Top 30 Complex Sim Users in America: 7 Are Derm/Fam Prac

[deleted1111261]

They can cut 10% off of the 90% that practice pretty good medicine and 50% from the Florida man, and the savings would still be higher from the paper cuts to the average practitioner.

We know you love to be the contrarian here and defend the establishment, but ask community folks what we fight with them about. It ain’t 20 fraction bone mets. It’s things like IGRT or VMAT for stage 3 lung (in years past, that has been fixed now).

Evicore isn’t the reason our costs have gone done. We practice EBM and shame the **** out of each other in #radonc. That’s how we do!

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[jondunn]

Dude I am a community guy that fights with them about IMRT for rectal cancer.

That’s not the point. Point is (by the way YOU were the one who on TWITTER defended evicore and why it existed so not sure why you’re arguing the point) - there’s obviously a reason some sort of regulation exists. And of course it’s to save them money, but some of that money saving they do is actually correct. A major pain in our ass, but objectively correct.

 

[deleted1111261]

Dude I am a community guy that fights with them about IMRT for rectal cancer.

That’s not the point. Point is (by the way YOU were the one who on TWITTER defended evicore and why it existed so not sure why you’re arguing the point) - there’s obviously a reason some sort of regulation exists. And of course it’s to save them money, but some of that money saving they do is actually correct. A major pain in our ass, but objectively correct.

Touché .. I did defend sometimes, didn’t I? I’ve ridden them pretty hard over the years, too. They do some good things. But mostly small bad things.

 

[RickyScott]

I will play devils advocate and defend Evercore. In what universe will employers not demand such an agent when some greedy hospitals are charging them 10 x cms rates?

 

[deleted1111261]

But, then the policy should be: “we are denying your single fraction at Sloan. Go get 10 fractions at your local freestanding center.” 😂

 

[RickyScott]

But, then the policy should be: “we are denying your single fraction at Sloan. Go get 10 fractions at your local freestanding center.” 😂

From my understanding they can’t do that if they have agreed to Sloan in network. In places like philadelphia or NorCal, employers have to play ball with upenn or Sutter health. Like any blunt, rigid, guideline formalized etc imperfect solution, there will be some injustice.

 

[deleted1111261]

From my understanding they can’t do that if they have agreed to Sloan in network. In places like philadelphia or NorCal, employers have to play ball with upenn or Sutter health. Like any blunt, rigid, guideline formalized etc imperfect solution, there will be some injustice.

I’m sure. I’m just saying if the goal was actually promoting cost effective medicine, location would be something they would care about. If insurers / third parties will pay 5-10x for same treatment at different centers, then it is a sham and they know it.

 

[Mandelin Rain]

If all evicore did was stop grossly fraudulent billing practices and wild deviations from typical practice (20 imrt fractions for bone Mets), I don’t think anyone would have a problem with it. I may have never even heard of them.

The parent company of evicore is express scripts. The parent company of express scripts is Cigna. Cigna has it's profits capped by the ACA at 20%. How can it make more money? Shunt a bunch of revenue to it's own subsidiaries for some service (like utilization oversight) at a premium price in excess of costs.

Of course it's a sham.

 

[Irradi8or]

I feel like this could be true. But we don't have the slightest idea or evidence as to how much it is true.

Agree - I've asked Evicore to open up the data and let us see what it shows (I've never gotten a response from them). Afterall, they use it to justify their position with insurance companies (they are now owned by Cigna I believe)

 

[RickyScott]

I. Cigna has it's profits capped by the ACA at 20%. How can it make more money? Shunt a bunch of revenue to it's own subsidiaries for some service (like utilization oversight) at a premium price in excess of costs.

Of course it's a sham.

It’s not just the ACA. All medical insurance profits are limited to a certain percentage. That is why the insurance companies love it when hospitals like Sloan charge 10x cms prices because the pie gets larger. They are “forced”to deploy evercore to show the employers that they are trying to limit costs.

 

[TheWallnerus]

Afterall, they use it to justify their position with insurance companies (they are now owned by Cigna I believe)

Certainly, an extreme amount of fudging and fuzzy math are used by the ROs at the top of the RO Evicore department to justify their existence. I wouldn't trust their data at all even if they made it available. I would need a third party to analyze; ain't ever gonna happen, so we are stuck w/ Evicore until the Sun goes red giant phase.

 

[Reaganite]

I feel like this could be true. But we don't have the slightest idea or evidence as to how much it is true.

Agree completely. Without seeing the actual data it's impossible to know. I never worked for Evicore but I briefly did reviews in a past life for a very reasonable insurer, and I was inundated with nutty requests. Everybody wanted to palliate every bone met with long course IMRT, and there was an NCI designated cancer guy who would request 30 IMRTs for every single breast case....R or L, >70 T1, didn't matter. Of course, as a physician reviewer those were the only cases I really saw (all the reasonable requests were approved by nurses), so it's hard to say how reflective this was of the network at large.

To the questions about redirecting away from NCI/hospitals to freestanding--unfortunately, things aren't that simple. Hospitals with market share have power and insurers need them as much as they need insurers. A freestanding radiation center can't do cardiac caths, admit patients, etc. Insurers can't just take away a lucrative service line like radiation, but ask the hospital to do everything else. It's a very complex dynamic.

 

[jondunn]

Agree completely. Without seeing the actual data it's impossible to know. I never worked for Evicore but I briefly did reviews in a past life for a very reasonable insurer, and I was inundated with nutty requests. Everybody wanted to palliate every bone met with long course IMRT, and there was an NCI designated cancer guy who would request 30 IMRTs for every single breast case....R or L, >70 T1, didn't matter. Of course, as a physician reviewer those were the only cases I really saw (all the reasonable requests were approved by nurses), so it's hard to say how reflective this was of the network at large.

To the questions about redirecting away from NCI/hospitals to freestanding--unfortunately, things aren't that simple. Hospitals with market share have power and insurers need them as much as they need insurers. A freestanding radiation center can't do cardiac caths, admit patients, etc. Insurers can't just take away a lucrative service line like radiation, but ask the hospital to do everything else. It's a very complex dynamic.

yes agree fully on both points.