothing. Who watches the watchmen. No one is accountable. Nobody will lose a job at CMS.

What no one is mentioning, and from ASTRO on down, is there is another way that APM decreases access to care. Let's say you want to become a doctor. And then in medical school you think about becoming a rad onc. Look at the drama in this specialty. Who would want to join this mess. You'd have to have a screw loose if you're a top med student and chose rad onc with all its existential threats. It would be like being very rich and investing all your money in highly volatile penny stock. And even if APM gets cancelled one gets the feeling that it would not be an eternal reprieve. Long-term, the govt is causing rad onc to become not a great specialty because there's no way anyone smart... or who loves patients... would want rad onc.

You would have to have screw loose to join the specialty without the apm. Unless you are an fmg from some horrible place, impeaching a candidates judgment would be legitimate at a job interview 5 years from now?

 

[madchemist89]

Great podcast. I am in apm and we are already extremely efficient. I don't know how we could survive with 20% cuts off the top followed by the burden of data entry and quality measures unrelated to ro.

 

[Sheldor]

What has the govt done which was pretentious and vindictive which has blown up in their faces in recent memory. I can think of nothing. Who watches the watchmen. No one is accountable. Nobody will lose a job at CMS.

What no one is mentioning, and from ASTRO on down, is there is another way that APM decreases access to care. Let's say you want to become a doctor. And then in medical school you think about becoming a rad onc. Look at the drama in this specialty. Who would want to join this mess. You'd have to have a screw loose if you're a top med student and chose rad onc with all its existential threats. It would be like being very rich and investing all your money in highly volatile penny stock. And even if APM gets cancelled one gets the feeling that it would not be an eternal reprieve. Long-term, the govt is causing rad onc to become not a great specialty because there's no way anyone smart... or who loves patients... would want rad onc.

Didn't they try something very similar to the APM a few years ago with med onc and it blew up in their faces and failed? (At least thats what my med onc colleague's have told me)

 

[elementaryschooleconomics]

What has the govt done which was pretentious and vindictive which has blown up in their faces in recent memory. I can think of nothing. Who watches the watchmen. No one is accountable. Nobody will lose a job at CMS.

What no one is mentioning, and from ASTRO on down, is there is another way that APM decreases access to care. Let's say you want to become a doctor. And then in medical school you think about becoming a rad onc. Look at the drama in this specialty. Who would want to join this mess. You'd have to have a screw loose if you're a top med student and chose rad onc with all its existential threats. It would be like being very rich and investing all your money in highly volatile penny stock. And even if APM gets cancelled one gets the feeling that it would not be an eternal reprieve. Long-term, the govt is causing rad onc to become not a great specialty because there's no way anyone smart... or who loves patients... would want rad onc.

I couldn't agree more.

Though I can't remember who was talking about it on this podcast (I think it was Adler), but they discussed how some of the potential payment models the government has explored (and continues to explore) would make radiation therapy a subset of an Oncology Care Model which would be driven entirely upstream of us by the Medical Oncologists (I believe this is why ASTRO started trying to design their own bunded payment model, to get ahead of CMS pursuing this in the last decade).

I was just floored by that scenario. Obviously, the incentive with a set amount of reimbursement per episode of care is to be as efficient as possible. While the current system inadvertently incentivizes using more fractions, bundled payment inadvertently incentivizes doing less of everything.

Thus, if an Oncology Care Model is introduced which bundles radiation in with workup and chemo, and the Medical Oncologists are the ones who control the start of the episode (which they would be), they would be incentivized to utilize radiation therapy as little as possible. At present, a significant amount of MedOnc research and practice goes into minimizing/omitting radiation, and whether or not we get reimbursed has no effect on their reimbursement. Imagine a world where using radiation means they lose reimbursement, and how practice patterns would change in response.

I honestly never considered this scenario, so thanks for that nightmare guys. People lament that we're glorified technicians now, but just picture practicing Radiation Oncology under an Oncology Care Model where ALL oncology care is bundled. We would only see patients deemed "appropriate" for XRT, and I guarantee (based on how the RO APM has been written) that we would have to treat those patients following an "approved regimen" that perhaps was decided upstream of us.

Once upon a time this possibility would have seem so far-fetched that I would have shrugged it off. But seeing what they're doing now with APM, it's entirely plausible. What if, at the end of the 5 years, instead of making every practice under this model, they decide it wasn't "effective enough" and instead move forward with an OCM with bundled radiation?

Why in the world would a student see what's going on and think that this is a good career decision? "The penny stock of medicine" is as devastatingly sad as it is accurate. But - sometimes people make money off penny stocks. Similar to IMRT in the early 2000s, maybe something will happen and RadOnc will thrive. I'm not Nostradamus, I don't know what's going to happen. But given, all of the information available to me right now, nothing like that is on the horizon.

If being a doctor in America is like the stock market, the majority of specialties right now are index funds from Vanguard. RadOnc is a whole life insurance policy a Northwestern Mutual "advisor" is trying to get you to buy coming out of residency. Yeah, someone's gonna profit from that policy...but probably not you.

 

[Gfunk6]

Didn't they try something very similar to the APM a few years ago with med onc and it blew up in their faces and failed? (At least thats what my med onc colleague's have told me)

My practice participated in the OCM (MO only). There were several key differences between RO-APM:

1. It was still fee for service at current Medicare rates.

2. OCM participants got more money on top of FFS for every patient that was enrolled on the program.

3. The objective of OCM was to obtain data on chemo regimens, toxicity and hospitalizations. They were trying to reduce costs to CMS by decreasing use of futile chemo, tracking patient symptoms meticulously and trying to mitigate hospitalization rates due chemo toxicity.

4. The additional monies given to OCM participants in #2 was to help defray the costs of hiring staff and implementing processes in #3.

5. For the first few years there were no mandates, it was just a fact finding mission.

6. OCM was VOLUNTARY, you had to apply to participate.

7. In later years, after CMS had collected sufficient data, they started demanding participating groups choose one or two sided risks based on performance.

8. At this juncture many practice started dropping. It was nice to get free money from CMS but not when you had a substantial risk of penalty for things you had limited or no control over.

 

[elementaryschooleconomics]

My practice participated in the OCM (MO only). There were several key differences between RO-APM:

1. It was still fee for service at current Medicare rates.

2. OCM participants got more money on top of FFS for every patient that was enrolled on the program.

3. The objective of OCM was to obtain data on chemo regimens, toxicity and hospitalizations. They were trying to reduce costs to CMS by decreasing use of futile chemo, tracking patient symptoms meticulously and trying to mitigate hospitalization rates due chemo toxicity.

4. The additional monies given to OCM participants in #2 was to help defray the costs of hiring staff and implementing processes in #3.

5. For the first few years there were no mandates, it was just a fact finding mission.

6. OCM was VOLUNTARY, you had to apply to participate.

7. In later years, after CMS had collected sufficient data, they started demanding participating groups choose one or two sided risks based on performance.

8. At this juncture many practice started dropping. It was nice to get free money from CMS but not when you had a substantial risk of penalty for things you had limited or no control over.

So basically, a couple of folks over at CMS looked at the OCM, thought "Hey, you know all those reasonable policies we had in that? Let's do the literal opposite for APM".

It honestly feels like they're trying to force practices to close through legislation. Luh made a point that, for the population he treats, the next closest linear accelerator is 3 hours away. That's a prohibitive distance for many people if he can't keep the lights on.

If the government is trying to send us the message that they don't care about the health of people in rural America, I can assure them: message received.

 

[deleted1111261]

Having been (at times correctly) critical of ASTRO, there is a lot behind the scenes that they and good people like Brian Kavanaugh had done and Medicare came in and ransacked it to the point of utter rubbish. We should give blame when it’s due, but this wasn’t our society for once - it was clearly a government misunderstanding and resultant failure.

 

[Gfunk6]

Having been (at times correctly) critical of ASTRO, there is a lot behind the scenes that they and good people like Brian Kavanaugh had done and Medicare came in and ransacked it to the point of utter rubbish. We should give blame when it’s due, but this wasn’t our society for once - it was clearly a government misunderstanding and resultant failure.

Agree with you, ASTRO engaged with CMS early and vigorously but their suggested improvements were flushed down the toilet. Although you cannot fault ASTRO per se, it does give you an indication of where CMS thinks RO falls on the totem poll.

 

[Irradi8or]

Agree with you, ASTRO engaged with CMS early and vigorously but their suggested improvements were flushed down the toilet. Although you cannot fault ASTRO per se, it does give you an indication of where CMS thinks RO falls on the totem poll.
Astro

Agree with you, ASTRO engaged with CMS early and vigorously but their suggested improvements were flushed down the toilet. Although you cannot fault ASTRO per se, it does give you an indication of where CMS thinks RO falls on the totem poll.

Agree - Astro has been at the table for years (and they really have done a lot in the background to try to make this model viable) and there’s a real existential threat to Rad Onc with hypofx. Most people have not run the numbers, but if you do, you will see that 5 fractions go breast, prostate, rectal and hypofx trends in nearly all disease sites is going to lead to massive revenue losses in FFS environment, not to mention the declining values of our Rad Onc codes in the RUC and CMS (given equipment valuation updates and E&M coding revaluations). APMs have potential to stabilize these losses and keep access to high quality care alive, otherwise there are going to be many facility closures which will esp hurt smaller volume practices more so than higher volume given high fixed costs. I’ve negotiated several commercial radiation APMs for my group - in ways that are less complicated than CMS RO Model and has a net advantage financially and with some reduction in prior auth burden. CMS however does NOT play well in the sandbox, and even straightforward common sense suggestions for improvements of the RO model have been struck down by bureaucrats that have very little understanding of radiation.

 

[medgator]

Agree with you, ASTRO engaged with CMS early and vigorously but their suggested improvements were flushed down the toilet. Although you cannot fault ASTRO per se, it does give you an indication of where CMS thinks RO falls on the totem poll.

ASTRO was actually opposed to payment bundles for several years which had been pushed by freestanding centers giving the ever widening disparity in payment over the years.

Basically CMS brought them to the table when they were ready to start going down this path

 

[deleted1111261]

ASTRO was actually opposed to payment bundles for several years which had been pushed by freestanding centers giving the ever widening disparity in payment over the years.

Basically CMS brought them to the table when they were ready to start going down this path

Relevance ?

Astro’s original APM is pretty good and pretty popular.

CMS ruined it… so, maybe ASTRO’s original strategy of fighting bundles made sense because CMS is bastardizing it?

 

[medgator]

Relevance ?

Astro’s original APM is pretty good and pretty popular.

CMS ruined it… so, maybe ASTRO’s original strategy of fighting bundles made sense because CMS is bastardizing it?

I never saw that? Care to link? Do they address site neutrality and protons well?

ASTROs original idea was to pretend to care about everyone and do nothing while some were treated worse than others for years. But i guess if we want to pretend none of that happened i guess that's cool?

 

[deleted1111261]

I never saw that? Care to link? Do they address site neutrality and protons well?

ASTROs original idea was to pretend to care about everyone and do nothing while some were treated worse than others for years. But i guess if we want to pretend none of that happened i guess that's cool?

We have one organization that has any sort of clout. If you want to fight them, too, that’s fine. I’m not a member and I have been publicly and vocally critical of them on social media and to their faces.

I don’t hold a view and continue to hold it until I’m blue in the face just because I want to believe a specific narrative. Yes, they messed stuff up in past, yes they have failed us (read transcript of my speech). I’m not a “splitter”. A is always good, B is always bad. Critical thinking requires us to analyze what’s happening in the moment.

Do I think that fighting ASTRO hard right now is the way to help us out of the APM disaster? I want everyone to listen to the podcast, read Join Luh’s article, read Tom Dvorak’s work, and many others. I want people writing their congressman. I’m tired of holding on to old grievances. Yes, I agree they should have been site neutral. Yes, I agree with wasted time with UroRad. You’re married right? Do you hold on to hold fights or do you try to get them to hear you and understand you?

Because of SDN, because of many voices on social media, because of engagement, they are trying to do better. Am I a member again? Not yet, but I don’t know if it will be in our best interest to fight actively against them and bring up old grudges and grievances. It gets petty and tiresome. Join us a person that I highly respect because he is the perfect example of someone who ASTRO continues to f*** over, yet he gets it - have to fight with what we have.

Anyway, 🐊 we are old friends but I think your arguments of consistently holding onto old grievances is neither healthy or forward looking. It’s just my opinion. When we get new data, new information and a common enemy, it makes more sense to collectively act against a rigged system than to stick with “what about ism” and “but remember when they did this ??”

I had a notable person in oncology offer me the first $10k to start an organization contra ASTRO. Even 100x that wouldn’t get us close to what we need to have a truly useful advocacy organization. My way forward is to do the best with what we have. “Fight with the army we have, not the army we want”.

 

[medgator]

We have one organization that has any sort of clout. If you want to fight them, too, that’s fine. I’m not a member and I have been publicly and vocally critical of them on social media and to their faces.

I don’t hold a view and continue to hold it until I’m blue in the face just because I want to believe a specific narrative. Yes, they messed stuff up in past, yes they have failed us (read transcript of my speech). I’m not a “splitter”. A is always good, B is always bad. Critical thinking requires us to analyze what’s happening in the moment.

Do I think that fighting ASTRO hard right now is the way to help us out of the APM disaster? I want everyone to listen to the podcast, read Join Luh’s article, read Tom Dvorak’s work, and many others. I want people writing their congressman. I’m tired of holding on to old grievances. Yes, I agree they should have been site neutral. Yes, I agree with wasted time with UroRad. You’re married right? Do you hold on to hold fights or do you try to get them to hear you and understand you?

Because of SDN, because of many voices on social media, because of engagement, they are trying to do better. Am I a member again? Not yet, but I don’t know if it will be in our best interest to fight actively against them and bring up old grudges and grievances. It gets petty and tiresome. Join us a person that I highly respect because he is the perfect example of someone who ASTRO continues to f*** over, yet he gets it - have to fight with what we have.

Anyway, 🐊 we are old friends but I think your arguments of consistently holding onto old grievances is neither healthy or forward looking. It’s just my opinion. When we get new data, new information and a common enemy, it makes more sense to collectively act against a rigged system than to stick with “what about ism” and “but remember when they did this ??”

I had a notable person in oncology offer me the first $10k to start an organization contra ASTRO. Even 100x that wouldn’t get us close to what we need to have a truly useful advocacy organization. My way forward is to do the best with what we have. “Fight with the army we have, not the army we want”.

Last i checked ACRO was still around and didn't sit there and tell CMS how dangerous general supervision might be to safely delivering radiation therapy while forgetting the small detail that critical access hospitals were general all along?

What do you think that does to the credibility of our "advocacy organization" in the eyes of CMS literally last year?

Maybe if ASTRO hadn't spent years fighting against payment bundles, CMS might have actually taken their apm proposal seriously for more than a second?

As Warren Buffett once said, it takes 20 years to build a reputation and 5 mins to ruin it and if ASTRO had been playing the long game, things may have actually turned out different by now.

Or another way of putting it... ASTRO has been pissing on everyone's collective leg who isn't part of a large hospital/academic system and now there's quite a few of us out there willing to acknowledge it isn't in fact rain.

Cry wolf enough time and eventually they'll stop taking you seriously. Urology groups buying proton machines this year still probably laughing at all that ASTRO PAC effort from years ago too

Effective advocacy requires credibility. How much do they have in the eyes of CMS? This is basically the supervision regs event all over again

 

[deleted1111261]

Last i checked ACRO was still around and didn't sit there and tell CMS how dangerous general supervision might be to safely delivering radiation therapy while forgetting the small detail that critical access hospitals were general all along?

What do you think that does to the credibility of our "advocacy organization" in the eyes of CMS literally last year?

Maybe if ASTRO hadn't spent years fighting against payment bundles, CMS might have actually taken their apm proposal seriously for more than a second?

As Warren Buffett once said, it takes 20 years to build a reputation and 5 mins to ruin it and if ASTRO had been playing the long game, things may have actually turned out different by now.

Cry wolf enough time and eventually they'll stop taking you seriously. Urology groups buying proton machines this year still probably laughing at all that ASTRO PAC effort from years ago too

Effective advocacy requires credibility. How much do they have in the eyes of CMS?

Ok. Fight ASTRO then. Your call.

 

[medgator]

Ok. Fight ASTRO then. Your call.

What's there to fight?

Urorads, supervision, and now payment reform. Not a hard pattern to see. They've lost every battle.

CMS gonna CMS while ASTRO outside telling everyone they've got the situation under control.

Our specialty organization has a bad sildenafil deficiency which isn't necessarily a bad thing if your practice isn't the focus of their lobbying efforts.

A good urorads job is better than a ****ty academic satellite one and relaxation of supervision regs has helped many practitioners out there in terms of their work/life balance and QOL even if they means not being able to support all those extra Linac babysitting jobs for all those extra ASTRO-associated training programs/residents

 

[RickyScott]

Whatever happens with roapm etc, supply and demand is what effects us: our take home pay/geographic options,and this is where asto works against our common interests.
Psych looses money for hospitals, but they are compensated well with a lot of geographic flexibility.
Medonc is not a big money maker for many hospitals despite what people on this board think, but medoncs are scarce and can demand high salaries.

 

[medgator]

Whatever happens with roapm etc, supply and demand is what effects our take home pay, and this where asto works against the common good.
Psych looses money for hospitals, but they are compensated well with a lot of geographic flexibility.

Bingo. The worst thing ASTRO has done (or not done) is regarding residency expansion. All impotence is bad, but that has to have been the worst kind.

 

[RickyScott]

Bingo. The worst thing ASTRO has done (or not done) is regarding residency expansion. All impotence is bad, but that has to have been the worst kind.

If radiation didn’t generate a profit/broke even, think of what would happen to the academic workforce that largely consists of docs seeing 3 new pts a week. You wouldn’t have 3 proton centers in jacksonsville or 4 gamma knifes within 3 miles of each other in philadelphia.

 

[TheWallnerus]

We have one organization that has any sort of clout. If you want to fight them, too, that’s fine. I’m not a member and I have been publicly and vocally critical of them on social media and to their faces.

I don’t hold a view and continue to hold it until I’m blue in the face just because I want to believe a specific narrative. Yes, they messed stuff up in past, yes they have failed us (read transcript of my speech). I’m not a “splitter”. A is always good, B is always bad. Critical thinking requires us to analyze what’s happening in the moment.

Do I think that fighting ASTRO hard right now is the way to help us out of the APM disaster? I want everyone to listen to the podcast, read Join Luh’s article, read Tom Dvorak’s work, and many others. I want people writing their congressman. I’m tired of holding on to old grievances. Yes, I agree they should have been site neutral. Yes, I agree with wasted time with UroRad. You’re married right? Do you hold on to hold fights or do you try to get them to hear you and understand you?

Because of SDN, because of many voices on social media, because of engagement, they are trying to do better. Am I a member again? Not yet, but I don’t know if it will be in our best interest to fight actively against them and bring up old grudges and grievances. It gets petty and tiresome. Join us a person that I highly respect because he is the perfect example of someone who ASTRO continues to f*** over, yet he gets it - have to fight with what we have.

Anyway, 🐊 we are old friends but I think your arguments of consistently holding onto old grievances is neither healthy or forward looking. It’s just my opinion. When we get new data, new information and a common enemy, it makes more sense to collectively act against a rigged system than to stick with “what about ism” and “but remember when they did this ??”

I had a notable person in oncology offer me the first $10k to start an organization contra ASTRO. Even 100x that wouldn’t get us close to what we need to have a truly useful advocacy organization. My way forward is to do the best with what we have. “Fight with the army we have, not the army we want”.

One of the main story lines in literature and cinema is a failure to recognize an enemy or an evil (see: No Country For Old Men). And deal with it. Now I am not saying ASTRO is an enemy or evil. But after multiple times of attempting to show me who they are, I have now accepted their efforts. They truly are Big Rad Onc. ASTRO is heavily tilted toward academics, and we all know the divide between academics and non-academic in Rad Onc. It is partly what has been a downfall of our specialty. ASTRO is not kind. ASTRO is not inclusive. ASTRO can be petty and short-sighted. Its foci are mis-aimed. It consistently is asleep at the wheel on the REAL issues.

I will not fight against ASTRO. But I won't give them oxygen or money. Join Luh is a special case. The man must be a goldfish to use a Ted Lasso-ism. I respect him and I also know that he has the smarts to be changing ASTRO from the inside with subtlety and cunning. You have those too. I do not have those smarts. So all I can do is like what is outlined in the book "The Sociopath Next Door." Which is total avoidance. Sometimes that's the "healthy" move. (Sorry ASTRO that I used the words evil and sociopath. These are metaphors only. You are not really evil or a sociopath. You are just a self-serving organization made of people whose values don't align with mine.)

 

[madchemist89]

So if we write our senator or representative, what do we say? We are for payment reform etc but the apm as currently proposed isn't the right way to go? Does astro have a sample letter?

 

[deleted1111261]

So if we write our senator or representative, what do we say? We are for payment reform etc but the apm as currently proposed isn't the right way to go? Does astro have a sample letter?

Yah - they do. Let me find.

 

[RickyScott]

My hospital is not going to pay me less because of the apm. They are going to pay me less because they can find 10 other radoncs who would take my job for a lot less.

 

[deleted1111261]

One of the main story lines in literature and cinema is a failure to recognize an enemy or an evil (see: No Country For Old Men). And deal with it. Now I am not saying ASTRO is an enemy or evil. But after multiple times of attempting to show me who they are, I have now accepted their efforts. They truly are Big Rad Onc. ASTRO is heavily tilted toward academics, and we all know the divide between academics and non-academic in Rad Onc. It is partly what has been a downfall of our specialty. ASTRO is not kind. ASTRO is not inclusive. ASTRO can be petty and short-sighted. Its foci are mis-aimed. It consistently is asleep at the wheel on the REAL issues.

I will not fight against ASTRO. But I won't give them oxygen or money. Join Luh is a special case. The man must be a goldfish to use a Ted Lasso-ism. I respect him and I also know that he has the smarts to be changing ASTRO from the inside with subtlety and cunning. You have those too. I do not have those smarts. So all I can do is like what is outlined in the book "The Sociopath Next Door." Which is total avoidance. Sometimes that's the "healthy" move. (Sorry ASTRO that I used the words evil and sociopath. These are metaphors only. You are not really evil or a sociopath. You are just a self-serving organization made of people whose values don't align with mine.)

You’re 100% right and so is our amphibian friend. That being said, it becomes a binary choice, until there is a true alternative. Mentioning ACRO as an option is laughable and shows how little insight people have.

You are not hearing me say “Join ASTRO and give them your money so they can help us”. I’m saying that RO-APM is THE existential threat that we can have some control over with our voices and with help. ASTRO until recently was not a partner with regards to the labor supply issue, but again, what can they actually do? If they speak, do we keep saying “I don’t care, nah nah nah boo boo you were against UroRad and site neutral payments so your new stance is not valid”. I mean come on. Be adults. You’re both right. But, you want to be on ASTRO’s said or CMS side? Those are the two options… sorry to say.

 

[deleted1111261]

My hospital is not going to pay me less because of the apm. They are going to pay me less because they can find 10 other radoncs who would take my job for a lot less.

That is true. But at least give me 5 more years so I can FIRE and than GTFO!!

 

[Lamount]

If radiation didn’t generate a profit/broke even, think of what would happen to the academic workforce that largely consists of docs seeing 3 new pts a week. You wouldn’t have 3 proton centers in jacksonsville or 4 gamma knifes within 3 miles of each other in philadelphia.

I have trained/worked in 3 large academic departments… and have yet to experience this cushy quiet academic life I hear so much about.

 

[medgator]

I have trained/worked in 3 large academic departments… and have yet to experience this cushy quiet academic life I hear so much about.

Must not be senior faculty at a PPS-exempt place

 

[RickyScott]

I have trained/worked in 3 large academic departments… and have yet to experience this cushy quiet academic life I hear so much about.

Got to learn how to play the game. Everyone in both community and academic practice seems to be busier than average. Take a random department like Jeff, Maryland, Rush and divide new pts or on beam by number of docs and you always get some rediculously low number.

 

[Lamount]

Must not be senior faculty at a PPS-exempt place

I have had some experience in PPS exempt centers… again, not nearly as much thumb-twiddling as you would guess from reading these forums. The only ones I knew who routinely saw <4 consults a week were department chairs.

As painful as it may be for you to admit, we really aren’t all that different.

 

[RickyScott]

I have had some experience in PPS exempt centers… again, not nearly as much thumb-twiddling as you would guess from reading these forums. The only ones I knew who routinely saw <4 consults a week were department chairs.

As painful as it may be for you to admit, we really aren’t all that different.

Noticed this year during review that acr average new pt per doc was around 210. In past it had been 250

 

[Lamount]

Got to learn how to play the game. Everyone in both community and academic practice seems to be busier than average. Take a random department like Jeff, Maryland, Rush and divide new pts or on beam by number of docs and you always get some rediculously low number.

Including physician scientists and our chair, my department averages 10-15 on beam… where almost all of us are only 0.6 FTE

 

[deleted1111261]

Noticed this year during review that acr average new pt per doc was around 210. In past it had been 250

That's really interesting. From fresh out to now, I'm seeing more consults than ever. I'm not even 1.0 FTE and see patients 3 days a week and I see more than I did in 5 days when I first started. But ... way way way less on beam.

 

[medgator]

I have had some experience in PPS exempt centers… again, not nearly as much thumb-twiddling as you would guess from reading these forums. The only ones I knew who routinely saw <4 consults a week were department chairs.

As painful as it may be for you to admit, we really aren’t all that different.

See RickyScott post above. It's not a hard calculation to make and can be quite telling

 

[Lamount]

That's really interesting. From fresh out to now, I'm seeing more consults than ever. I'm not even 1.0 FTE and see patients 3 days a week and I see more than I did in 5 days when I first started. But ... way way way less on beam.

Agree. I am 0.6 and it’s a rare week that I see <6 new pts, not to mention many many re-tx

 

[deleted1111261]

Including physician scientists and our chair, my department averages 10-15 on beam… where almost all of us are only 0.6 FTE

My frenemy Potters as a chair keeps 10-15 on beam, guessing historic fractionation LOL.
Talked to a friend at Emory, keeps >20 head and necks on beam. My UAZ faculty friend keeps >20 HNCs routinely.
The folks at my alma mater tended to be quite busy. Beriwal routinely at 15-20k RVUs.
Sloan folks are busy. Satellite folks see >10 consults a week.
My friend at OKC (I know, I know, the program shouldn't exist blah blah blah) has >20+ on treat for head and neck service.

It's this splitting thing - "all community docs are like this" or "all academic docs are like this" is just not that helpful.

EDIT: Before I sound like a turncoat, trust me, the other direction is way worse. The academics talk so much smack about PP, and they do it to the residents. It is terrible. They really don't get exposed to the real world, and they think they know everything. It's fascinating.

 

[RickyScott]

See RickyScott post above. It's not a hard calculation to make and can be quite telling

Probably a selection bias on this site. low volume docs may be less engaged.

 

[Lamount]

My frenemy Potters as a chair keeps 10-15 on beam, guessing historic fractionation LOL.
Talked to a friend at Emory, keeps >20 head and necks on beam. My UAZ faculty friend keeps >20 HNCs routinely.
The folks at my alma mater tended to be quite busy. Beriwal routinely at 15-20k RVUs.
Sloan folks are busy. Satellite folks see >10 consults a week.
My friend at OKC (I know, I know, the program shouldn't exist blah blah blah) has >20+ on treat for head and neck service.

It's this splitting thing - "all community docs are like this" or "all academic docs are like this" is just not that helpful.

EDIT: Before I sound like a turncoat, trust me, the other direction is way worse. The academics talk so much smack about PP, and they do it to the residents. It is terrible. They really don't get exposed to the real world, and they think they know everything. It's fascinating.

I don’t doubt that some academics trash talk PP, but it isn’t something that I see much of personally.

 

[deleted1111261]

I don’t doubt that some academics trash talk PP, but it isn’t something that I see much of personally.

Over and over, I'd hear "that's how they do it in the community" (like it's a monolith).

One fella said "community doctors shouldn't treat head and neck cancers." Etc. etc.

This was not unique to UPMC. I'm sure people say all kinds of nonsense based on never having worked outside the tower, but hearing some anecdote about some Florida yahoo and assuming we all treat that way.

 

[elementaryschooleconomics]

I think there's a lot of selection bias when we talk about this on the internet. Many of us who are active on SDN and Twitter are early to mid career, and Medicine (especially RadOnc) is a pyramid scheme of sorts. At my residency institution, most of the senior people had found a way to have very few (<10) on beam, at the expense of the junior people (who can have between 20-30), though almost all of the busy attendings had resident or mid-level support. In the community, you'll sometimes have a "sleepy" hospital staffed by a doc from a group who's generally busier at their other sites, but this gives them a geographic advantage and is "worth it" in terms of controlling an area.

I believe @TheWallnerus has posted a couple times about the maldistribution of patients. If we take all the patients receiving radiation in a year and divide by all Radiation Oncologists, then yes, we have frighteningly low numbers. Many people can look at that number and think "I'm much busier than that, the math must be wrong". In reality, there's a cohort of us carrying a lot of patients, and a cohort of us carrying very few. I know that I, personally, far exceed the "average" numbers that @TheWallnerus has calculated. I could easily spin my experience into a tale about how RadOnc is stronger than ever, blah blah. But I know how many patients the other docs in my group have, and how many my close friends have, and know these averages to be true.

The docs I know with 5-10 on beam aren't on generally on Twitter or SDN. Those that are will definitely not be open about it (with a few exceptions).

I don’t doubt that some academics trash talk PP, but it isn’t something that I see much of personally.

You must have been in kinder environments than the bogs I've lurked. I have heard terrible things said about private practice docs - said to me when I was a resident, or said to me when I was a medical student. It was actually a big reason I wanted to leave. I felt like many faculty took better care of their egos than their patients, and I couldn't see myself spending my career around that attitude.

 

[Lamount]

Over and over, I'd hear "that's how they do it in the community" (like it's a monolith).

One fella said "community doctors shouldn't treat head and neck cancers." Etc. etc.

This was not unique to UPMC. I'm sure people say all kinds of nonsense based on never having worked outside the tower, but hearing some anecdote about some Florida yahoo and assuming we all treat that way.

The biggest issue I have had with PP in my bubble has nothing to do with physician competence but rather technology. A fair number of centers around me don’t utilize 4D and/or CBCT for definitive lung. I know of some that do use this technology and some that don’t… but many are a black box. There are lots of rural small towns where I don’t know the local docs or the tech.

I never discourage patients from getting treated locally for definitive lung but if I don’t know the group and the patient asks “would they have the exact same approach if I was treated at X?” I honestly tell them “I don’t know”. My center is well known and most people who I encounter in consult prefer to get treated with us unless I assure them it would be the same.

I know the right thing to do would be to always reach out to the local center to ask about how they do things, but there aren’t enough hours in the day and I don’t see enough of my kid as it is. I have been giving talks in some PP conferences and getting to know so great docs. Perhaps with time, I will develop a greater Rolodex of regional PPs to whom I enthusiastically refer patients.

 

[deleted1111261]

This is a really good point. Lot of old tech and non modern techniques.

 

[TheWallnerus]

Over and over, I'd hear "that's how they do it in the community" (like it's a monolith).

One fella said "community doctors shouldn't treat head and neck cancers." Etc. etc.

This was not unique to UPMC. I'm sure people say all kinds of nonsense based on never having worked outside the tower, but hearing some anecdote about some Florida yahoo and assuming we all treat that way.

On your last day of residency, you're academic.

One day later, you're in the community...

It is in this 24h transition that any human man or woman's IQ takes the biggest, most rapid decrease that has or ever will be witnessed in the history of measured IQs.

 

[RickyScott]

On your last day of residency, you're academic.

One day later, you're in the community...

It is in this 24h transition that any human man or woman's IQ takes the biggest, most rapid decrease that has or ever will be witnessed in the history of measured IQs.

You would have thought we could have avoided this precipitous drop on IQ by graduating 2000+ Aoa with 95 percentile step scores over the last 15 years.

 

[deleted1111261]

You would have thought we could have avoided this precipitous drop on IQ by graduating 2000+ Aoa with 95 percentile step scores over the last 15 years.

there was also the “dud” class that failed in 2018, but magically got smart in 2019.

This field…