ROCR

[Neuronix]

With all this talk of proton overuse, I suddenly believe in utilization review and prior auth. Maybe I’ll even try for a part time gig myself. One of the few ways that we as individuals can reign in protons.

“The enemy of my enemy is my friend.”

Deny me all you want, I will just appeal to the health plan and get it.

Muahahahahahahahaha *evil laugh and twirling of my mustache ensues*

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[Mandelin Rain]

Do we really think he has the power to shut down protons? He is simply admitting the truth that it is DOA because of proton lobby. He is not necessarily saying he disagrees with you. Getting things done takes some pragmatism. If there is more “good” to come to having them as an ally, i’ll embrace anything that helps this field at this point. Remember dont let perfect be the enemy of the good. This is the making of the sausage. You want something, proton lobby wants something. You agree on something, you find common ground and you get it passed assuming it will help the specialty (ROCR).

Not at all. I was more questioning the power of ASTRO more generally. Are they truly just a public facing limb of the proton lobby? Is that all there is at this point? Definitely seems like at the very least, the tail is wagging the dog.

 

[yesmaster]

Protons use is very appropriate and high value high efficacy at your institution @Neuronix 🙂

 

[Upgrayedd]

Wasn't going after UroRads a decade of friendly fire?

I would argue this is even worse, b/c it is "our own" applying misinformation and lies (I appreciate that is a strong word, but have you seen the literature?) to enrich themselves and their centers. It has nothing to do with patient care when you give a prostate patient a worse treatment (per existing data). It is not patient centered to have to switch a breast patient to photons midway through b/c of skin reaction. It is not patient centered to make someone pay a co-pay for a treatment that is just as good as a cheaper one.

I don't know. I feel like "closing ranks" would be coming up with a common sense policy on proton usage, not using it as a cash register.

Thanks for the thoughtful reply. The only part I disagree with is the very end. Granted; you may understand the nuances much better than myself. But, big picture; the differences between proton and community rad oncs remain small compared to other specialties trying to compensate for their ballooning costs by cutting rad onc as a whole (in a budget neutral environment).

I think you broght this up before; but our lobbying should be with radiology. Then they could be the adult in the room.

 

[RickyScott]

I think a lot of the focus on proton centers is essentially friendly fire. The major medical/governmental powers won’t be able to discern the details, and we risk loosing more ground to the ballooning costs of immunotherapy. Close ranks, thats my advise. Seems like SK is on the right track.

When you pick winners, you invite consolidation. Dropping protons from the ROCR makes nearby competing centers more valuable to the proton centers than their present owners, encouraging a sale. Not addressed at all in the model.

 

[elementaryschooleconomics]

At the end of the day I remain confused - why have any exemptions at all?

If it's truly better in terms of reimbursement, wouldn't there be a fight to ensure inclusion in the model?

ROCR is being sold as Noah's Ark. The flood of cuts are coming, this is how we survive!

But...right out the gate, we're not encouraging everyone on the Ark.

The proton lobby is going to choose the more profitable path. I support whatever the proton lobby supports.

That doesn't appear to be ROCR.

 

[NotMattSpraker]

I think a lot of the focus on proton centers is essentially friendly fire. The major medical/governmental powers won’t be able to discern the details, and we risk loosing more ground to the ballooning costs of immunotherapy. Close ranks, thats my advise. Seems like SK is on the right track.

Oh come on. Do you really believe that? If people wanted to teach policy makers about proton therapy, they would and could. Immunotherapy is way outside scope, it's paid out of another program and CMMI is simultaneously designing bundled oncology models.

If you haven't yet, I suggest all here read Mark Storey's recent blog post. He seems to be one of the only people out there with enough respect for his colleagues to have an honest discussion about proton therapy.

Why we require randomized data for protons.

In the past, some in leadership actually argued against this approach. With greater time and more hindsight, I'll try to discuss why this data is critical to the industry.

protons101.substack.com

 

[deleted1111261]

With all this talk of proton overuse, I suddenly believe in utilization review and prior auth. Maybe I’ll even try for a part time PA gig myself. One of the few ways that we as individuals can reign in protons.

“The enemy of my enemy is my friend.”

So much of trying this out was about this. I truly care about our specialty. I’m starting to see where I can make a difference.

I’ll have an interesting update soon on something that really annoys practicing ROs that they won’t have to deal with PA for (at least for our contracts)

 

[thecarbonionangle]

Assume positive intent until proven otherwise. It is possible that low risk prostate receiving 81 GyE is patient-driven in affluent areas where proton centers are located rather the clinicians routinely pushing them on the unsuspecting public.

I would hate to have the job of routinely trying to talk Jim Jimmers Jr., VP of operations at Jimmers Lexus, out of protons on a daily basis. It's too bad there's even that option.

Spot on. A lot of people love to make fun of Curt Deville for sending those messages “begging” for proton prostates. Do people really think this dude is some sort of crook? Doubtful. People are under pressure to “grow business”. The dude was railroaded. The people pushing these treatments are mostly pawns doing what their job demands of them. It isn’t some nefarious intent. Not to mention the annoying patient driven consults who are “only coming” for protons to these places. Bottomline the poor job market gives people zero options to lateral or make a move. So i try not to be so condemning of the proton pushers.

 

[Upgrayedd]

Oh come on. Do you really believe that? If people wanted to teach policy makers about proton therapy, they would and could. Immunotherapy is way outside scope, it's paid out of another program and CMMI is simultaneously designing bundled oncology models.

If you haven't yet, I suggest all here read Mark Storey's recent blog post. He seems to be one of the only people out there with enough respect for his colleagues to have an honest discussion about proton therapy.

Why we require randomized data for protons.

In the past, some in leadership actually argued against this approach. With greater time and more hindsight, I'll try to discuss why this data is critical to the industry.

protons101.substack.com

I think you may be confusing what is morally right and ethical with what is politically possible. You have to excuse some of my unfamiliarity as I am DoD/VA, and I understand that you all are very well versed on these matters (more so than myself). I simply want to point out that from my own experiences with gov leadership and rad onc; we get forgotten. And when we start having internal bickers they treat us like two children fighting. The “leaders” have been detailed on protons enough to be at the very least intentionally confused and wowed.

Politically; the time to fight protons was over the last decade; or again in the future. We don’t have the high ground right now and risk getting flanked by other budget priorities. Of course; take this with a grain of salt; I very much respect the expertise that you all bring on this and you all know far more on this than I do.

 

[deleted1111261]

I think you may be confusing what is morally right and ethical with what is politically possible. You have to excuse some of my unfamiliarity as I am DoD/VA, and I understand that you all are very well versed on these matters (more so than myself). I simply want to point out that from my own experiences with gov leadership and rad onc; we get forgotten. And when we start having internal bickers they treat us like two children fighting. The “leaders” have been detailed on protons enough to be at the very least intentionally confused and wowed.

Politically; the time to fight protons was over the last decade; or again in the future. We don’t have the high ground right now and risk getting flanked by other budget priorities. Of course; take this with a grain of salt; I very much respect the expertise that you all bring on this and you all know far more on this than I do.

Insightful and distilled. I think you're right.

I just don't know that I'm ready to give up on doing this the right way.

 

[deleted1111261]

Spot on. A lot of people love to make fun of Curt Deville for sending those messages “begging” for proton prostates. Do people really think this dude is some sort of crook? Doubtful. People are under pressure to “grow business”. The dude was railroaded. The people pushing these treatments are mostly pawns doing what their job demands of them. It isn’t some nefarious intent. Not to mention the annoying patient driven patients who are “only coming” for protons to these places. Bottomline the poor job market gives people zero options to lateral or make a move. So i try not to be so condemning of the proton pushers.

Carbon, I still don't know who you are, but I get the sense if you were in a situation that required you to "grow the business" by begging people on Doximity to send you patients, you'd probably quit - just by the tone of your posts, you don't seem to like being "told" what to do, especially if you don't believe in it.

I don't know Dr. Deville. I appreciate his writing, despite not agreeing with much of it. I am sure another proton facility or another academic center would love to have someone of his stature do something other than shill for protons.

 

[RickyScott]

At the end of the day I remain confused - why have any exemptions at all?

If it's truly better in terms of reimbursement, wouldn't there be a fight to ensure inclusion in the model?

ROCR is being sold as Noah's Ark. The flood of cuts are coming, this is how we survive!

But...right out the gate, we're not encouraging everyone on the Ark.

The proton lobby is going to choose the more profitable path. I support whatever the proton lobby supports.

That doesn't appear to be ROCR.

seems such an obvious point that someone needs to make this at the towhnall

 

[communitydoc13]

Spot on. A lot of people love to make fun of Curt Deville for sending those messages “begging” for proton prostates. Do people really think this dude is some sort of crook? Doubtful. People are under pressure to “grow business”. The dude was railroaded. The people pushing these treatments are mostly pawns doing what their job demands of them. It isn’t some nefarious intent. Not to mention the annoying patient driven consults who are “only coming” for protons to these places. Bottomline the poor job market gives people zero options to lateral or make a move. So i try not to be so condemning of the proton pushers.

The proton lobby is going to choose the more profitable path. I support whatever the proton lobby supports.

That doesn't appear to be ROCR.

@thecarbonionangle You are right of course. We shouldn't begrudge the individual docs. But the larger narrative has to be said somewhere, and this seems like the only place for that.

That an intervention, 50+ years in the making, doesn't have a clearly positive differential clinical value by the standards we apply to other interventions and is not financially viable under a case based payment model, tells you all you need to know....this is special interest and regulatory capture at work.

The docs that give the protons should know this and be motivated to establish the clinical value of what they are doing as clearly as possible. Hopefully, they are all digging deep into the physics, translational bio and dosimetry work associated with what they are giving. I do believe this is a reasonable standard to apply to a proton doc. Photons are just a bit more forgiving and the dosimetry quite a bit more established. Even a community doc like me can give photons.

ROCR is about offering some savings on the backs of community hospitals (their technical) in order to preserve a very profitable environment for very expensive and low value departments in large centers (usually academic). Given the scale, negotiating power and payor mix of radiation patients at a typical academic place without protons, I am not sure that ROCR would have a very significant impact on any academic place.

 

[deleted1111261]

@thecarbonionangle You are right of course. We shouldn't begrudge the individual docs. But the larger narrative has to be said somewhere, and this seems like the only place for that.

That an intervention, 50+ years in the making, doesn't have a clearly positive differential clinical value by the standards we apply to other interventions and is not financially viable under a case based payment model, tells you all you need to know....this is special interest and regulatory capture at work.

The docs that give the protons should know this and be motivated to establish the clinical value of what they are doing as clearly as possible. Hopefully, they are all digging deep into the physics, translational bio and dosimetry work associated with what they are giving. I do believe this is a reasonable standard to apply to a proton doc. Photons are just a bit more forgiving and the dosimetry quite a bit more established. Even a community doc like me can give photons.

ROCR is about offering some savings on the backs of community hospitals (their technical) in order to preserve a very profitable environment for very expensive and low value departments in large centers (usually academic). Given the scale, negotiating power and payor mix of radiation patients at a typical academic place without protons, I am not sure that ROCR would have a very significant impact on any academic place.

Please come to town hall and speak up.
You have so much to offer in such a well spoken way, without harshness or an edge. I think it will be received well.

 

[Neuronix]

Please come to town hall and speak up.
You have so much to offer in such a well spoken way, without harshness or an edge. I think it will be received well.

If I was planning this, I would ensure that the town hall has an hour dedicated specifically for discussion. Is that the case here?

My money is still on this post repeating itself.

That's what this is all about for politicians. Pretending that you have reached out, doing what you want anyway, and controlling the message.

ROCR

Aside from obvious issues (proton/adaptive/SGRT carve out, PPS exemption exemption, etc., lack of transparency, etc.), what are you all thinking? - case rates make a lot of sense in our world; however, prior auth cannot be the rationale - pure MCR does not have prior auth - playing with...

forums.studentdoctor.net

Fully agreed. Though it’s quite dubious any of these “town hall” or “education” sessions will allow for meaningful conversations.

I remember the RO APM educational session back when I was a resident at Astro annual. Pretty much it went like this — on the podium were the same Astro staffers who have been the face of ROCR so far. And the “Q&A” in the overpacked standing room only room was like 5 min after being talked at for 55 min.

That’s not a discussion. It’s a beat down.

I imagine more of the same at Astro annual this year based on the vague description on the FAQ page. And the town hall is a webinar format (on Teams too, worst virtual platform imo) so we’ll be restricted to typing in the chat, all muted of course, and then they can easily say “well that’s all folks” after doing politician style double talk and pivoting around all of our pointed Qs. In true lack of transparency style I bet all of our questions will be filtered so they won’t even be posted publicly on the group chat on the webinar.

I bet $100 it’s gonna be this way.

Next week we shall see.

If I’m wrong I’ll buy y’all in this forum a drink at ACRO next year (yep I meant ACRO - it’s in Orlando in 2024 then Vegas 2025 woohoo)

Would love for SK to prove me wrong by giving you your voice back at ROHub.

I'm not in a position where I can publicly question the establishment. Glad you're doing it for us.

 

[RadOncDoc21]

Please come to town hall and speak up.
You have so much to offer in such a well spoken way, without harshness or an edge. I think it will be received well.

The absolute opposite of me! I’m all about being snarky.

 

[Doctorer]

Spot on. A lot of people love to make fun of Curt Deville for sending those messages “begging” for proton prostates. Do people really think this dude is some sort of crook? Doubtful. People are under pressure to “grow business”. The dude was railroaded. The people pushing these treatments are mostly pawns doing what their job demands of them. It isn’t some nefarious intent. Not to mention the annoying patient driven consults who are “only coming” for protons to these places. Bottomline the poor job market gives people zero options to lateral or make a move. So i try not to be so condemning of the proton pushers.

No, but hypothetically, it might make me uncomfortable to be put in a situation like that. Some might be uncomfortable being pressured by administration/etc to treat patients with protons/MRI guided radiation/etc to increase revenue/business, despite photon radiation being perfectly acceptable or even preferred. That may be one of the factors in someone moving/switching jobs. Hypothetically, of course.

You don't "get to" work at Hopkins and get recognized by ASTRO, but you get to sleep better at night.

 

[RickyScott]

Spot on. A lot of people love to make fun of Curt Deville for sending those messages “begging” for proton prostates. Do people really think this dude is some sort of crook? Doubtful. People are under pressure to “grow business”. The dude was railroaded. The people pushing these treatments are mostly pawns doing what their job demands of them. It isn’t some nefarious intent. Not to mention the annoying patient driven consults who are “only coming” for protons to these places. Bottomline the poor job market gives people zero options to lateral or make a move. So i try not to be so condemning of the proton pushers.

It always comes back to the oversupply, which encourages overutilization.

 

[Ray D. Ayshun]

No, but hypothetically, it might make me uncomfortable to be put in a situation like that. Some might be uncomfortable being pressured by administration/etc to treat patients with protons/MRI guided radiation/etc to increase revenue/business, despite photon radiation being perfectly acceptable or even preferred. That may be one of the factors in someone moving/switching jobs. Hypothetically, of course.

You don't "get to" work at Hopkins and get recognized by ASTRO, but you get to sleep better at night.

on a $7000 mattress. Yes, I know exactly what you're talking about...#

 

[deleted1111261]

If you’re not spending $10k on the mattress, do you even treat dcis with 33 fx of protons, bro?

 

[Ray D. Ayshun]

If you’re not spending $10k on the mattress, do you even treat dcis with 33 fx of protons, bro?

The math 20/33 (for idc, still dont really boost my yearly dcis) and 28/44 just about works here, bc, tbh, I only dropped 6k on my mattress.

 

[medgator]

Deny me all you want, I will just appeal to the health plan and get it.

Muahahahahahahahaha *evil laugh and twirling of my mustache ensues*

Anthem’s Coverage Denial for Proton Beam Therapy OK’d by Judge

Anthem Blue Cross Blue Shield properly declined to cover a prostate cancer patient’s proton beam therapy treatment, a California judge ruled, saying the case was governed by a recent Ninth Circuit decision involving the same treatment and the same doctor.

news.bloomberglaw.com

Blue Shield won't cover controversial, pricey cancer treatment

Blue Shield of California says it won't pay for an expensive, controversial cancer treatment, despite an influx of new treatment centers focusing on proton beam therapy. | Blue Shield of California says it won't pay for an expensive, controversial cancer treatment, despite an influx of new...

www.fiercehealthcare.com

 

[RickyScott]

Anthem’s Coverage Denial for Proton Beam Therapy OK’d by Judge

Anthem Blue Cross Blue Shield properly declined to cover a prostate cancer patient’s proton beam therapy treatment, a California judge ruled, saying the case was governed by a recent Ninth Circuit decision involving the same treatment and the same doctor.

news.bloomberglaw.com

Blue Shield won't cover controversial, pricey cancer treatment

Blue Shield of California says it won't pay for an expensive, controversial cancer treatment, despite an influx of new treatment centers focusing on proton beam therapy. | Blue Shield of California says it won't pay for an expensive, controversial cancer treatment, despite an influx of new...

www.fiercehealthcare.com

If you read some of these complaints by Blue Cross or Aetnae, the insurance company makes it abundantly clear that they are not fitting the bill for the protons, but acting as a middleman with the employer actually paying.

 

[NotMattSpraker]

I think you may be confusing what is morally right and ethical with what is politically possible. You have to excuse some of my unfamiliarity as I am DoD/VA, and I understand that you all are very well versed on these matters (more so than myself). I simply want to point out that from my own experiences with gov leadership and rad onc; we get forgotten. And when we start having internal bickers they treat us like two children fighting. The “leaders” have been detailed on protons enough to be at the very least intentionally confused and wowed.

Politically; the time to fight protons was over the last decade; or again in the future. We don’t have the high ground right now and risk getting flanked by other budget priorities. Of course; take this with a grain of salt; I very much respect the expertise that you all bring on this and you all know far more on this than I do.

I totally agree with you, you are probably right that our opportunity to fight this politically has passed or maybe never even existed. But this line of reasoning does not forgive the way ASTRO is acting in my opinion. I agree with Simul that people can disagree and still respect each other, so I mean no disrespect in my prior post. I consider the lack of discussion by ASTRO executives such as Dave Adler, even when offered the opportunity to talk in private, to be personally insulting and disrespectful. If we get to a place where radiation oncologists cant critique the actions of profit-driven individuals in medicine, we have a huge problem.

I do not agree that we have to allow proton centers to lie to our patients because we do not have the high ground in oncology discourse. I have asked why it is not politically possible and radiation oncologists deserve an answer. They have given a clear answer on why PPSE must be excluded and it makes sense. I suspect I know why they have to exclude proton therapy, but they aren't brave enough to even give a bulls**t PR answer like "inclusion would harm the economic stability of the industry, which is developing a radiation modality that is beneficial to some patients". Don't forget that the NAPT publicly took this position with RO-APM. I didn't like it, but I at least respected their willingness to put their opinions on paper.

Today, I find their unwillingness to speak on it while buddying up with the NAPT and individual proton center business leaders to be very disrespectful to all radiation oncologists.

As I told Dave, we can agree to disagree, but I will abstain from supporting ASTRO, and we can go our separate ways. They are free to boost up the proton industry in secret and I am free to use our platform highlight ASTRO's lack of integrity and teach patients and colleagues the truth.

Finally, I agree with this point about assuming the best intents. As I mentioned, it is not constructive to attack treating physicians, they have very little if any control over this problem.

It's interesting, though, that these pleas for kindness always seems so one-sided. When is ASTRO going to come with kindness toward Simul? Are they going to apologize to all the anonymous members of SDN for how they have talked about them in the past? Is Dave going to apologize to me for his very rude and condescending phone call?

Time will tell. I don't have my hopes up.

 

[deleted1168505]

Cut the residency numbers in half, shut down the hellpits, then deal with the proton problem. The former is much more readily addressable and will have a larger impact on all of us in the community. Focus efforts. I'm sure ASTRO will be fine with allowing a pointless back-and-forth on protons than even uttering a syllable about resident numbers based on what I've seen so far.

 

[thecarbonionangle]

Cut the residency numbers in half, shut down the hellpits, then deal with the proton problem. The former is much more readily addressable and will have a larger impact on all of us in the community. Focus efforts. I'm sure ASTRO will be fine with allowing a pointless back-and-forth on protons than even uttering a syllable about resident numbers based on what I've seen so far.

Is there people around still who know how the programs in 1990s were closed? we have to do the same thing again. Dramatic cuts and closures. Some suggest a Salomon move, split the baby in half so nobody is upset (i.e cut all programs). I disagree with this mainly because i think we can reduce numbers while at the same time leaving programs which offer a good residency experience. Lots of emotional arguments every time i say close down the hellpits, have been attacked for these views. Anti closure arguments always: It is elitist to have a “kill list”, my friend works there, i know someone there who is good, new chair is improving things let them cook (places that have been around for decades and never improved), no don't close down my residency!, etc etc. lol

 

[RadOncDoc21]

Is there people around still who know how the programs in 1990s were closed? we have to do the same thing again. Dramatic cuts and closures. Some suggest a Salomon move, split the baby in half so nobody is upset (i.e cut all programs). I disagree with this mainly because i think we can reduce numbers while at the same time leaving programs which offer a good residency experience. Lots of emotional arguments every time i say close down the hellpits, have been attacked for these views. Anti closure arguments always: It is elitist to have a “kill list”, my friend works there, i know someone there who is good, new chair is improving things let them cook (places that have been around for decades and never improved), no don't close down my residency!, etc etc. lol

Let’s just close up all the residencies and go from there. I know I’m a “free radical.”

 

[deleted1111261]

Indiscriminate is my approach

Can have 100 positions

Each program can make their case.

Sit in a room and if no conclusion, lottery based.

 

[communitydoc13]

Please come to town hall and speak up.
You have so much to offer in such a well spoken way, without harshness or an edge. I think it will be received well.

Kind of you to say, but if you met me, you wouldn't be impressed.

Parentheticals () in person come off as patronizing and pedantic. Some folks are just meant to be anonymous keyboard warriors.

But... I do strongly believe in the value of semi-anonymous and moderated internet spaces, where there is some barrier to entry, like you are at least a med-stud interested in radonc. (If you let everyone in or don't moderate, it always becomes 4chan.)

SDN Radonc will never again be a place to express your neurosis over your 260 Step I or 6 publications at age 24, but it can become the honest place for practicing radoncs to discuss their marginal field.

Hoping that more people (particularly academics) join and share. Would love a rebuttal to my proton stance with paper links and specifics indicating why it is now safe and preferred.

 

[medgator]

Cut the residency numbers in half, shut down the hellpits, then deal with the proton problem. The former is much more readily addressable and will have a larger impact on all of us in the community. Focus efforts. I'm sure ASTRO will be fine with allowing a pointless back-and-forth on protons than even uttering a syllable about resident numbers based on what I've seen so far.

ASTRO is impotent to literally do any of it. Residency expansion, protons, payment reform etc. Everything thus far with regard to any of it has been purely reactive.

They literally had to get shamed into doing a workforce study that ended up getting watered down anyways.

Freestanding community argued for case base/fraction agnostic payment models to ASTRO decades ago which fell on deaf ears etc. Instead ASTRO thought it an appropriate use of PAC funds and resources to attack PP/urorads folks who were competing with academic centers

 

[deleted1168505]

Indiscriminate is my approach

Can have 100 positions

Each program can make their case.

Sit in a room and if no conclusion, lottery based.

That solution would make far too much sense.

I think it's fine to have a few 4-6 resident programs in the midwest. They will produce the grads needed to fill the # positions nobody else wants.
The 4-6 resident programs in the coast need to go. Then it's just a matter of giving the rest of them a reasonable haircut.

 

[deleted1111261]

The vast majority of us are aspirational - we want to rise up, make more, do more, treat more, cure more. We feel it in our bones. We don’t get mad when a UroRad opens up - good on them for offering a better treatment than surgery. At least they are doing it with the same set of rules.

Astro people and many academics are not that way. If someone getting to big, bring them down. If making a lot of money, find a way to slow that roll. Equity focus means each slice of the pizza is the same, even if that means a smaller pie. We want a bigger pie, where even the smallest slice is bigger than the “equitable” ones.

But, the special rules… the carve outs. When it’s for them, it’s all good. We should accept it. It’s actually for our own good. “Just trust us”.

No. No. No. Enough is enough

 

[NotMattSpraker]

Cut the residency numbers in half, shut down the hellpits, then deal with the proton problem. The former is much more readily addressable and will have a larger impact on all of us in the community. Focus efforts. I'm sure ASTRO will be fine with allowing a pointless back-and-forth on protons than even uttering a syllable about resident numbers based on what I've seen so far.

You are right. ASTRO behavior is not proton-specific. They refuse to act on all the issues that require selfless action by chairs and board leaders. End of the day, cutting trainees harms chairs, they have published it!

The sad thing is that the medical students are trying to correct the market on their own! Predatory chairs happily SOAP desperate medical students that know nothing about this field.

Based on my understanding of the workforce data, the number of SOAPs each year is right in the meat of the "oversupply" confidence (edit: really, the unconfidence interval, true CIs were not given ) interval for new entrants into the workforce. There is some debate to be had on this idea, but that was my take away from a deeper read of that data.

 

[deleted1168505]

The sad thing is that the medical students are trying to correct the market on their own! Predatory chairs happily SOAP desperate medical students that know nothing about this field.

If you are ever bored, look at the current roster of PGY-2s and 3s at some of the lower quality residencies on their websites. It is self-explanatory.

 

[Rad Onc SK]

I love your ROCR posts.

Frankly, ASTRO needs to say more than "it's DOA" here given the clearly biased updated payment model and ROCR exclusion. If they don't say anything more, I will have serious concerns about integrity and I'm not sure I could join the society again regardless of other actions. Their behavior on this narrow issue is disgraceful so far.

That said, I don't think its useful to name and shame individual treating physicians. Very reasonable to call out their COI, but many deal with significant pressure to treat from local leadership and its not like its so easy to go get another job these days. We also should have nuance when discussing the modality. Some patients can benefit. We don't want parents afraid to seek out proton care for their children.

Physicians and patients are most harmed by the behavior of the "proton cabal".

I think the only way forward is to educate our colleagues and patients about the truth and head this off in clinic and online on our own. More to come.

1. PPSE - 2015 GAO report didn’t phase them. A GAO report has 1000 times the impact of all the lobbying power in medicine.

2. Protons - we literally JUST went through this with RO-APM. They have a small but very effective lobby, coupled with incredible congressional support.

In the big picture, we’re going to need case rates for stability. If ROCR fails, then it’s going to be another 2-3 years before another model comes up. The case rates will be lower.

NO ONE in this lengthy thread, besides me, is discussing the Cigna MA pilot. That isn’t theoretical. That is happening right now as people type back-and-forth in this forum.

That would be, if I was reading this, what I would be focused on. Am I better with CIGNA making the decisions or with the ROCR model?

In my opinion, it’s time to be pragmatic.

 

[communitydoc13]

NO ONE in this lengthy thread, besides me, is discussing the Cigna MA pilot.

We have zero specifics regarding this. I don't know how anyone who is not subject to the pilot could even comment.

 

[deleted1111261]

We have zero specifics regarding this. I don't know how anyone who is not subject to the pilot could even comment.

You keep mentioning Cigna

If you’re in Phoenix, prominent RO, future Astro president and you don’t know - how would any of us know?

I asked OncoHealth (company I work with) and they have no idea other than what you told me.

 

[deleted1111261]

Sameer

If this stabilizes is and protects us

Why wouldn’t protonists want stabilizing and protection? Why wouldn’t Mdacc want it?

They don’t because they are worse off.

If I go to a restaurant with a menu, and they say “we have many options, but you can only have the special. It’s on sale. You’ll love it, trust us, it’s the best thing on the menu” and then you look at the other tables and many are not eating the special, what would you think?

 

[NotMattSpraker]

1. PPSE - 2015 GAO report didn’t phase them. A GAO report has 1000 times the impact of all the lobbying power in medicine.

2. Protons - we literally JUST went through this with RO-APM. They have a small but very effective lobby, coupled with incredible congressional support.

In the big picture, we’re going to need case rates for stability. If ROCR fails, then it’s going to be another 2-3 years before another model comes up. The case rates will be lower.

NO ONE in this lengthy thread, besides me, is discussing the Cigna MA pilot. That isn’t theoretical. That is happening right now as people type back-and-forth in this forum.

That would be, if I was reading this, what I would be focused on. Am I better with CIGNA making the decisions or with the ROCR model?

In my opinion, it’s time to be pragmatic.

Haha, look dude, I am being pragmatic. That doesn't mean "Let ASTRO do whatever they want with no accountability".

Im 5 years out. I've been really lucky to find an honest and supportive director so I hope I have this job forever. There is actually evidence that other private payer pilots are here, not just Cigna. I'm guessing you have heard about them. I have no info on them at all. It doesn't seem like anyone does. If my practice enters into a pilot and I'm not under NDA, Id be more than happy to discuss it with you.

I know I will have to practice the way I am allowed and will deal with models when they come. I will trust my boss to advocate for my own job as the finances of radiation oncology changes, and I will do the best I can for my patients. I know some of my early career colleagues may not be protected as these changes come, and that is sad.

If you are saying that this small proton lobby has captured ASTRO, then I won't ever be a member. I really appreciate your honesty though. Genuinely. So few seem to have the courage to offer transparency. For what it's worth, I support the majority of ROCR and my own practice will do just fine if it passes. Simul and I spent time talking about all the things we liked on our recent podcast. ASTRO have addressed zero of people's concerns so far. It has to be two-way. We will see how things go in 1 hour.

If it doesn't pass, we will adjust. This narrative that ASTRO is going to rescue the specialty with ROCR is clearly falling flat for a lot of people.

At this point, I do not know if I am better off with Cigna or ASTRO making decisions. Honestly. Medicare and Cigna both want to pay less, so we've gotten paid less. I know radiation oncologists that work for private payers and they are impacting real, positive change. I know the current president of ASTRO really well. I am not confident that he will advocate for me in my own job, out of state, better than a radiation oncologist in Cigna. That might sound crazy, but I bet many don't think so.

You really should check out Common Sense Oncology that launched last week. Doctors can be pragmatic and push back against lobbies and all this non-sense in a powerful way. There is no ASTRO or radiation oncology without radiation oncologists. It seems like people forget that sometimes.

Your current president is probably the opposite of Chris Booth though. It's going to take some major change. I will be super, super hyped if that change is you.

Thanks again for engaging. Im sure its frustrating, but it is valuable and it seems to resonate with people.

 

[CaesarRO]

Everyone asking why the proton centers wouldn't want to be included are missing the point, imho.

Of course they want to have their cake and eat it too.

Case based rate *might* stabilize prices for photon treatments, which have been getting progressive cuts compounded by falling fractions.

Protons are generally reimbursed much higher. Why not get your photons stabilized and still bill higher for protons? It can be better and more stable for photons and undercut protons are the same time.

If there was a separate ROCR for proton cases that reimbursed at proton levels I bet they'd jump on it. But that's not where the case reimbursement is going to be.

The argument "if it were the greatest thing since sliced bread then protons would want on board too" is disingenous.

 

[communitydoc13]

But that's not where the case reimbursement is going to be.

Case based reimbursement only works when it includes all comparable interventions and approaches.

Case based for me means that I may increase IMRT utilization, because it is not getting denied and at times it spares acute toxicity. (Real time planning can at times be better as well). I can deal with making less on IMRT. I am not choosing IMRT to make more money at present anyway. My personal pro-fees will be fine.

A limited case based model with exceptions is not really a case based model and only incentivizes places with multiple modalities to choose the exception.

The better question (from a clinical standpoint) is: if protons paid the same, would their utilization go up or down?

I think we know the answer.

edit: case based will also have essentially zero impact on fractionation for me.

 

[CaesarRO]

Case based reimbursement only works when it includes all comparable interventions and approaches.

Case based for me means that I may increase IMRT utilization, because it is not getting denied and at times it spares acute toxicity. (Real time planning can at times be better as well). I can deal with making less on IMRT. I am not choosing IMRT to make more money at present anyway. My personal pro-fees will be fine.

A limited case based model with exceptions is not really a case based model and only incentivizes places with multiple modalities to choose the exception.

The better question (from a clinical standpoint) is: if protons paid the same, would their utilization go up or down?

I think we know the answer.

edit: case based will also have essentially zero impact on fractionation for me.

Completely agree on every point except possibly the first. Incentivizing non-included modalities is an interesting side effect that should be brought up at the town hall if there is an opportunity.

I think proton utilization would go down if they paid the same.

I actually think many proton places would close up shop if they paid the same. That's not the situation we are in. When folks say "if proton places don't want ROCR, it's obviously a bad deal" I think there is a gaping hole in that logic. Protons get paid more, they want to continue to get paid more, so they lobby for an exception. Let's not all cut off our noses to spite our faces.

I would generally use hypofrac and would definitely increase the relative amount of IMRT usage because I think it is better for patients too.

 

[elementaryschooleconomics]

NO ONE in this lengthy thread, besides me, is discussing the Cigna MA pilot. That isn’t theoretical. That is happening right now as people type back-and-forth in this forum.

Dude.

It's because NO ONE but you knows about it.

Personally, I have seen a single email, from a conversation I'm not a participant in, originating from a friend-of-a-friend, discussing eviCore piloting payment models.

But if you want to talk about it:

ASTRO is, yet again, committing an obvious unforced error with ROCR. They are handing benefit managers, on a silver platter, a playbook for what to do, yet again. Just like with Choosing Wisely. Just like with breast hypofrac "guidelines". Just like with prostate hypofrac "guidelines".

What else needs to be talked about? How ASTRO has zero chance of actually getting ROCR through Congress because they won't get support from the Radiation Oncology community in general, ACRO in particular, and the ACR most importantly?

 

[John William Coltrane]

This guy is clearly a 100% opportunist only out for his self interests. No different to anyone else in the profession, basically just another obama esque global corporatist spewing out the same talking points with zero substance.

Why do people even bother caring?

The 750k or GTFO guy is right. If you want any semblance of autonomy and control over your career just work rurally and live wherever you want.

 

[Ray D. Ayshun]

I stick with astro bc the hospital pays my dues and every 4 yrs or so I have the opportunity to head to San Antonio and eat tacos by an open sewer system while I commiserate with old friends.

 

[RickyScott]

I stick with astro bc the hospital pays my dues and every 4 yrs or so I have the opportunity to head to San Antonio and eat tacos by an open sewer system while I commiserate with old friends.

Hospital pays would pay mine as well, but I save them the money.

 

[sirspamalot]

This guy is clearly a 100% opportunist only out for his self interests. No different to anyone else in the profession, basically just another obama esque global corporatist spewing out the same talking points with zero substance.

Why do people even bother caring?

The 750k or GTFO guy is right. If you want any semblance of autonomy and control over your career just work rurally and live wherever you want.

I don't know about the Obama part all politicians are out for themselves. They all suck and some are downright seditious rapist pigs it turns out.

But as to the #.. Yessir this is the way.

 

[sirspamalot]

I stick with astro bc the hospital pays my dues and every 4 yrs or so I have the opportunity to head to San Antonio and eat tacos by an open sewer system while I commiserate with old friends.

A bunch of posts seem to have been deleted here.. Please tell me that is not happening..


DISREGARD.. THREAD SEPARATED BY MODS..

 

[CaesarRO]

A bunch of posts seem to have been deleted here.. Please tell me that is not happening..

Possibly broken out into the other threads by mods?