ROCR

[Rad Onc SK]

That is a really dismissive answer, SK.

We are paying that salary, man. I don't care who they use to review the contract. The membership has been frustrated with the direction of the leadership for a long time. Criticism of her leads to being banned for serving. This sounds more like a dictatorship than a servant-leader.

A similarly small specialty (but larger than ours) - dermatology - Elizabeth Usher makes $660k. So, how are we in line? 90k less for the CEO of a larger specialty?

I’m sorry, I don’t understand how my answer was dismissive. I can tell it’s an answer that you did not like

That’s fine, but please don’t tell me I dismissed you. Because that’s not true.

I’ve been on the board of my local Ronald McDonald House since 2013. I’m currently board chair.

I served on the ASTRO’s Board Directors from 2014 to 2018. As a reminder, I’m not on the board right now.

I have served on the board of ASCO cancerlinq for four years and I’m currently on the board of regents for my sons high school.

I do have nonprofit experience, and nonprofit experience that goes beyond ASTRO. I reviewed multiple 990s and been a part of multiple CEO compensation reviews.

I’m not saying this to impress anyone. I’m saying this to tell people that I do have experience in doing this. I think I understand how this works in the nonprofit space better than the average individual.

There are firms which review nonprofit companies, and can give benchmark salary data. There are many factors that go into these benchmarks. They include employee satisfaction surveys and member satisfaction surveys. ASTRO staff has a high opinion of Laura Thevenot. She has promoted a culture that is inclusive and safe. The culture is diverse. There is a high level of functioning in the core aspects of the ASTRO business. The finances of Astro are in good shape. Member reviews have been very favorable. I don’t know how many people here are ASTRO members. I don’t think it’s a very high percentage. But by definition, you have to be an Astro member to participate in the membership survey. Again, membership surveys, like the staff surveys have been favorable. Finances are good. All of this warrants a favorable review by the Board of Directors.

When I was on the ASTRO Board, we obtained an outside firm to review nonprofits in the medical space. They gave us multiple data points with salaries from 990s. They look at the size of the organization, number of employees, annual revenues, and many more factors beyond that.

When you take all of that into account, Laura is paid fairly.

I told you when I came on SDN that I would answer the questions to the best of my ability. I would listen to criticisms, and as long as they weren’t personal, I would stay. There are some questions being asked, which have to do with confidentialities, specifically to the RUC. I cannot answer those because it jeopardizes Astros status at the RUC. Questions I can answer, I will. I also recognize that this is a public forum. I’m not going to get into a back-and-forth with people. There are people who is opinions I will never change.

All I can do is try to listen and answer questions when I can. I recognize that’s not going to be good enough for many posters here. I personally can live with that. I’m gonna do my best. That’s all I can do.

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Members don't see this ad.

 

[Rad Onc SK]

Resource-based relative value scale - Wikipedia

en.wikipedia.org

Important read for anyone not familiar with RUCs and value setting. The link to RUC within this one is excellent, from the link:

Before the 1992 implementation of the Medicare fee schedule, physician payments were made under the "usual, customary and reasonable" payment model (a "charge-based" payment system).

All weird as hell of course. I am not convinced that RUCs acting as de-facto rate setters or CMS acting as de-jure rate setters do any calculations that are more meaningful than setting rates by "usual, customary and reasonable" standards. Clearly CMS (appropriately) has a will to pay less and RUCs are incentivized to preserve or increase payments. The government employs a lot of really smart boffins, who I'm sure believe that they can determine value analytically. While I'm not sure that this is possible ever, the whole RUC process certainly makes it impossible.

It is also true that we clearly pay too much for healthcare overall.

I do believe that within our specialty at least (probably many specialties), the narrative between CMS and these RUCs is largely that there are rogue and greedy private practice docs overcharging CMS and that this is what needs to be rooted out and not rewarded and is costing big money. Meanwhile, large institutions with enormous administrative overhead and economies of scale are exempted from much of the cost cutting (and often serve private patients disproportionately).

The critique here regarding ASTRO is relating payment to setting, picking winners within a field or encouraging high value for interventions only provided at large centers that really have very little value demonstrated in terms of outcomes. At some point, institutions become too large and all of us are hurt. There's got to be a curve out there somewhere relating value to institution size. It's not going to be monotonic.

Culturally, the FED is going to relate to Mayo or MD Anderson more than they are to private practice docs. They are also clearly valuing these larger places preferentially over smaller community hospitals. ASTRO seems to be willing to go along with this regarding therapeutic radiation (encouraging it even). It's a very bad calculation IMO.

In the mid-1980s, customary prevailing and reasonable (CPR) was reformed. RBRVS won out over a modification of CPR. President Reagan’s 1986 cobra legislation led to the concept of MPFS. And President Bush 41s OBRA legislation lead to RBRVS.

HOPPS went into a different system.

For the first, 15 to 18 years (starting in 1992), in our field, MPFS far outpaced HOPPS.

In the mid-2000s, hospital-based IMRT was less than $300 a fraction. It was $700 a fraction in freestanding.

The rapid adoption of IMRT, spurred heavily by urorads, brought unwanted scrutiny from the RUC. This led to multiple draconian cuts. In my opinion, the cuts would’ve been significantly worse without a strong defense at the RUC.

By 2010 or so, depending where you lived, hospital-based reimbursement for IMRT had surpassed free-standing reimbursement for IMRT.

The cuts have continued. Especially to the technical component. 77427 has remained largely untouched, largely due to work led by ASTRO. If anyone wants to debate that off-line, I’ll be happy to do it at ASTRO or another meeting. But I was there for this. That is a true statement. 77427 has been under attack for a long time. It remain steady at roughly $190 and for many physicians working on PC, it remains their number one or number two charge.

IMPO, It is going to be hard to maintain the current codes that valuation, especially in the freestanding setting.

 

[Rad Onc SK]

Sameer is a thoughtful guy and he handles criticism well, and often times convinces me that I should take a different view of things.
This is not the same as CEO of a publicly traded company - that's why I'm more critical of it.

My point is that many of us think that $750k is a lot of money. Many of us think that the society does not serve us well.
If the only answer to this is - "well some benchmarking company said this is the number" - I think it doesn't really sit well.

I'm not saying to lower by any specific number. I was curious what other societies pay - Derm is still competitive and so it was just an example. I am certain IM society is paid more. If I have time later, I can look up some other small specialty societies.

$750k is a lot of money. It a lot more than I make. But I don’t run a $25 million per year organization with 100+ employees either.

That being said, as you know, I treat pediatric patients. That’s the bulk of my practice. If we follow some of the logic in this thread forward, can I really justify my salary verses that of a pediatric oncologist?

My view is that we are fairly compensated. I also think that pediatric specialists, especially the Pediatric Oncologists I work with, are woefully under compensated.

Nonprofit CEOs have their own pay scale. I don’t know where LT sits, I’m sure it’s above the 50th percentile and probably around the 75th percentile. She has a very good track record of performance and has 20 years of experience. Those things, in my opinion, justify her being at the higher end of the salary range.

Again, that’s my opinion. I respect the fact that reasonable people can disagree. All I can do is give you my logic. People can take it or leave it as they please.

 

[Rad Onc SK]

CMS reimbursement is down significantly adjusted or unadjusted for inflation over the past 10 years, but large radonc departments are still earning more than ever due to price gouging from monopolistic leverage. Sure, they could have earned even more if cms reimbursement was stable and kept pace with inflation, just like they can earn more by deliberately oversupplying the market with residents.

Codes and reimbursement have become completely disconnected from salaries and the job market in the setting of widespread employment. As noted, the ROCR can improve reimbursement but will almost certainly hurt the job market/mobilty/salaries etc.

You make some very good points here.

Under RBRVS, starting in 1992 in for 15 to 20 years there after, being in private practice was terrific. There’s been a lot of stress in the past 12 years or so.

RUC has been tough on our field and HOPPS has been fair.

On the commercial side, hospital consolidation has led to a stronger bargaining position, as you noted. Smaller centers do not enjoy the same position.

20 years ago, life in freestanding centers was incredible. I still think it’s good today, but if you compare it to 20 years ago, clearly, it’s not as good. Conversely, things are pretty good in the hospital setting today. Much better than they were 20 years ago. The pendulum always goes back-and-forth. But it’s hard to Accept that when you’re in the midst of a timeframe where it’s not as great to be in private practice as it was in the past. I do get that. I don’t live it on a day-to-day basis like many of you, but I do get it.

 

[RickyScott]

You make some very good points here.

Under RBRVS, starting in 1992 in for 15 to 20 years there after, being in private practice was terrific. There’s been a lot of stress in the past 12 years or so.

RUC has been tough on our field and HOPPS has been fair.

On the commercial side, hospital consolidation has led to a stronger bargaining position, as you noted. Smaller centers do not enjoy the same position.

20 years ago, life in freestanding centers was incredible. I still think it’s good today, but if you compare it to 20 years ago, clearly, it’s not as good. Conversely, things are pretty good in the hospital setting today. Much better than they were 20 years ago. The pendulum always goes back-and-forth. But it’s hard to Accept that when you’re in the midst of a timeframe where it’s not as great to be in private practice as it was in the past. I do get that. I don’t live it on a day-to-day basis like many of you, but I do get it.

I know exactly one radonc now who owns a linac. 10-15 years ago, ownership in the technical component was not uncommon. I would guess 80%+ of us are employed.

 

[Rad Onc SK]

CMS reimbursement is down significantly adjusted or unadjusted for inflation over the past 10 years, but large radonc departments are still earning more than ever due to price gouging from monopolistic leverage. Sure, they could have earned even more if cms reimbursement was stable and kept pace with inflation, just like they can earn more by deliberately oversupplying the market with residents.

Codes and reimbursement have become completely disconnected from salaries and the job market in the setting of widespread employment. As noted, the ROCR can improve reimbursement but will almost certainly hurt the job market/mobilty/salaries etc.

I know I’ve written this before. Case rates are coming. Whether people like it or not. ASTRO could sit this one out and let the insurance companies and/or CMMI dictate the case rates. People will almost certainly like those rates. Much less than a proposal championed by ASTRO and the other Radiation Oncology centric specialty societies.

Right now, there’s an Medicare advantage pilot for case rates going on in the Phoenix metro. Again, this is not a concept. This is happening right now, as we are going back-and-forth in this thread. The pilot is being done with some of the large private practices. I haven’t been able to get more information because I suspect NDA’s have been signed. I don’t know what those reimbursement rates are. I’m friends with a lot of private practice doctors. Even the practicing physicians don’t know what the rates are,…or they are not telling me

 

[Neuronix]

Nonprofit CEOs have their own pay scale. I don’t know where LT sits, I’m sure it’s above the 50th percentile and probably around the 75th percentile.

Not hard to Google

Chief Executive Officer (CEO), Non-Profit Organization Salary in 2024 | PayScale

The average salary for a Chief Executive Officer (CEO), Non-Profit Organization is $109,291 in 2024. Visit PayScale to research chief executive officer (ceo), non-profit organization salaries by city, experience, skill, employer and more.

www.payscale.com

The ASTRO CEO at 750k is well above 75th percentile no matter which site you use.

 

[Neuronix]

I don't think this is a great strategy, especially if you are younger and have 20+ years left in this field.

ASTRO says nothing about resident oversupply, and that's what impacts our future the most as junior radiation oncologists.

RO docs are still envied by other docs. We got so far out ahead when RBRVS went into effect in 1992 and we got another boost in the early to mid 2000's with IMRT (77418 and 77301). TBH, I don't see something like that coming down the pike anytime soon. We have been able to protect those codes, along with some from the 1990's, pretty well. ASTRO RUC is admired by other specialties. I know many people on this forum won't believe that, but it's true. ASTRO is the only society to send a team to each RUC, the last I checked. This is expensive. But it keeps us aware of the landscape and helps us build relationships.

All this talk about reimbursement is just the sport of kings. My chairman knows what he collects off my efforts and wants to increase his margin. Meanwhile, my future is dictated by supply, demand, and 25th percentile on a salary survey.

 

[RickyScott]

I know I’ve written this before. Case rates are coming. Whether people like it or not. ASTRO could sit this one out and let the insurance companies and/or CMMI dictate the case rates. People will almost certainly like those rates. Much less than a proposal championed by ASTRO and the other Radiation Oncology centric specialty societies.

Right now, there’s an Medicare advantage pilot for case rates going on in the Phoenix metro. Again, this is not a concept. This is happening right now, as we are going back-and-forth in this thread. The pilot is being done with some of the large private practices. I haven’t been able to get more information because I suspect NDA’s have been signed. I don’t know what those reimbursement rates are. I’m friends with a lot of private practice doctors. Even the practicing physicians don’t know what the rates are,…or they are not telling me

If bundled rates are coming, shouldn’t Astro be vocal about existential threats to the job market? They were preparing the RORC at the same time as the workforce report.
Also, most radoncs feel that oversupply is huge problem compared with other similarity sized specialties. Astro tells us that is not. Almost by definition, they do not represent our primary interests and concerns.

 

[sirspamalot]

If bundled rates are coming, shouldn’t Astro be vocal about existential threats to the job market? They were preparing the RORC at the same time as the workforce report.
Also, most radoncs feel that oversupply is huge problem compared with other similarity sized specialties. Astro tells us that is not. Almost by definition, they do not represent our primary interests and concerns.

"We're doing the best we can, our CEO is paid fairly for her outstanding track record over 20 years and I know everyone won't agree with me.. but you're going to take this **** sandwich, chew it slowly, savor the taste and swallow it all because it's the same as you've always gotten and will always get. "



PS. Until you stop paying ASTRO dues it's gonna be the same flavor. But.. With a new shiny wrapper!

 

[grenz]

3.34% CMS Paycut 2024 - The White Coat Investor Forum - Investing & Personal Finance for Doctors

https://www.aha.org/news/headline/2023-07-13-cms-issues-cy-2024-physician-fee-schedule-proposed-rule Has it always been like this? According to most surveys i think incomes in general increase over time but I have no clue how that's possible if medicare enacts cuts every single year

forum.whitecoatinvestor.com

Reading other physicians’ despair over continued cuts confirms my belief that ASTRO is on to something. It’s not perfect, but it would provide financial stability to rad onc practices. Financial predictability=more likely to feel confident hiring new docs

 

[RickyScott]

3.34% CMS Paycut 2024 - The White Coat Investor Forum - Investing & Personal Finance for Doctors

https://www.aha.org/news/headline/2023-07-13-cms-issues-cy-2024-physician-fee-schedule-proposed-rule Has it always been like this? According to most surveys i think incomes in general increase over time but I have no clue how that's possible if medicare enacts cuts every single year

forum.whitecoatinvestor.com

Reading other physicians’ despair over continued cuts confirms my belief that ASTRO is on to something. It’s not perfect, but it would provide financial stability to rad onc practices. Financial predictability=more likely to feel confident hiring new docs

large radonc departments are earning more money not less because of insurance leverage/consolidation. That’s largely why the money spent on health care increased so much over the past 15 years. (It’s the prices stupid).
With the incentive to move to hypofractionated Prostates and breast at 5 fractions and palliative at one, do you really think that is going to lead to hiring.

 

[madchemist89]

Prostate and breast at 5 fractions will decimate most practices volume and reimbursement, especially if not currently hypofractionating. Lots of departments continue to use number on treatment as a marker of productivity. In fact, we work harder now for less patients on treatment as new starts need to be higher. For a physician, a new start is much more work than a few more weeks of treatment. If you go from conventional to hypofrac, you are looking at about a 1/3 reduction in number on treatment. Going to 5 would crush your volume, expect no hiring, expect firing.

 

[grenz]

large radonc departments are earning more money not less because of insurance leverage/consolidation. That’s largely why the money spent on health care increased so much over the past 15 years. (It’s the prices stupid).
With the incentive to move to hypofractionated Prostates and breast at 5 fractions and palliative at one, do you really think that is going to lead to hiring.

Under ROCR, a lot of clinics that are doing the right thing on breast hypofractionation will be net positive or neutral on revenue, and there will be more certainty of what their finances will look like long-term. That’s a set-up for a positive hiring environment. Some of the shadier practices in Florida probably won’t do well, but what new grad dreams of working for ******* Cancer center anyway?

 

[grenz]

Prostate and breast at 5 fractions will decimate most practices volume and reimbursement, especially if not currently hypofractionating. Lots of departments continue to use number on treatment as a marker of productivity. In fact, we work harder now for less patients on treatment as new starts need to be higher. For a physician, a new start is much more work than a few more weeks of treatment. If you go from conventional to hypofrac, you are looking at about a 1/3 reduction in number on treatment. Going to 5 would crush your volume, expect no hiring, expect firing.

Are you arguing against ROCR? Because the sensitivity to fractionation is way more of a FFS problem, not ROCR since revenue is tied to new starts.

 

[RickyScott]

Are you arguing against ROCR? Because the sensitivity to fractionation is way more of a FFS problem, not ROCR since revenue is tied to new starts.

Let’s say the ROCR reimburses twice as much as FFS: my hospital will treat everyone in either 5 or one fraction, close the department and satellite at 1:00 and happily keep the money. Some of us will go part time, and the last thing we would ever do is hire. Our salaries would go down as now all those sketchy Florida radoncs you mentioned hit the job market.

 

[TheWallnerus]

Let’s say the ROCR reimburses twice as much as FFS: my hospital will treat everyone in either 5 or one fraction, close the department and satellite at 1:00 and happily keep the money. Some of us will go part time, and the last thing we would ever do is hire. Our salaries would go down as now all those sketchy Florida radoncs you mentioned hit the job market.

overheard in the room where ROCR committee was ironing out the plan…

“We will all make about the same amount of money but we can start working a lot less than we already do!”

Truth be told this was going to happen with APM also. I kind of would like to have seen widespread adoption of 5 fraction breast in America. Tyler Durden, rock bottom, and all that.

 

[grenz]

Let’s say the ROCR reimburses twice as much as FFS: my hospital will treat everyone in either 5 or one fraction, close the department and satellite at 1:00 and happily keep the money. Some of us will go part time, and the last thing we would ever do is hire. Our salaries would go down as now all those sketchy Florida radoncs you mentioned hit the job market.

I don’t know about you, but with dosimetry stuff, consults, f/us, the occasional special procedure, I work until 4-5pm regardless of what the machine is doing. I don’t see why machine hours would significantly influence employment. I get that some low volume centers, the physician FTE is influenced by machine hours, but they probably don’t account for a large % of national rad onc FTEs

 

[NotMattSpraker]

I mean I’d still be seeing patients even if the machine ended earlier. I’d probably beef up my follow up clinic and take more interest in special procedures like brachy or radiopharm

I think the models imply that this is what would happen, no? “RVU inflation”

But if utilization is flat or down, then that means you need less radiation oncologists per departments.

You beefing up is going to be rough for new graduates then?

 

[Ray D. Ayshun]

What does "beef up my follow up clinic" mean? Bring patients in for no reason?

 

[Neuronix]

I don't believe this concept that we'll make the same for less work.

Employers expect us to be working 9-5 or more, and when we're not working it, they will either expect more work per MD to fill the work week or cut our salaries to part-time. This will create less need for rad oncs and worsen the already bad job market.

If there was a dearth of radiation oncologists, sure we could negotiate this to our benefit. But there's an oversupply with no end in sight, so this isn't going to happen.

 

[Mandelin Rain]

I don't believe this concept that we'll make the same for less work.

Employers expect us to be working 9-5 or more, and when we're not working it, they will either expect more work per MD to fill the work week or cut our salaries to part-time.

 

[RickyScott]

I don't believe this concept that we'll make the same for less work.

Employers expect us to be working 9-5 or more, and when we're not working it, they will either expect more work per MD to fill the work week or cut our salaries to part-time. This will create less need for rad oncs and worsen the already bad job market.

If there was a dearth of radiation oncologists, sure we could negotiate this to our benefit. But there's an oversupply with no end in sight, so this isn't going to happen.

abso- f--g lutely. When our satellite is slow and ending at 1-2, like today, I stick around. Administration would explode if i went home. Punctuality, working at least 8 hours, excessive documentation, getting along with staff- those are the most important traits in a physician to an administrator. (probably replaced the 3 As)

 

[Mandelin Rain]

I have way too much hope tied up in Fran Drescher getting highly compensated rank and file professionals a long needed raise in this country.

What the AMA and specialty medical orgs can't accomplish, maybe The Nanny can.

 

[deleted1111261]

abso- f--g lutely. When our satellite is slow and ending at 1-2, like today, I stick around. Administration would explode if i went home. Punctuality, working at least 8 hours, excessive documentation, getting along with staff- those are the most important traits in a physician to an administrator. (probably replaced the 3 As)

They really make you stay there?

 

[Mandelin Rain]

They really make you stay there?

When you're their employee, they can make you do a lot of things.

Lately, there's been a groundswell on this board suggesting that employed work is better in many ways than PP or PSA arrangements where you're your own boss. While there's pros and cons to all approaches, all employed docs are always one admin change away from being miserable/happy. Admins change like the wind. Be careful out there.

 

[RickyScott]

They really make you stay there?

No, but it would look really bad if I left. Then they will get pretextual on my a—- you didn’t sign off on a dictation in 24 hrs, secretary complained you didn’t greet her etc. suddenly there will be a problem with 101 things. Everything needs to be 100% perfect, and it never is.
Otherwise you should be doing your time like all the other doctors. Maybe you should be sitting on some more committees if you have so much free time?

 

[deleted1111261]

Ugh. I don't like that, at all.

Prime Health runs lean, though. We send people home all the time. But, that's good b/c most of our staff does not want to work 40 hours (me included!)

 

[sirspamalot]

No, but it would look really bad if I left. Then they will get pretextual on my a—- you didn’t sign off on a 3 dictation in 24 hrs, secretary complained you didn’t greet her etc. suddenly there will be a problem with 101 things. Everything needs to be 100% perfect, and it never is, if you are leaving early frequently. Otherwise you should be doing your time like all the other doctors. Maybe you should be sitting on some more committees if you have so much free time?

Your first problem was to become a W2 employee..

1099 for lyfe.

 

[sirspamalot]

I don’t know about you, but with dosimetry stuff, consults, f/us, the occasional special procedure, I work until 4-5pm regardless of what the machine is doing. I don’t see why machine hours would significantly influence employment. I get that some low volume centers, the physician FTE is influenced by machine hours, but they probably don’t account for a large % of national rad onc FTEs

Found the ASTRO mole

 

[sirspamalot]

When you're their employee, they can make you do a lot of things.

Lately, there's been a groundswell on this board suggesting that employed work is better in many ways than PP or PSA arrangements where you're your own boss. While there's pros and cons to all approaches, all employed docs are always one admin change away from being miserable/happy. Admins change like the wind. Be careful out there.

#

 

[sirspamalot]

What does "beef up my follow up clinic" mean? Bring patients in for no reason?

You win this month's ASTRO Mole Hunter award.

(family guy narrator voice)

ASTRO. Just make it up with more follow ups.

 

[RickyScott]

Ugh. I don't like that, at all.

Prime Health runs lean, though. We send people home all the time. But, that's good b/c most of our staff does not want to work 40 hours (me included!)

We shouldn’t do the bare minimum. Face time is Flair!

 

[deleted1111261]

I’m W2. I’m leaving after last patient done. 1ish.

 

[RickyScott]

Large hospital departments are making more than ever even with cms. ROCR very well could be an attempt to further cheapen labor by the same people who overexpanded residencies.

 

[Mandelin Rain]

I have way too much hope tied up in Fran Drescher getting highly compensated rank and file professionals a long needed raise in this country.

What the AMA and specialty medical orgs can't accomplish, maybe The Nanny can.

 

[metallica81788]

abso- f--g lutely. When our satellite is slow and ending at 1-2, like today, I stick around. Administration would explode if i went home. Punctuality, working at least 8 hours, excessive documentation, getting along with staff- those are the most important traits in a physician to an administrator. (probably replaced the 3 As)

I cannot stand this grade school stuff. If I'm done my work and patients are finished, I'm gone.
My old hospital employed job was super micromanaging about that and my clinic schedule, can't say I miss it.
If someone truly needed to be on site for "emergencies" (that don't really exist), then we should have 24/7 in house call.

Now, my job is busy enough to where I'm there until at least 4-430pm vast majority of the time anyway so it doesn't matter. Plus I am solo at a freestanding and the machine almost never finishes before 4pm
But you best believe I'm taking advantage of any 30-60 minutes early I can get out.

 

[Mandelin Rain]

We (as docs) very much have a perception problem in this country.

The general public largely conflates "health care costs" with "doctors' salaries" thinking they move in a 1:1 ratio together.

Obviously, nothing could be further from the truth. Not sure how to message that widely.

"We ceded all control over healthcare and the money associated with it long ago," seems like it's not a winner.

Still, most docs I know are increasing upset with shrinking salaries while providing UHC shareholders, BMS execs, and hospital CEOs with all the monetary value of our work. Going to take some drastic moves to change the conversation.

 

[deleted1168505]

I am reading all of this about ROCR. How would this affect one's decision to transition from a very busy, very hypofrac practice to a W2 low volume lifestyle friendly hospital practice with salary guarantee? The downsides I am seeing would be that ROCR would cause the hospital to eat into the PC to try and maintain margins and cut my salary or that it would have benefitted the PP so much that it would have been worth staying purely from a financial standpoint.

I am 1099 for a multispecialty PP (not rad onc owned, but some have partial tech buy in) for a fixed daily rate. Very high volume (>90tile), lots of hypofrac, comp is basically 75tile-ish (owners are taking some pro). Unclear if I ever will have buy-in or be able to collect full pro. My autonomy is very low as the owners decide everything. Kind of like being an indefinite locums at one site.

I am considering an employed W2 position at a rural hospital (solo). Guaranteed base and RVU factor around the 75th percentile without cap. Very lifestyle friendly, remote work OK if not needed on site, leave when done, etc. Everybody there seems great and I think it will be a good fit professionally. Seems like a no-brainer, same pay but with benefits for far less work, more autonomy, and better lifestyle.

Am I stupid for considering leaving PP with this coming down the pipe? Would ROCR change the calculus in terms of long-term stability on this?

Your first problem was to become a W2 employee..

1099 for lyfe.

I am 1099. Self employment tax sucks. From a tax standpoint, it is worse than W2 + pretax benefits. There is very little I can shelter through my LLC without overtly breaking the law. Maybe if you are only doing locums you can expense some travel (travel you wouldn't be paying anyway for if you worked at a single site), but if you are working at a single site, I don't understand how 1099 is better. Even if you are 1099 (with or without a PSA), the hospital still "owns" you in that they can terminate your contract whenever they want. I hear this a lot, but having done both, I feel like 1099 is over-hyped.

A satisfying upside to it is you can stash your earnings earmarked for quarterly estimated taxes in a high yield savings account earning 5% these days before turning it over to the IRS. This gets you about an extra 2.5% a year. Nice, but overall a drop in the bucket.

Employers expect us to be working 9-5 or more, and when we're not working it, they will either expect more work per MD to fill the work week or cut our salaries to part-time. This will create less need for rad oncs and worsen the already bad job market.

This is an effect of oversupply in desirable areas. This is obviously nonsense and does not fly in hard-to-recruit locations. ASTRO should directly make an effort to address this very clear elephant in the room.

 

[TheWallnerus]

I don’t know about you, but with dosimetry stuff, consults, f/us, the occasional special procedure, I work until 4-5pm regardless of what the machine is doing. I don’t see why machine hours would significantly influence employment. I get that some low volume centers, the physician FTE is influenced by machine hours, but they probably don’t account for a large % of national rad onc FTEs

This is called being intentionally obtuse (thanks Andy Dufresne)

 

[TheWallnerus]

I am reading all of this about ROCR. How would this affect one's decision to transition from a very busy, very hypofrac practice to a W2 low volume lifestyle friendly hospital practice with salary guarantee? The downsides I am seeing would be that ROCR would cause the hospital to eat into the PC to try and maintain margins and cut my salary or that it would have benefitted the PP so much that it would have been worth staying purely from a financial standpoint.

I am 1099 for a multispecialty PP (not rad onc owned, but some have partial tech buy in) for a fixed daily rate. Very high volume (>90tile), lots of hypofrac, comp is basically 75tile-ish (owners are taking some pro). Unclear if I ever will have buy-in or be able to collect full pro. My autonomy is very low as the owners decide everything. Kind of like being an indefinite locums at one site.

I am considering an employed W2 position at a rural hospital (solo). Guaranteed base and RVU factor around the 75th percentile without cap. Very lifestyle friendly, remote work OK if not needed on site, leave when done, etc. Everybody there seems great and I think it will be a good fit professionally. Seems like a no-brainer, same pay but with benefits for far less work, more autonomy, and better lifestyle.

Am I stupid for considering leaving PP with this coming down the pipe? Would ROCR change the calculus in terms of long-term stability on this?



I am 1099. Self employment tax sucks. From a tax standpoint, it is worse than W2 + pretax benefits. There is very little I can shelter through my LLC without overtly breaking the law. Maybe if you are only doing locums you can expense some travel (travel you wouldn't be paying anyway for if you worked at a single site), but if you are working at a single site, I don't understand how 1099 is better. Even if you are 1099 (with or without a PSA), the hospital still "owns" you in that they can terminate your contract whenever they want. I hear this a lot, but having done both, I feel like 1099 is over-hyped.

A satisfying upside to it is you can stash your earnings earmarked for quarterly estimated taxes in a high yield savings account earning 5% these days before turning it over to the IRS. This gets you about an extra 2.5% a year. Nice, but overall a drop in the bucket.



This is an effect of oversupply in desirable areas. This is obviously nonsense and does not fly in hard-to-recruit locations. ASTRO should directly make an effort to address this very clear elephant in the room.

I think take the the rural job, but you should have explored S-corp’ing instead of 1099’ing

 

[deleted1168505]

I think take the the rural job, but you should have explored S-corp’ing instead of 1099’ing

Thanks. If I stay I will switch the tax election to s-corp. I don't hear a lot of people leaving PP for hospital employed, and while there are a lot of suboptimal things about PP, it is for-profit physician-owned at the end of the day. I think this may be a unique situation and wanted to make sure I wasn't missing something with ROCR. I feel sorry for those above working for large systems in big cities where all professional autonomy has been stripped and are basically owned labor from 8-5 like a factory employee. I guess they will make them clean the bathrooms if the OTVs are done until the whistle blows at 5.

 

[Mandelin Rain]

I am reading all of this about ROCR. How would this affect one's decision to transition from a very busy, very hypofrac practice to a W2 low volume lifestyle friendly hospital practice with salary guarantee? The downsides I am seeing would be that ROCR would cause the hospital to eat into the PC to try and maintain margins and cut my salary or that it would have benefitted the PP so much that it would have been worth staying purely from a financial standpoint.

I am 1099 for a multispecialty PP (not rad onc owned, but some have partial tech buy in) for a fixed daily rate. Very high volume (>90tile), lots of hypofrac, comp is basically 75tile-ish (owners are taking some pro). Unclear if I ever will have buy-in or be able to collect full pro. My autonomy is very low as the owners decide everything. Kind of like being an indefinite locums at one site.

I am considering an employed W2 position at a rural hospital (solo). Guaranteed base and RVU factor around the 75th percentile without cap. Very lifestyle friendly, remote work OK if not needed on site, leave when done, etc. Everybody there seems great and I think it will be a good fit professionally. Seems like a no-brainer, same pay but with benefits for far less work, more autonomy, and better lifestyle.

Am I stupid for considering leaving PP with this coming down the pipe? Would ROCR change the calculus in terms of long-term stability on this?

I honestly think physician satisfaction/burnout is very closely associated with autonomy. There are low autonomy PP-adjacent jobs (sounds like you're in one) and high autonomy employed jobs (sounds like the one you're considering). All this can change quickly, however.

I doubt ROCR will change your pay substantially in either.

As always, call the doc who left the job you're considering to get some insight, and beware of the high-turnover, low-volume employed job with the dreaded 2-year guarantee with onerous non-compete and year-3 renegotiation.

 

[RickyScott]

Just to belabor the point. Suppose cms decided to reduce proffesional fees to zero or a slight negative- we actually have to pay cms to treat patients. Would that really impact employed docs? The hospital departments would still be way ahead of where they were 20 years ago and their profit will continue to accelerate. Medoncs make very little off proffesional billing 5-6k rvus. The supply of radoncs is what impacts our salary and this move will put more radoncs on the job market.

 

[Mandelin Rain]

Quick question re: ROCR.

Set aside the specifics of the legislation for a second, and consider a more basic question.

It's obvious that ASTRO believes they have a clear mandate to pursue (or impose, depending on how you look at it) sweeping legislation on behalf of the entire specialty, but do the members/non-members with boots on the ground agree?

 

[RickyScott]

Quick question re: ROCR.

Set aside the specifics of the legislation for a second, and consider a more basic question.

It's obvious that ASTRO believes they have a clear mandate to pursue (or impose, depending on how you look at it) sweeping legislation on behalf of the entire specialty, but do the members/non-members with boots on the ground agree?

hell, same people unilaterally decided to expand resident numbers. none of us were consulted.

 

[deleted1168505]

Quick question re: ROCR.

Set aside the specifics of the legislation for a second, and consider a more basic question.

It's obvious that ASTRO believes they have a clear mandate to pursue (or impose, depending on how you look at it) sweeping legislation on behalf of the entire specialty, but do the members/non-members with boots on the ground agree?

I am not an ASTRO member and have never been.
If they would make a clearly defined plan to address the wanton racket of residencies selfishly flooding the job market then I would join tomorrow.
Not gently praising programs that cut a slot here or there.
Reduce the number of residents by 50%. Shut superfluous programs down. Rip the band aid off.

The interests of program chairs and the vast majority of clinicians in America are not aligned. ASTRO has clearly sided with the academics even if it's just by ignoring and feigning ignorance.

Enough. Stop overtraining. Stop filling residency spots with FMGs, mid career switchers, anybody with a pulse, etc. This is killing the specialty and not just because of numbers. Refusing to address it is implicitly supporting it. I will never be a part of ASTRO until this changes.

 

[Mandelin Rain]

I think the legitimacy threshold to lobby for fundamental changes and impositions that impact the entire field should be a pretty high bar. I'm not sure ASTRO has crossed that bar.

 

[sirspamalot]

I am not an ASTRO member and have never been.
If they would make a clearly defined plan to address the wanton racket of residencies selfishly flooding the job market then I would join tomorrow.
Not gently praising programs that cut a slot here or there.
Reduce the number of residents by 50%. Shut superfluous programs down. Rip the band aid off.

The interests of program chairs and the vast majority of clinicians in America are not aligned. ASTRO has clearly sided with the academics even if it's just by ignoring and feigning ignorance.

Enough. Stop overtraining. Stop filling residency spots with FMGs, mid career switchers, anybody with a pulse, etc. This is killing the specialty and not just because of numbers. Refusing to address it is implicitly supporting it. I will never be a part of ASTRO until this changes.

SK has left the building..



(tips hat, waves and steps out of Pleasantville aka SDN)

TIME TO WAKE UP LIKE IT OR NOT

 

[thecarbonionangle]

I am not an ASTRO member and have never been.
If they would make a clearly defined plan to address the wanton racket of residencies selfishly flooding the job market then I would join tomorrow.
Not gently praising programs that cut a slot here or there.
Reduce the number of residents by 50%. Shut superfluous programs down. Rip the band aid off.

The interests of program chairs and the vast majority of clinicians in America are not aligned. ASTRO has clearly sided with the academics even if it's just by ignoring and feigning ignorance.

Enough. Stop overtraining. Stop filling residency spots with FMGs, mid career switchers, anybody with a pulse, etc. This is killing the specialty and not just because of numbers. Refusing to address it is implicitly supporting it. I will never be a part of ASTRO until this changes.

I see no sign that the perennial hellpit warm body SOAP issue will ever be resolved. Keep in mind recent ASTRO president was “chair” of a program at WVU literally nobody needed or wanted and has mostly been filled year after year outside the match. There are many other hellpits which go unfilled sometimes skip a year and hellpits which have lowered their standards so much just to fill “anyone” so they are not on SOAP and congratulate themselves years after year for “matching”. Hellpit list is well known. You know the list.