So would you advise rising M4s to enter this field at this point?

[seper]

Doing peer-to-peer discussions is a reasonably useful skill for graduating residents.

---

Members don't see this ad.

 

[Reaganite]

I do reviews and a lot of the hate here is misguided! Reviewers can only exercise so much judgment. At the end of the day we are beholden to the health plan guidelines. It doesn't matter what we think--if a guidelines says a particular treatment is never covered, there's almost nothing we can do. We are hired to enforce the healthplan guideline. For us to overturn a denial, there has to be some kind of wiggle room in the guideline itself. For example, some guidelines will say exceptions exist under certain circumstances and a comparative DVH is required. In those circumstances, the approval is at our discretion. Otherwise, we have to follow the guideline. Sorry. That being said, I'm always amazed at how little some rad oncs are willing to "think outside the box." OK, I can't approve SBRT, but nothing is stopping you from doing some other kind of highly conformal hypofractionated treatment. Is it really that much worse?

 

[medgator]

. It doesn't matter what we think--if a guidelines says a particular treatment is never covered, there's almost nothing we can do. We are hired to enforce the healthplan guideline.

I've seen that happen before.

Which begs the question of why hire a rad onc to do the p2p calls in the first place if nothing can be overturned as a result of that call? Easy enough to just send what is and is not covered to the treating physician and let them break the news to the patient

 

[maruchan]

I am glad, that despite being labeled as a “troll”, I stimulated discussion. So let me break down your points.

First, I am not sure why my specialty is relevant to the discussion. The point of contention is “Will radonc be around in 100 years”.

So let’s look at the year 1917. At that point, many essential aspect of medicine have not been invented. Antibiotics weren’t here yet. Neither did vitamin D. Transfusion is either not there or in its very infancy.

We used to treat TB with surgery. Now, except the very very rare resistant cases, such therapy is unheard of. We also used to induce artifical pneumothroax. That’s no more.

Sure, people in the 50s proclaimed victory of chemo over radiation, but our time is different. We actually have near full understanding of more and more types of cancer at a molecular level. We know what gene causes what. We have sophisicated molecular targets.

We have therapies right now that are replacing surgery and radiation. What about certain lymphomas? When is the last time you’ve seen someone getting splenectomy for splenic marginal zone lymphoma? Or radiation for that matter (which used to have a role).

So here’s the problem. I am saying surgery and IR will be around 100 years from now because you can’t treat a bullet (or laser) wound with medicine alone. Angiography will remain the easiest way to get into the middle cerebral artery until teleportation happen. I am certain of those two things above. Will IR treat cancer then? Probably not but that’s not what I am talking about. I am talking about the fact that surgery, medicine, radiology and IR will be there as a field, with or without AI involvement.

On the other hand, radiation deals with a narrow indication and have significant side effects. We suffer through radiation because we have to. Because of limitation of our healing arts.

Lastly, a bit about AI. You are right that there is exploration of using AI for imaging diagnosis, but you know what’s beyond exploration and in operational stage?

Watson oncology. It’s here. What is it to stop a NP/PA plus sophisificated AI to do your job? Or Medonc plus AI to do your job? Why would a medonc refer to you when a computer program autocontoura and proscribe the treatment? Oh, you own the machines? What about the big hospitals that also own the machines? What then? Can you afford to compete with the big bad AI with similar or better outcome and software package you can’t afford.

Here’s the problem with AI and radonc. Any AI sophisticated enough to replace radiology will replace radonc first.

Again, I appreciate radonc as a service for my patient and I have nothing but respect for my mentors in NYC during my radonc research years and the friends I made now who are at big deal places now, but in 100 years? I am not so sure.

Sigh.

You posted this same thing in another thread....you obviously didn't read the responses. This is horribly inaccurate. You have barely any understanding of what a radiation oncologist does, and you have no understanding of the capabilities/limitations of AI.

AI is not well suited at all to clinical oncology. Watson oncology is worthless and it's laughable to think it will replace oncologists of any sort. The limit of current AI techniques is probably to be a replacement for looking up NCCN guidelines. Even that is shaky.

There is substantial complexity and individualized decision making that goes into treatment planning that current AI techniques are extremely poorly suited to address. AI is good at processing images, so autocontouring will probably happen. But outside of drawing circles there's basically nothing in a rad onc's job description that can be replaced without quantum advances in AI. A significantly higher percentage of a diagnostic radiologist's daily task burden could be replaced by current AI techniques, though obviously not 100%.

 

[Reaganite]

I've seen that happen before.

Which begs the question of why hire a rad onc to do the p2p calls in the first place if nothing can be overturned as a result of that call? Easy enough to just send what is and is not covered to the treating physician and let them break the news to the patient

Because some guidelines have a line that gives the reviewer some discretion to approve...It'll usually be a non-specific line about "IMRT may be approved if clinically meaningful reduction in normal tissues can be achieved relative to 3D conformal therapy" or something to that effect.

That being said, I highly, highly suggest you get a copy of all the healthplan guidelines and make sure the treatment you are offering is covered for a given diagnosis. Even if it is I suggest you write in your plan "I am offering IMRT. IMRT is considered medically necessary per healthplan guideline '1234' for diagnosis "x" and should be covered for this case." If IMRT, SBRT, etc. isn't covered for the diagnosis, but the guideline has a line giving some wiggle room to the reviewer, then again I suggest you first QUOTE the guideline in your plan and then spell out how your therapy meets that exclusion. You need to be very specific. "Guideline '1234' says IMRT may be medically necessary if it leads to meaningful sparing of normal tissues. I am recommending IMRT because a 3D conformal plan would exceed the TD5/5 of "x Gy" for the optic chiasm." You might even need to look in the healthplan guideline to see what normal tissue constraints they use (emami vs. quantec, etc.). Just a little inside knowledge that may get your case approved by the nurse reviewer before it even has to go to a physician reviewer for appeal.

 

[DrfluffyMD]

It’s a bit sad, that you proceed to blast me on my lack of understanding on rad onc’s workflow then completely demostrate complete ignorance in the day to day of a diagnostic radiologist.

So tell me, what is image processing to you? How is current AI based radiology solution derived? (Hint: it uses radiologist’s report and sometimes identify pneumonia by the presence of central lines rather than actual pneumonia).

Meanwhile, clinically oncology is guideline driven, backed up by concrete data, has finite numbers of variables...

Like I said before, any AI capable of automating diagnostic radiology would have long automated oncology. I merely point out watson oncology as the furthest advancement on the AI front. No radiology AI solution has gone that far.

I humbly suggest you to read up more about AI and diagnostic radiology.

 

[medgator]

Just a little inside knowledge that may get your case approved by the nurse reviewer before it even has to go to a physician reviewer for appeal.

What frustrates me is when our pre-auth personnel (it's amazing that we literally have to hire multiple FTEs just to practice medicine and get paid for what we are doing!) go through the computer algorithm and put down that the patient had previous XRT at an adjacent area, thereby meeting medical necessity for IMRT, it still will kick the case to a physician P2P reviewer! Invariably it gets approved, but it still wastes everyones time. Not sure why they make our staff fill out the questions on the computers and talk to a nurse reviewer in those situations.

 

[deleted18755]

What frustrates me is when our pre-auth personnel (it's amazing that we literally have to hire multiple FTEs just to practice medicine and get paid for what we are doing!) go through the computer algorithm and put down that the patient had previous XRT at an adjacent area, thereby meeting medical necessity for IMRT, it still will kick the case to a physician P2P reviewer! Invariably it gets approved, but it still wastes everyones time. Not sure why they make our staff fill out the questions on the computers and talk to a nurse reviewer if those situations.

I totally agree. 95-100% of the information I provide in a peer to peer is in the form (or certainly in the consult note). When I asked one reviewer why she is just asking me what I already wrote in the form she flat out said “oh I never look at those since they are usually filled out by a secretary and are incorrect.” When I said I actually fill them out myself and make sure they are accurate so I don’t have to waste your time she basically said she doesn’t mind calling us (didn’t seem to care about my time) and gave me the impression that she gets paid for each call so an easy call for her is good for her wallet.

One random thing I learned the other day: I wrote that I needed IMRT for IIIB NSCLC with supraclav involvement and it went to peer review but got approved in two seconds but he said next time just write N3 disease and the nurse will approve right away (she is looking for key words and N3 is one of them but she doesn’t know that supraclav = N3).

 

[medgator]

I totally agree. 95-100% of the information I provide in a peer to peer is in the form (or certainly in the consult note). When I asked one reviewer why she is just asking me what I already wrote in the form she flat out said “oh I never look at those since they are usually filled out by a secretary and are incorrect.” When I said I actually fill them out myself and make sure they are accurate so I don’t have to waste your time she basically said she doesn’t mind calling us (didn’t seem to care about my time) and gave me the impression that she gets paid for each call so an easy call for her is good for her wallet.

One random thing I learned the other day: I wrote that I needed IMRT for IIIB NSCLC with supraclav involvement and it went to peer review but got approved in two seconds but he said next time just write N3 disease and the nurse will approve right away (she is looking for key words and N3 is one of them but she doesn’t know that supraclav = N3).

Yup... insurance companies have arbitrarily decided the 0617 data is only good for imrt in patients with N3 disease.

In N2 patients they will sometimes ask for a plan comparison dvh, which they often do in many sites, yet they aren't willing to pay my dosimetrist time to do all that extra work. And even when the imrt plan is clearly and significantly better, they only want to pay for the cheaper plan even if the V20 is 36% and the mean esophagus dose is 33 Gy

 

[RickyScott]

I am going to play devils advocate. With many institutions charging ASTRO rates (defined as monopolistic like prices charged by home institutions of those in ASTRO leadership positions,) insurance review is a necessary evil. For example on medinet, mayo clinic acknowledged they were charging 60,000$ for a course of sbrt to treat an oligo bone met. I have seen bills from MDACC and MSK where their hypofractionation is much more expensive than community conventional treatments. These rates are hidden by NDAs, but high enough in many cases that IMRT pricing for protons can justify a proton center.

If we dont control prices/utilization, someone else will- typically broadly without much individualization such that most insurances have policies about IMRT/radiation fractionation and the reviewing physician does not have much discretion.

BTW: "Choosing wisely" is a cynical attempt to separate utilization from prices, and it is cost that ultimately matters.

 

[hbosch]

I tried to avoid getting sucked into this but it's so hard... where I practice we have a lot of medicare/medicaid and many patients on medicare get tricked into getting the worst form of medicare with very poor compensation in everything. When we try to send patients to academic institutions (like T&Os, or second opinions on extremely complicated cases (this is rare) or to talk about clinical trials or management by a specialist (like urogyn))- they are flat out denied because the academic institutions don't accept those patient's insurance. Then the patients have to drive 2.5 hrs to hospital that will provide the service. Those same institutions poo poo community rad oncs claiming they suck and provide inferior treatment, but yet if a medicaid patient ends up in their ED and gets a cancer dx there, they will refer out to community hospitals telling the patient we don't accept your insurance and such and such community hospital is great (literally I have seen this happen). They are however super happy to take our few patients with good insurance, telling these individuals that the community hospitals suck. I literally end up seeing patients that live closer to an academic center than to me and are driving >1 hr to get tx. I've seen spinal cord compressions get transferred to OUR hospital from an hour away when they could have easily gone to an academic hospital 30-45 min away because the academic hospital "didn't take the insurance." How are they a tertiary center when they are refusing cord compressions? It's incredibly hypocritical and immoral. Obviously the rad oncs in the academic hospitals are likely not involved in choosing which insurances they accept (I'm sure it's a higher level hospital policy) but it makes the entire academic institution look nasty, money grubbing and immoral. Essentially they come off as hating poor people. And, not just as a rad onc, but as a human being, i's disappointing at best and infuriating at worst. I didn't realize this in residency and possibly that hospital did it too and because we never saw those patients to begin with, I didn't know (not to mention as a resident you know nothing about insurance and billing). But it's an incredibly sad state of affairs for the US and it's frustrating how academic hospitals get all the spot light and glory while practicing such shameless picking and choosing.

Doesn't flat out not treating an entire group of human beings because of their economic status also count as poor medical practice?

 

[deleted18755]

I tried to avoid getting sucked into this but it's so hard... where I practice we have a lot of medicare/medicaid and many patients on medicare get tricked into getting the worst form of medicare with very poor compensation in everything. When we try to send patients to academic institutions (like T&Os, or second opinions on extremely complicated cases (this is rare) or to talk about clinical trials or management by a specialist (like urogyn))- they are flat out denied because the academic institutions don't accept those patient's insurance. Then the patients have to drive 2.5 hrs to hospital that will provide the service. Those same institutions poo poo community rad oncs claiming they suck and provide inferior treatment, but yet if a medicaid patient ends up in their ED and gets a cancer dx there, they will refer out to community hospitals telling the patient we don't accept your insurance and such and such community hospital is great (literally I have seen this happen). They are however super happy to take our few patients with good insurance, telling these individuals that the community hospitals suck. I literally end up seeing patients that live closer to an academic center than to me and are driving >1 hr to get tx. I've seen spinal cord compressions get transferred to OUR hospital from an hour away when they could have easily gone to an academic hospital 30-45 min away because the academic hospital "didn't take the insurance." How are they a tertiary center when they are refusing cord compressions? It's incredibly hypocritical and immoral. Obviously the rad oncs in the academic hospitals are likely not involved in choosing which insurances they accept (I'm sure it's a higher level hospital policy) but it makes the entire academic institution look nasty, money grubbing and immoral. Essentially they come off as hating poor people. And, not just as a rad onc, but as a human being, i's disappointing at best and infuriating at worst. I didn't realize this in residency and possibly that hospital did it too and because we never saw those patients to begin with, I didn't know (not to mention as a resident you know nothing about insurance and billing). But it's an incredibly sad state of affairs for the US and it's frustrating how academic hospitals get all the spot light and glory while practicing such shameless picking and choosing.

Doesn't flat out not treating an entire group of human beings because of their economic status also count as poor medical practice?

I have no reason to doubt you but I’m having a difficult time believing this (maybe because it’s just so sad).

I have to admit that I honestly had no idea that at least some of these large academic centers are compensated so much more for the exact same therapies but those of us in community practice know that we sometimes basically treat patients for free (there are some situations like patients with Medicaid who are non-English or Spanish speaking when I use the translator phone service when I’m pretty sure I’m paying to treat patients) while a relatively small proportion compensate very well and it balances out ... boy would it be nice to just cherry pick the 20% highest revenue generating patients and on top of that get paid extra “academic” rates even for them! I always wondered how some of these academic guys can afford to have so much support staff while having <10 patients on treatment and still make so much.

Anyway what you’re describing above is at best being immoral and at worst unethical (even illegal), isn’t it? Is there really no way to change this horrible situation for the patients sake? At this point in my life I couldn’t care less if academic physicians think I’m some doufus backwoods doctor and look down on me but it makes my blood boil to think that patients aren’t able to access care.

 

[medgator]

I always wondered how some of these academic guys can afford to have so much support staff while having <10 patients on treatment and still make so much.

Anyway what you’re describing above is at best being immoral and at worst unethical (even illegal), isn’t it? Is there really no way to change this horrible situation for the patients sake? At this point in my life I couldn’t care less if academic physicians think I’m some doufus backwoods doctor and look down on me but it makes my blood boil to think that patients aren’t able to access care.

The smart insurers like Medicaid and Medicare advantage issuers etc will preferentially seek to contract with freestanding/private centers over the hospital/academic ones in many cases because the cost of care is cheaper there, both on the RO and MO side of things. I imagine this is true in much of the country.

Some Medicare advantage/Medicaid plans won't allow referral to the local tertiary/NCI designated CC unless auth is obtained for a specific service that is not available in the local market in our area

So, I do believe it actually, and yes I can't believe 10-15 patients under beam is considered a full load at some places but I guess we both know why now

 

[Reaganite]

I am going to play devils advocate. With many institutions charging ASTRO rates (defined as monopolistic like prices charged by home institutions of those in ASTRO leadership positions,) insurance review is a necessary evil. For example on medinet, mayo clinic acknowledged they were charging 60,000$ for a course of sbrt to treat an oligo bone met. I have seen bills from MDACC and MSK where their hypofractionation is much more expensive than community conventional treatments. These rates are hidden by NDAs, but high enough in many cases that IMRT pricing for protons can justify a proton center.

If we dont control prices/utilization, someone else will- typically broadly without much individualization such that most insurances have policies about IMRT/radiation fractionation and the reviewing physician does not have much discretion.

BTW: "Choosing wisely" is a cynical attempt to separate utilization from prices, and it is cost that ultimately matters.

I'll second your opinion. As a private practitioner, insurance companies have always been my friend, and I'm glad they are aggressively monitoring their utilization. Honestly, nobody has helped me build a robust practice more than the local IPAs and now some of the bigger insurance companies. In my area, a big payor is buying out medical groups and one of their first edicts on the cancer side has been to get rid of academic centers. A particularly aggressive local academic entity has had its expansion efforts significantly disrupted by medical groups and insurance companies that won't contract with their satellite centers. This stuff is starting to make it's way to the PPO world too. Lots of talk of narrow PPO networks that will exclude the academic guys.

 

[deleted18755]

I'll second your opinion. As a private practitioner, insurance companies have always been my friend, and I'm glad they are aggressively monitoring their utilization. Honestly, nobody has helped me build a robust practice more than the local IPAs and now some of the bigger insurance companies. In my area, a big payor is buying out medical groups and one of their first edicts on the cancer side has been to get rid of academic centers. A particularly aggressive local academic entity has had its expansion efforts significantly disrupted by medical groups and insurance companies that won't contract with their satellite centers. This stuff is starting to make it's way to the PPO world too. Lots of talk of narrow PPO networks that will exclude the academic guys.

Very interesting ... I had no idea.

Just curious how the academic center “pushes back”. I can’t imagine they just say oh well

 

[OTN]

The very large, very, very well-known academic center closest to our city (who, as an aside, costs 5x more than we do in order to achieve equivalent outcomes, according to insurance data) also refuses to see/treat patients without insurance, despite receiving both state and federal funds. They told a patient of mine with oral tongue cancer she would need to pony up $30,000 to be seen- it might as well have been $30 million.

She was unable to get an operation at any hospital in the state, as she was from a small county without a large public assistance program and without a local hospital which could do the operation. She saw us, we had her fill out a form confirming her complete lack of finances, and we treated her with chemoRT for oral tongue cancer for free- $0 from her to our practice. We're a larger private practice which allows us to do this, but it's still something we pride ourselves on.

She's now 4 years out and NED.

The academic medical center should be ashamed at how they treat the poor citizens of the state they're charged with helping, and the academicians in the center should be ashamed at how fall they've fallen as true physicians. I'm sure they would hide behind the administration/processes, etc, but that's exactly my point: The academicians have allowed their practice of medicine to be run by administrators and bureaucrats, with exactly the results one would expect.

 

[seper]

I've tried this but quickly noticed that Evicore reviewers do not have access to consult notes. They read case info from an online form.

Because some guidelines have a line that gives the reviewer some discretion to approve...It'll usually be a non-specific line about "IMRT may be approved if clinically meaningful reduction in normal tissues can be achieved relative to 3D conformal therapy" or something to that effect.

That being said, I highly, highly suggest you get a copy of all the healthplan guidelines and make sure the treatment you are offering is covered for a given diagnosis. Even if it is I suggest you write in your plan "I am offering IMRT. IMRT is considered medically necessary per healthplan guideline '1234' for diagnosis "x" and should be covered for this case." If IMRT, SBRT, etc. isn't covered for the diagnosis, but the guideline has a line giving some wiggle room to the reviewer, then again I suggest you first QUOTE the guideline in your plan and then spell out how your therapy meets that exclusion. You need to be very specific. "Guideline '1234' says IMRT may be medically necessary if it leads to meaningful sparing of normal tissues. I am recommending IMRT because a 3D conformal plan would exceed the TD5/5 of "x Gy" for the optic chiasm." You might even need to look in the healthplan guideline to see what normal tissue constraints they use (emami vs. quantec, etc.). Just a little inside knowledge that may get your case approved by the nurse reviewer before it even has to go to a physician reviewer for appeal.

 

[medgator]

I'll second your opinion. As a private practitioner, insurance companies have always been my friend, and I'm glad they are aggressively monitoring their utilization. Honestly, nobody has helped me build a robust practice more than the local IPAs and now some of the bigger insurance companies. In my area, a big payor is buying out medical groups and one of their first edicts on the cancer side has been to get rid of academic centers. A particularly aggressive local academic entity has had its expansion efforts significantly disrupted by medical groups and insurance companies that won't contract with their satellite centers. This stuff is starting to make it's way to the PPO world too. Lots of talk of narrow PPO networks that will exclude the academic guys.

Bundles will be the real equalizer to private/freestanding vs hospital/academic centers, which is why ASTRO opposed them for so long. Certain insurance companies are already experimenting with cancer bundles in certain markers, with the freestanding centers, of course.

 

[seper]

This buzz regarding bundled payments for oncologic treatments has been going on for a while, but I personally not aware of any implementation.

 

[medgator]

This buzz regarding bundled payments for oncologic treatments has been going on for a while, but I personally not aware of any implementation.

UnitedHealthcare, MD Anderson deal may spur more bundled payments in cancer

21st Century Oncology and Humana Break New Ground with Case Rate Reimbursement Agreement | 21st Century Oncology

There are others as well, I believe in the Midwest

 

[seper]

Sure, these are pilot programs, and I know a few more involving radiation therapy bundles. It's just I don't get the sense they are expanding geographically or expanding to include other specialties.

UnitedHealthcare, MD Anderson deal may spur more bundled payments in cancer

21st Century Oncology and Humana Break New Ground with Case Rate Reimbursement Agreement | 21st Century Oncology

There are others as well, I believe in the Midwest

 

[thecarbonionangle]

I think in one of my ACGME evaluation I once wrote the residents where I was training were nothing more then PAs b/c of all the stuff kristofer wrote. That did not go over well when the evaluation were reviewed.

And this program is likely still doing the same thing to current and future residents. What did you do and have you considered posting about your experience as a warning?

What advice would you offer to anybody reading your post, relating to some, perhaps relating to all. How did you navigate this or recommend someone navigate this?

To me its so sad to read and hear from fellow residents about their experiences. Some of the things Ive seen or heard are crazy. This is a lot more rampant than people think