ROCR

[Lamount]

Nobody has ever assuaged my proton concerns and I have never met a good clinician who wasn't willing to abandon protons personally for all adult malignancies.

I’ll buy you a drink sometime and you can decide if I am a good clinician 😀

---

Members don't see this ad.

 

[RickyScott]

Just wanted to bring this up again. Per cms, freestanding radiation oncologists over utilize to offest declining cms payments. What will happen when that gets taken away from them and some of those overutilization bandits hit the job market as pts on beam are cut in half? Wont impact Join Luh and that doc from Ten- both feel their collections will be stabilized/improved with ROCR. A tight job market is in Constantine Mantz's interest. He certainly hasnt benefited from th 200-300% increase in CMS technical fees to hospitals. (Salaries are probably Genesis cares biggest expense! He would love to see them go down.)

The rest of us employed docs are going to be hugely impacted by an even tighter job market as patient load is cut in half. No wonder ASTRO didnt feature an employed doc on the panel, despite them making up a supermajority of the workforce.

https://www.hhs.gov/sites/default/files/CMS-5527-P.pdf
Page 51 of the rationale/proposal for RO-APM:

"Our analysis showed that from January 1, 2015 through December 31, 2017, HOPDs furnished 64 percent of episodes nationally, while freestanding radiation therapy centers furnished the remaining 36 percent of episodes. We intend to make this data publically accessible in a summary-level, de-identified file titled the “RO Episode File (2015-2017),” on the RO Model’s website. Our analysis also showed that, on average, freestanding radiation therapy centers furnished (and billed for) a higher volume of RT services within such episodes than did HOPDs. Based on our analysis of Medicare FFS claims data from that time period, episodes of care in which RT was furnished at a freestanding radiation therapy center were, on average, paid approximately $1,800 (or 11 percent) more by Medicare than those episodes of care where RT was furnished at a HOPD. We are not aware of any clinical rationale that explains for these differences, which persisted after controlling for diagnosis, patient case mix (to the extent possible using data available in claims), geography, and other factors. These differences also persist even though Medicare payments are lower per unit in freestanding radiation therapy centers than in HOPDs. Upon further analysis, we observed that freestanding radiation therapy centers use more IMRT, a type of RT associated with higher Medicare payments, and perform more fractions (that is, more RT treatments) than HOPDs."

 

[sirspamalot]

Wake up sheeple. ASTRO and it's leadership will die on the hill to protect it's own.

You are an afterthought.

Like UBS bank ..

"us before you."

And when you are scrambling to work and the masses of formerly employed W2s are like rats trying to get out of the bucket... Remember.. ASTRO will be polite.

"we're sorry...". (south park style)

 

[NotMattSpraker]

The rest of us employed docs are going to be hugely impacted by an even tighter job market as patient load is cut in half. No wonder ASTRO didnt feature an employed doc on the panel, despite them making up a supermajority of the workforce.

I think you are right about all your comments, but I don’t think it was intentional to feature community PP over community employed.

I suspect the intention was that they were not academic, these were “community physicians” who do not (on a superficial level) benefit from the ROCR exclusions.

 

[RickyScott]

I think you are right about all your comments, but I don’t think it was intentional to feature community PP over community employed.

I suspect the intention was that they were not academic, these were “community physicians” who do not (on a superficial level) benefit from the ROCR exclusions.

None of them are hurt by the ROCR.

 

[NotMattSpraker]

None of them are hurt by the ROCR.

Well Join was 1% down but was optimistic about the future 😃

I don’t know, obviously I was not involved haha. I just the sense many at ASTRO still view things a “academic or private practice” so I’m not sure there is an intention to not include employed non-academic.

 

[RickyScott]

Well Join was 1% down but was optimistic about the future 😃

I don’t know, obviously I was not involved haha. I just the sense many at ASTRO still view things a “academic or private practice” so I’m not sure there is an intention to not include employed non-academic.

He seems to be a good guy, but I bet if he was employed and thought about, he would be opposed.

 

[NotMattSpraker]

He seems to be a good guy, but I bet if he was employed and thought about, he would be opposed.

Yea, he advocates a lot for “small community” and rural, I’m hesitant to label his practice haha. He has a ton of experience with policy across multiple orgs and had great comments at ROAPM time so I look forward to more of his thoughts.

You may be right. There are a ton of really good points here about the impact this may have on employed physicians, the job market, and consolidation. I thought their discussion of consolidation on yesterdays webinar was kind of a nonsense answer to the concerns raised here. That’s just my initial opinion and hope to discuss this more on accelerators.

ASTRO might earn a lot of trust and support if they recognized and addressed the concerns in this thread, but I’m not getting my hopes up.

 

[communitydoc13]

I’ll buy you a drink sometime and you can decide if I am a good clinician 😀

I'm sure you're a great doc.

But, If I offered you a major grant to do fundamental proton work, really really fundamental dosimetry, phantom, cell culture, variation in populations regarding RBE ratio type stuff. Let you keep your same salary for the next 10 years and told you you had to use photons to treat all your lungs and livers during that time frame (I'd let you use the present proton machine for 24Gy CSI on kids).

```would you feel bad about it, or would you be like "F yeah!"

 

[sirspamalot]

I'm sure you're a great doc.

But, If I offered you a major grant to do fundamental proton work, really really fundamental dosimetry, phantom, cell culture, variation in populations regarding RBE ratio type stuff. Let you keep your same salary for the next 10 years and told you you had to use photons to treat all your lungs and livers during that time frame (I'd let you use the present proton machine for 24Gy CSI on kids).

```would you feel bad about it, or would you be like "F yeah!"

What if I told you.. There is no ROCR spoon...

 

[medgator]

What if I told you.. There is no ROCR spoon...

 

[IonsAreOurFuture]

Please send these comments to that ASTRO “feedback” email. No idea what will happen to them but at least they were sent then. They are great comments.

I too am wondering why this guarantees stability?

As one of the growing group of employed rad oncs, I’m worried what decreased technical will do to my life as a cog haha.

There is no guarantee of stability in life, except maybe death and taxes, right?

 

[Lamount]

I'm sure you're a great doc.

But, If I offered you a major grant to do fundamental proton work, really really fundamental dosimetry, phantom, cell culture, variation in populations regarding RBE ratio type stuff. Let you keep your same salary for the next 10 years and told you you had to use photons to treat all your lungs and livers during that time frame (I'd let you use the present proton machine for 24Gy CSI on kids).

```would you feel bad about it, or would you be like "F yeah!"

It would be fun, no doubt. For the time being, I wouldn’t mind availing myself of protons for the thymic carcinoma, or IIIC NSCLC where VMAT gets me a V20 of 42%.

Some jobs call for a screwdriver, others call for a drill. No need to forsake one for the other when both are available.

 

[communitydoc13]

It would be fun, no doubt. For the time being, I wouldn’t mind availing myself of protons for the thymic carcinoma, or IIIC NSCLC where VMAT gets me a V20 of 42%.

Some jobs call for a screwdriver, others call for a drill. No need to forsake one for the other when both are available.

Yeah, I got you.

I just want our government to act rationally and our professional organizations to advocate for rational payment reform.

ASTRO doesn't want me to be incentivized to use IMRT over 3D or complex planning. Or to be incentivized for longer fractionation schedules. I understand.

But they do want to incentivize choices towards protons, perhaps even proton center growth. Or at least, they are not worried about this.

This, in the setting of the data that we have (or don't) and the peculiarities of proton toxicity.

Farcical.

The feds should also know that the standard of a "better plan" on a treatment planning platform is a terrible standard for choosing protons in general (not to say you aren't thinking deeper than this).

Perhaps ASTRO could just factor in the presumably judicious present use of protons and adaptive RT into what the case based reimbursement should be? Pay everything the same, but let protons and adaptive raise all ships? Then trust the docs to use the more expensive strategy only when they see clinical benefit.

Wonder what the cost analysis of that would be.

That would be rational.

 

[Rad Onc SK]

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

You might have the best job in rad onc

 

[medgator]

You might have the best job in rad onc

1-2/3 for most of us, but Simul may have hit that perfect trifecta

 

[sirspamalot]

You might have the best job in rad onc

Negative Ghost Rider... The bank account is full (3.5 day work week)..

Callsign: #

 

[deleted1111261]

The heart and home and all emotional cups are full #infinity

 

[Lamount]

Yeah, I got you.

I just want our government to act rationally and our professional organizations to advocate for rational payment reform.

ASTRO doesn't want me to be incentivized to use IMRT over 3D or complex planning. Or to be incentivized for longer fractionation schedules. I understand.

But they do want to incentivize choices towards protons, perhaps even proton center growth. Or at least, they are not worried about this.

This, in the setting of the data that we have (or don't) and the peculiarities of proton toxicity.

Farcical.

The feds should also know that the standard of a "better plan" on a treatment planning platform is a terrible standard for choosing protons in general (not to say you aren't thinking deeper than this).

Perhaps ASTRO could just factor in the presumably judicious present use of protons and adaptive RT into what the case based reimbursement should be? Pay everything the same, but let protons and adaptive raise all ships? Then trust the docs to use the more expensive strategy only when they see clinical benefit.

Wonder what the cost analysis of that would be.

That would be rational.

Not unreasonable suggestions. In my opinion, the ideal payment approach would be to compensate the physician proportional to the effort necessary. Cases that need protons likely need more effort (implying correlation, not causation). The question is... how can the need for effort be quantified to payers honestly and efficiently?

 

[deleted1111261]

I had a case recently for H+ and was going to deny - the doctor was very friendly about it. I asked if patient was going on study. She said “well that won’t change anything”. I said it most certainly does. She enrolled patient, sent the info, and case was approved. Part of this is doing the legwork - even the evil PA guy believes in science and we have an ability to use a waiver if we have proof of enrollment and an NCT #

 

[RickyScott]

I strongly advise anyone in practice for a few years to do a small amount of pa work. Pay sucks, but you learn so much. Key is to do it for just a handful of hours per week for several months.

 

[communitydoc13]

Not unreasonable suggestions. In my opinion, the ideal payment approach would be to compensate the physician proportional to the effort necessary. Cases that need protons likely need more effort (implying correlation, not causation). The question is... how can the need for effort be quantified to payers honestly and efficiently?

Sweet sentiment, but I can't see this working in any regard. I hope the feds don't believe that they are doing this when they assign value.

2 OTVs is more effort than 1.
2 isocenters more effort than 1.
C-section more effort than not (maybe?)
Surgery is likely more concerted effort than anything else always.
AC is more effort than TC.
Sim more effort than clinical set-up for skin.

We do have codes for extraordinary cases and special physics work. (Re-irradiation, etc).

Payors should be concerned with outcomes. Medicare lets you bill for time regarding patient encounters, which is fair, as time spent with patient has value IMO (surprisingly human take by CMS).

From a technical standpoint, outside of duration of treatment (more treatments and smaller fractions), more effort seems strongly correlated with more risk.

We don't want to promote more risk (although sometimes it is necessary).

Don't see how one could ever have both case based payment and effort based payment. (I'm in favor of case based payment BTW).

 

[Lamount]

Sweet sentiment, but I can't see this working in any regard. I hope the feds don't believe that they are doing this when they assign value.

2 OTVs is more effort than 1.
2 isocenters more effort than 1.
C-section more effort than not (maybe?)
Surgery is likely more concerted effort than anything else always.
AC is more effort than TC.
Sim more effort than clinical set-up for skin.

We do have codes for extraordinary cases and special physics work. (Re-irradiation, etc).

Payors should be concerned with outcomes. Medicare lets you bill for time regarding patient encounters, which is fair, as time spent with patient has value IMO (surprisingly human take by CMS).

From a technical standpoint, outside of duration of treatment (more treatments and smaller fractions), more effort seems strongly correlated with more risk.

We don't want to promote more risk (although sometimes it is necessary).

Don't see how one could ever have both case based payment and effort based payment. (I'm in favor of case based payment BTW).

I mean, it is certainly possible… but it requires a competent coding system created by disinterested experts and approved by well-intentioned bureaucrats. It’s about as likely as all of the air spontaneously assembling on the other side of the room… but there is a nonzero chance.

I bet i can rattle off one-liners and you could “rank” the difficulty of creating a plan and delivering the treatment. What makes a lung case take 30 min vs 90 min to plan? Everyone on this forum knows exactly which cases should pay more.

Perhaps we should just bill by the hour like attorneys…

Bet the hospital would think twice about making me do those damn modules every year lol

 

[RickyScott]

A

I strongly advise anyone in practice for a few years to do a small amount of pa work. Pay sucks, but you learn so much. Key is to do it for just a handful of hours per week for several months.

It’s actually one of the reasons I joined sdn. It quickly became apparent that all is not well with this field. Yes, there is an occasional bad apple trying for a mammosite boost after imrt for dcis, but far more prevalent are academic centers in the “choosing wisely grey zone” . First case, was a top 3 center requesting 28 fractions of protons for a small asymptomatic sagital sinus meningioma (stereo would probably give you better plan). Plenty of protons for Gleason 6 prostate cancer and whole breast protons for small postmenopausal UOQ left breast cancers.
The experience brings home that academic centers are operating in a full court press for profit mode. 5-10 years ago this was not obvious, nor was it widely known that many of these same centers had negotiated rates with insurers 3-10 x cms.

(Medical oncology and pharmacy are transparent abt prices drugs and profit motive. Astro and many of these centers fraction and modality shame desipite being the worst abusers)

 

[deleted1111261]

The cases I see from academic centers are egregious.

 

[deleted1168505]

Astro and many of these centers fraction and modality shame desipite being the worst abusers)

I watched it week 1 of residency. Taking pride in delivering 8 Gy x 1 with an AP-PA field to a spine met because the greedy PP would use IMRT in 10 fractions. Now they have protons. Hah. What's best for the patient was probably 10 fractions IMRT all along.

 

[RickyScott]

I watched it week 1 of residency. Taking pride in delivering 8 Gy x 1 with an AP-PA field to a spine met because the greedy PP would use IMRT in 10 fractions. Now they have protons. Hah. What's best for the patient was probably 10 fractions IMRT all along.

And no reason to almost ever treat the spine ap/pa. Also Academic centers selectively deploy hypofract for patients they know will have transportation issues.

 

[sirspamalot]

And no reason to almost ever treat the spine ap/pa. Also Academic centers selectively deploy hypofract for patients they know will have transportation issues.

8 in1? My god man think of the lost Proton billing opportunity.. You will not get promoted with this poor billing attitude!

 

[RickyScott]

8 in1? My god man think of the lost Proton billing opportunity.. You will not get promoted with this poor billing attitude!

The issue is that when you add up the number of patients on beam divided by number of docs at these centers, the average per doc sucks. Yes, there are academics who have a lot of rvus or grant funding, but they are a Pareto 20%. Huge number seeing 3-4 new pts/wk so when they see a pt, there is a strong pressure to meet rvu targets. Even the absolute laziest docs, or those that believe they deserve a vastly reduced load because they wrote 40 seer papers, when they are forced to see an actual pt are going to “make it count” rvu wise.

I really get the sense that overutilization is promoted by over hiring. We are not like other specialties - like im-where the supply of pts is infinite, so if doc wants more pts, just open more office hrs.

 

[communitydoc13]

The experience brings home that academic centers are operating in a full court press for profit mode.

Maybe some of the academic docs on here can speak to the pressures they feel regarding maximizing reimbursement?

I live far away from any MAYO clinic and I know MAYO has one of the most equitable payment structures out there for docs. Still, I have seen multiple RA plans with IGRT for extremity bone mets come from these places. (I live where people retire, so I get to see a lot of prior plans). I doubt the doc gets reimbursed for this, so what is the rationale? Have they already negotiated case based rates with some payors and think there is value to this approach?

In my opinion (not the best informed regarding this), many academic places were markedly underbilling in the mid 2000s. (Just hadn't caught on how to bill properly for IMRT/IGRT type work that was becoming SOC for many definitive cases) but had become remarkable financially conscious by the early 2010s. This correlated with massive expansion (both of clinical departments and residency programs).

The cynic in me believes that there was a generation of radonc chairs that benefited from this, some of whom have been able to graduate from our field and become corporate academic leaders. (Big academia is very corporate at this point).

I feel like my training program, at a very research focused institution, is markedly more conscious of payment than I am as a community doc with a PSA.

 

[deleted1111261]

Oh, I always do IGRT for pretty much every thing. Getting paid for it or not doesn't matter.

Todd Scarborough explained rationale a few years ago, Sushil stated the same rationale recently.

IGRT is one of the best things about modern RO.

 

[RickyScott]

Oh, I always do IGRT for pretty much every thing. Getting paid for it or not doesn't matter.

The great Todd Scarborough explained rationale a few years ago, Sushil stated the same rationale recently.

IGRT is one of the best things about modern RO.

Igrt prevents mis administration and (theoretically 2ndry malignancies, by confining radiation to treated area, not spreading it around due to setup uncertainties)

 

[communitydoc13]

Igrt prevents mis administration and (theoretically 2ndry malignancies, by confining radiation to treated area, not spreading it around due to setup uncertainties)

Oh, I always do IGRT for pretty much every thing. Getting paid for it or not doesn't matter.

Hmm, I don't know here. I also IGRT almost everything, because keeping treatment volumes down, even in the palliative setting, matters some for acute toxicity or heme toxicity in the pelvis, abdomen, thorax and head and neck regions.

But RA for an extremity bone met? Come on. More integrated dose, more low dose bath (including from imaging). Never ever seen meaningful fibrosis from palliative doses in these areas. They are not sparing bone like in sarcoma.

Maybe just me.

SDN crew is diverse.

 

[RickyScott]

Hmm, I don't know here. I also IGRT almost everything, because keeping treatment volumes down, even in the palliative setting, matters some for acute toxicity or heme toxicity in the pelvis, abdomen, thorax and head and neck regions.

But RA for an extremity bone met? Come on. More integrated dose, more low dose bath (including from imaging). Never ever seen meaningful fibrosis from palliative doses in these areas. They are not sparing bone like in sarcoma.

Maybe just me.

SDN crew is diverse.

surface guidance is an option, but the main benefit with igrt is catching some type of set up mid administration that occurs 1/1000+ . If 2nd malignancy is a concern, you don’t want that 300cgy /per fraction randomly being floated around a 1 cm cross section of body around the target due to setup variability. A cone beam is less than 1cgy with almost all that dose being absorbed on the surface.

In 2007, when we 1st started using kv/cbct, caught 2 potential misadministrations within first 3 months.

 

[deleted1168505]

but had become remarkable financially conscious by the early 2010s. This correlated with massive expansion (both of clinical departments and residency programs).

The cynic in me believes that there was a generation of radonc chairs that benefited from this, some of whom have been able to graduate from our field and become corporate academic leaders. (Big academia is very corporate at this point).

This is basically why I am a rad onc now, the expansinon of training spots during that time gave me a window into a very competitive field. It's like chars went to a seminar in 2008 or so and all came out with the exact same three step plan to success:

1. Acquire local PPs and turn into satellites
2. Expand residency program
3. Cut salaries

Then you're on your way to the next big thing!

 

[RickyScott]

This is basically why I am a rad onc now, the expansinon of training spots during that time gave me a window into a very competitive field. It's like chars went to a seminar in 2008 or so and all came out with the exact same three step plan to success:

1. Acquire local PPs and turn into satellites
2. Expand residency program
3. Cut salaries

Then you're on your way to the next big thing!

May not be intentional but something like natural selection where these are the best steps to achieve maximum profit, which is their real mission despite “nonprofit” status.

 

[sirspamalot]

May not be intentional but something like natural selection where these are the best steps to achieve maximum profit, which is their real mission despite “nonprofit” status.

It's always about the money

#

 

[communitydoc13]

surface guidance is an option, but the main benefit with igrt is catching some type of set up mid administration that occurs 1/1000+ . If 2nd malignancy is a concern, you don’t want that 300cgy /per fraction randomly being floated around a 1 cm cross section of body around the target due to setup variability. A cone beam is less than 1cgy with almost all that dose being absorbed on the surface.

In 2007, when we 1st started using kv/cbct, caught 2 potential misadministrations within first 3 months.

Not arguing about the IGRT. I'll IGRT almost anything to reduce treatment volume.

It's the RA in this setting that I don't get. Particularly if it costs more.

If it's not an SBRT or reirradiation case, my palliative extremity cases are getting AP/PA typically.

To each their own. Apparently MAYO will also choose RA (at least in 2/2 cases that I got to see).

As an aside, 2nd malignancies are weird and I don't believe there is a monotonic correlation between dose and risk.

 

[sirspamalot]

Not arguing about the IGRT. I'll IGRT almost anything to reduce treatment volume.

It's the RA in this setting that I don't get. Particularly if it costs more.

If it's not an SBRT or reirradiation case, my palliative extremity cases are getting AP/PA typically.

To each their own. Apparently MAYO will also choose RA (at least in 2/2 cases that I got to see).

As an aside, 2nd malignancies are weird and I don't believe there is a monotonic correlation between dose and risk.

RA?

Also how many of you use VisionRT and are successful billing for it? Was supposed to eliminate tattoos but with PriorA.. Hospital says we can't do something if we dont bill for it. And I don't want to charge my poor patients who can't afford the extra cost not covered by insco.

"then you can't do it"

Well..

I give the same response the entrapped leader at bastogne did:

NUTS.

 

[RickyScott]

I missed the RA. At least 5-7years ago on mednet,ken Oliver stated that mayo receives 60k for ra. Should be quite a bit higher now.

That’s not appropriate unless oligo. One strategy to maximize RA revenue: constantly scan the patient and hope that one or 2 Mets slightly precede the others, justifying treating oligo disease- sounds like mskcc does this.

 

[deleted1111261]

Hmm, I don't know here. I also IGRT almost everything, because keeping treatment volumes down, even in the palliative setting, matters some for acute toxicity or heme toxicity in the pelvis, abdomen, thorax and head and neck regions.

But RA for an extremity bone met? Come on. More integrated dose, more low dose bath (including from imaging). Never ever seen meaningful fibrosis from palliative doses in these areas. They are not sparing bone like in sarcoma.

Maybe just me.

SDN crew is diverse.

Definitely diverse view points - it took me a while to get to where I am now on IGRT. I started at Banner in 2018 and they did it on every bone met, drove me nuts.

I think integrated dose concerns are over stated (there is some recent article about IMRT and second malignancy).

When I do rotational/VMAT it's only if it is a non standard dose. I do a lot of 12-16 Gy in 1 or 25/5 for bone mets.

 

[deleted1111261]

If it was the same reimbursement / cost to system, what would you do for a mid femur met, non-surgical, but has widespread disease, so we are not treating for cure, just pain relief.

I would do VMAT and probably 16/1, per Anderson paper.

 

[RickyScott]

If it was the same reimbursement / cost to system, what would you do for a mid femur met, non-surgical, but has widespread disease, so we are not treating for cure, just pain relief.

I would do VMAT and probably 16/1, per Anderson paper.

What would happen to your patients on beam?

 

[deleted1111261]

What would happen to your patients on beam?

Well

Though we track wRVUs, the global revenue is what my superiors care about. I explained to death when I got here about SRS/SBRT, HypoFx, technical fees, etc. I said don't even look at on beam number. Just look at what we produce. That being said, I always like more rather than less

 

[deleted1168505]

Well

Though we track wRVUs, the global revenue is what my superiors care about. I explained to death when I got here about SRS/SBRT, HypoFx, technical fees, etc. I said don't even look at on beam number. Just look at what we produce. That being said, I always like more rather than less

Do they share the actual collection numbers with you?

Is it legal for a hospital to compensate an employed doc in actual collections (the way a PP usually does) instead of RVUs with a conversion factor? Or if the hospital does the billing is that not permitted?

 

[deleted1111261]

Do they share the actual collection numbers with you?

Is it legal for a hospital to compensate an employed doc in actual collections (the way a PP usually does) instead of RVUs with a conversion factor?

Yeah, they share all financial with me. Tech and prof.

I wish we were busier, b/c other than that, this is the best group of people I've worked with - admin and such.

I don't know the answer to that. I can ask my CEO. He knows all the technicalities.

 

[communitydoc13]

I would do VMAT and probably 16/1, per Anderson paper.

Good reference. I looked up the paper. Still a little nervous giving 16 Gy x1 to mid femur (this is like 60Gy in 30 and is close to fracture inducing dose). Paper had a minority of extremity lesions and may have had very few extremity lesions getting 16Gy. 1 fracture in the 16 Gy group, don't know story on it.

That 16Gy x 1 for a RCC met to the bony pelvis though, baller.

 

[RickyScott]

Yeah, they share all financial with me. Tech and prof.

I wish we were busier, b/c other than that, this is the best group of people I've worked with - admin and such.

I don't know the answer to that. I can ask my CEO. He knows all the technicalities.

It sounds like you have a more progressive administration, but I get the sense that most hospitals are more like my own: technical collections are never shared and admins would jump at the chance to cut physician FTE if we were leaving routinely at 1:00 or supervision was relaxed. Staff hours would be flexed and we would lose them to larger systems.

 

[Ray D. Ayshun]

Do they share the actual collection numbers with you?

Is it legal for a hospital to compensate an employed doc in actual collections (the way a PP usually does) instead of RVUs with a conversion factor? Or if the hospital does the billing is that not permitted?

Yes, it's legal. Was the way of my old PSA. They charged 5% for collections. I make more with rvu based pay.

 

[deleted1111261]

It's just really interesting, just musing about how I got here. I got what I thought was a "dream job" in PNW - big management opportunity, leadership role, lotta money. It wasn't for me.

(I can't say much here, as it is quite the story - one day I will in the near future - but some people there still read my posts and then send it to my former cancer center director - this happened when I had stopped working there, lol, they got mad that I posted a news article listing a former employee's salary; bless their heart, as my Arkansas-native wife says; Hi, if you are reading, hope it stopped raining!).

Anyway, I quit on the phone on a Friday evening, my son's 1st birthday. Felt amazing, like skydiving without a parachute, b/c I didn't have a job lined up, but I knew things work themselves out. A few days prior to quitting, I call this recruiter to do some locums in Port Huron; find out he's a family friend of a friend, basically. He golfs with one of my dad's buddies. I did a "virtual interview" and after talking to the retiring doc, he says to me "You're a family man, two kids, like me, this is perfect for you, trust me, son." And I did.

They asked me what I made base, offered a little bit more, added some vacation days that I wanted and some CME. I googled the company, Prime Healthcare. For-profit, not the best media coverage, so I was anxious. But, I got here, and I found that the staff was high quality and nice, even though doc was 70, he had a mid 30s doc check every IMRT plan (they basically split the clinic), so though the fraction numbers were higher than I was used to, the contouring was very well done. The administrators are lovely people. The CEO - I look up to him, he is very kind and intelligent and helping me learn higher level admin concepts. We are a profitable hospital, RO revenue is up 2.7x since I got here; the hospital 3 miles away (that is currently cleaning our clock in oncology) is losing a $1m a month. We got a great urologist starting in a few weeks and hopefully a breast surgeon. The volume is picking up, but I still had some bandwidth, so I picked up the PA project and that has been really fun. And, Prime has me hired internally as a consultant to help some of the other RO departments in the network.

I feel like I am getting what I want out of my career. But, I want to be just a bit busier - like get into a routine of 12-15 on beam. Once we are there, I feel like I have my real "dream job", not the "chairman-lite" thing I tried to do.

I did zero research on this job. I didn't visit. I spoke to people for about 30 minutes total. And, it may have been the best decision I ever made.