CMS changes supervision rule. Rad Oncs no longer needed for daily operation of clinics. Med Students. Please read. You deserve to know implications.

[radiation]

In my experience with doing some locums, I would rather quit radonc and retrain than have a job where I'm just sitting in an office doing nothing. If retraining wasn't a possibility, I'd rather quit medicine entirely than have to face that for a lifetime. Absolutely the worst.

That's the elephant in the room that's not being discussed. We're all highly-functioning, ambitious people or we would have never gone to medical school. None of us want to just sit and do nothing most of the time for a career.

Does it have to be that way though? There are some locums where you actually see new pts, see on treats etc. Not sure direct supervision and doing meaningful work is mutually exclusive (even if that's what many current gigs have devolved to). Issues with "babysitter" jobs in medicine is a separate issue I think, its not unique to rad onc (ie Rads contrast coverage, anesthesia CRNA coverage etc)

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[MidwestRadOnc]

Does it have to be that way though? There are some locums where you actually see new pts, see on treats etc. Not sure direct supervision and doing meaningful work is mutually exclusive (even if that's what many current gigs have devolved to). Issues with "babysitter" jobs in medicine is a separate issue I think, its not unique to rad onc (ie Rads contrast coverage, anesthesia CRNA coverage etc)

Definitely not. I know of multiple rural hospitals that operate exclusively with locums. The quality of care is dismal. Physics and dosi basically run the place. Locums will be signing off on whatever plan was started by the guy that was there before. So yeah, sure if you just don't want to babysit, there are definitely jobs where you draw some circles on a patient you didn't see in consult and some different guy comes in a few days later and approves the plan.

 

[medgator]

The writing was on the wall even 15 years ago when I was searching for pp gigs- small practices were going to continue to get squeezed by both payors and equipment providers and were never going to have the economies of scale to be able to compete with larger private practices or hospital systems/academic medical centers, who not only had access to economies of scale, but also artificially increased reimbursement rates due to crony capitalism.

I didn't anticipate the depths of cronyism and the extent to which ASTRO would be hostile to private practices, but fortunately being wary of smaller clinics helped me make the right call.

Lots of those smaller private practices are now gone or suffering. I agree that finding a good pp gig now is a matter of luck more than anything else, so I completely understand why new grads look to hospital jobs.

ASTRO PAC took member donations and fought against urorads docs and the entire concept of independent ownership of linacs by any physician by going after the in office ancillary exemption (IOAE) @Rad Onc SK

Starting a freestanding center nowadays is a highly risky and dicey proposition to be sure unless you can hit the ground running with optimized staff and patients out the door ready to start. Medicare changed the calcs a few years to even remove the vault construction as an expense when valuing codes.

 

[medgator]

Maybe that’s the problem with our field… too expectations. Let’s not forget that rad onc was one of the least competitive fields in the early 90’s and then exploded. Maybe it was always fool’s gold to begin with.

Mid 90s too. Also early 70s when you could dual board in diagnostic rads.

And now the 2020s+!

 

[radoncle]

Lets get this straight:

- I am not a member of ASTRO because I do not believe they represent physicians in small solo practice hospital-based and freestanding centers.
- They want to not only end virtual supervision but also roll back general supervision requirements to a pre-2019 "incident to" era for everybody.
- This preferentially discriminates against these same small centers.
- And their solution is to open up a forum and town hall to members only. The ones most affected by this left their organization long ago because we felt like they hate us.
- So we cannot provide feedback on not smacking us in the face even more as we left them in the past for constantly beating us down.

There is no way around this. This will hurt care of patients in small communities. Rad oncs that have moved to 4 and 3 day weeks so they can commute out to the boonies are not going to go back. They will move on and the hospital will fill the gap with a hodgepodge of rotating locums. What's better? Having a competent BC rad onc physically there 3-4 days a week and available via phone/Facetime otherwise or having a different ABR-grandfathered geriatric locums every other week?

Screw ASTRO.

I heard the “town hall” is happening on April 5th at 5 pm. Is it really only open to Astro members? There’s a zoom link. Can I change my name to Jeff Michalski and join? Frankly, outside of the APM/ROCR stuff, this seems like the most important issue facing rad onc now. It really feels like big rad onc is trying to squash solo docs (mostly covering remote areas) with these proposed changes. Why can’t we weigh in? I’m not an Astro member because they don’t represent my interests and I feel like paying their dues is basically akin to providing bullets to someone trying to murder me.

 

[metallica81788]

I heard the “town hall” is happening on April 5th at 5 pm. Is it really only open to Astro members? There’s a zoom link. Can I change my name to Jeff Michalski and join? Frankly, outside of the APM/ROCR stuff, this seems like the most important issue facing rad onc now. It really feels like big rad onc is trying to squash solo docs (mostly covering remote areas) with these proposed changes. Why can’t we weigh in? I’m not an Astro member because they don’t represent my interests and I feel like paying their dues is basically akin to providing bullets to someone trying to murder me.

They let me sign up for it and pretty sure my ASTRO membership just lapsed

 

[radoncle]

They let me sign up for it and pretty sure my ASTRO membership just lapsed

Is there a link to sign up? I haven’t been an Astro member in years

 

[metallica81788]

See if this works

 

[radoncle]

See if this works

Thank you!

 

[cuedot]

Can someone please summarize what the current supervision rules are? (and/or point me to the definitive source)

 

[TheWallnerus]

Can someone please summarize what the current supervision rules are?

Virtual direct supervision acceptable for anything and everything (highest, most safely compliant level). General supervision for all treatments in a hospital; APP or virtual supervision of IGRT. Any MD or DO can provide true physical supervision.

 

[NotJasonBeckta]

Can someone please summarize what the current supervision rules are? (and/or point me to the definitive source)

Beckta, Jason (2024). Supervision Rules - Executive Summary and Revised List of Support - RadOnc March 2024. figshare.
https://doi.org/10.6084/m9.figshare.25506319.v1

 

[Gfunk6]

I thought this file would be of interest and generate discussion - enjoy!

 

[MidwestRadOnc]

This kind of company is NOT needed unless volume is absurdly low.

Hospitals can hire rad oncs DIRECTLY to commute out and work less than 5 days a week on site.

Bridge Oncology takes a cut. No reason hospitals can't make an attractive enough offer to rad onc DIRECTLY rather than pay a middleman to do the same thing.

This model is only going to be feasible for very low volume rural centers that cannot pay enough for a rad onc directly to get them to come there. So they hire the middleman. The only way this is going to work for rad oncs going through bridge oncology is going to be them covering multiple rural centers at once. At that's only going to work if they are on site 1 day a week or less. How else are you going to cover 4-5 centers to approximate a full time rad onc income? How many places are there out like that? We'd have to be talking 10 on treatment or less to make this feasible.

NO problem with the hospital direct hire model for rad onc on site 3-4 days a week.
I see a problem with BO oncology model for rad onc on site once every week or 2.
It would be a shame to take down the former because of fears of the latter.

 

[Reaganite]

Not sure if Jordan lifted Beckta or the other way around, but those slides make ASTRO look like the class clown. Is there a society in medicine more out of touch with its constituents?

 

[elementaryschooleconomics]

This kind of company is NOT needed unless volume is absurdly low.

Hospitals can hire rad oncs DIRECTLY to commute out and work less than 5 days a week on site.

Bridge Oncology takes a cut. No reason hospitals can't make an attractive enough offer to rad onc DIRECTLY rather than pay a middleman to do the same thing.

This model is only going to be feasible for very low volume rural centers that cannot pay enough for a rad onc directly to get them to come there. So they hire the middleman. The only way this is going to work for rad oncs going through bridge oncology is going to be them covering multiple rural centers at once. At that's only going to work if they are on site 1 day a week or less. How else are you going to cover 4-5 centers to approximate a full time rad onc income? How many places are there out like that? We'd have to be talking 10 on treatment or less to make this feasible.

NO problem with the hospital direct hire model for rad onc on site 3-4 days a week.
I see a problem with BO oncology model for rad onc on site once every week or 2.
It would be a shame to take down the former because of fears of the latter.

Yeah it is...absolutely insane to me that Bridge Oncology seems to be just...driving so much anxiety.

I'm very curious to see how long it survives. Maybe it lasts? I genuinely don't know.

What I DO know is this single startup is not the crazy boogeyman people are bizarrely imagining it to be.

If you're worried about TeleRadOnc taking jobs, you should be scared of:

Mayo
MD Anderson
Sloan Kettering
Penn
and on
and on
and on

Mayo already has their "MCCN" thing, it's like, READY TO GO for TeleRadOnc. They're probably already doing it.

In short - THE CALL IS COMING FROM INSIDE THE HOUSE, ASTRO.

 

[radoncle]

Yeah it is...absolutely insane to me that Bridge Oncology seems to be just...driving so much anxiety.

I'm very curious to see how long it survives. Maybe it lasts? I genuinely don't know.

What I DO know is this single startup is not the crazy boogeyman people are bizarrely imagining it to be.

If you're worried about TeleRadOnc taking jobs, you should be scared of:

Mayo
MD Anderson
Sloan Kettering
Penn
and on
and on
and on

Mayo already has their "MCCN" thing, it's like, READY TO GO for TeleRadOnc. They're probably already doing it.

In short - THE CALL IS COMING FROM INSIDE THE HOUSE, ASTRO.

It’s not one versus the other. It’s all predatory and an effort to prevent physicians (not “providers” - we’re physicians) who worked their asses off and jumped through all the hoops to become board certified radiation oncologists from being independent and being compensated for what they bring in. None of these organizations are adding value to community oncology in any meaningful way.

Unfortunately, unlike MidwestRadOnc, many people cannot see the distinction between the problems with these organizations versus virtual supervision.

 

[udrag14]

Most rad oncs want some flexibility like virtual direct. We don't want on site constant supervision by a rad onc because this doesn't work for a single practice. We also don't want no physician coverage to prevent no physician pratices and/or entry of PE.

BTW, being scared of academic centers is laughable, we should be scared of private equity. Look what they have done with emergency medicine. They have merged multiple ERs and decreased attendings postions while expanding residency postions.

 

[medgator]

Most rad oncs want some flexibility like virtual direct. We don't want on site constant supervision by a rad onc because this doesn't work for a single practice. We also don't want no physician coverage to prevent no physician pratices and/or entry of PE.

BTW, being scared of academic centers is laughable, we should be scared of private equity. Look what they have done with emergency medicine. They have merged multiple ERs and decreased attendings postions while expanding residency postions.

Private equity in ER? HCA isn't PE but afaik they are a big culprit in all of these extra ER training programs and slots.

Emcare and team health are PE that definitely screw ER docs in practice. I guess maybe you could say the same about Genesiscare/21c, not sure

In rad onc, however, PE didn't expand all these residencies and create new programs, academic chairs and PDs did

 

[drowsy12]

Most rad oncs want some flexibility like virtual direct. We don't want on site constant supervision by a rad onc because this doesn't work for a single practice. We also don't want no physician coverage to prevent no physician pratices and/or entry of PE.

BTW, being scared of academic centers is laughable, we should be scared of private equity. Look what they have done with emergency medicine. They have merged multiple ERs and decreased attendings postions while expanding residency postions.

Private equity is a real concern, I totally agree. Look around.

 

[TheWallnerus]

Most rad oncs want some flexibility like virtual direct. We don't want on site constant supervision by a rad onc because this doesn't work for a single practice. We also don't want no physician coverage to prevent no physician pratices and/or entry of PE.

BTW, being scared of academic centers is laughable, we should be scared of private equity. Look what they have done with emergency medicine. They have merged multiple ERs and decreased attendings postions while expanding residency postions.

Similar to Galbraith’s take in “The Economics of Innocent Fraud” that the public sector and private sector are so blurred and in cahoots with one another now that essentially there is no distinction between the two, there is not a clear distinction between the activities or motives of large academic centers and private equity anymore.

Fear them both.

 

[RickyScott]

Private equity is a real concern, I totally agree. Look around.

too many barriers for private equity in this field. 21c failed. In major markets, pe would need to control the reffering docs and somehow negotiate 3-4x cms rates.

 

[elementaryschooleconomics]

too many barriers for private equity in this field. 21c failed. In major markets, pe would need to control the reffering docs and somehow negotiate 3-4x cms rates.

Bingo.

PE in medicine, in general, is to be feared.

Sadly, RadOnc is too weak for PE to care about us.

People can disagree with me if they want, but the proof is literally in the real-world data/events. How long has PE been destroying medicine for now, a decade? 15 years? Longer? And how much has PE come into RadOnc in all that time?

21C is the only entity making a deal with a devil in 2008.

That...went poorly.

I genuinely am not aware of anyone else. I guess we could count the practices associated with US Oncology? But not really, because RadOnc is more a side dish there to the fillet mignon that is MedOnc.

Ironically, this also has a lot to do with consolidation.

The Andersons and Northwells of the world are the RadOnc version of PE.

 

[medgator]

Bingo.

PE in medicine, in general, is to be feared.

Sadly, RadOnc is too weak for PE to care about us.

People can disagree with me if they want, but the proof is literally in the real-world data/events. How long has PE been destroying medicine for now, a decade? 15 years? Longer? And how much has PE come into RadOnc in all that time?

21C is the only entity making a deal with a devil in 2008.

That...went poorly.

I genuinely am not aware of anyone else. I guess we could count the practices associated with US Oncology? But not really, because RadOnc is more a side dish there to the fillet mignon that is MedOnc.

Ironically, this also has a lot to do with consolidation.

The Andersons and Northwells of the world are the RadOnc version of PE.

Vantage oncology was oak Hill partners PE. But they sold to uson

 

[elementaryschooleconomics]

Vantage oncology was oak Hill partners PE. But they sold to uson

I thought Vantage was also MedOnc/RadOnc?

 

[Ray D. Ayshun]

PE does own whole hospital systems, which have many linacs.

 

[elementaryschooleconomics]

PE does own whole hospital systems, which have many linacs.

Definitely - which is why, in general, PE is standing over the corpse of Medicine, holding a gun in one hand and Medicine's wallet in the other.

(There just has not, and never will be, the kind of PE issue in RadOnc specifically like there was for Emergency Medicine)

 

[drowsy12]

The Andersons and Northwells of the world are the RadOnc version of PE.

'(There just has not, and never will be, the kind of PE issue in RadOnc specifically like there was for Emergency Medicine)'




One of the major issues in PE in fields like EM is reducing the need for employed docs. By increasing the work each individual ER doc is required to do. This is done by raising the bar for required productivity on an ongoing basis, but also of course by using midlevels more and more, so that each ER doc is overseeing more patients than in the past, which otherwise would have been done by multiple ER docs.

Academic medical center corporations have not done this. in fact, they are keeping the job market afloat by buying up small centers that they can justify having one doc for 8-10 patients for because of the amount of money they're able to generate with that patient load.

I don't think you have put forth a convincing argument on why we should not be somewhat concerned about the same PE systems who own the hospitals with linacs doing the same and slowly sucking more out of each employed doc while increasing the use of midlevels. @NotMattSpraker nailed it earlier in the thread.

never is a very strong word.

 

[TheWallnerus]

PE will never succeed just owning some rad onc centers, or rad onc docs. If PE could not just look at rad onc as a thing unto itself, and that it needs an upstream referral chain… and then go and buy that upstream referral chain PLUS the rad oncs and rad onc centers… rad onc would be lucrative for PE. (Don’t let PE hear this, but rad onc has the best profit margin of any medical specialty.) However it will be hard/impossible for PE to accomplish this “vertical integration” in most cities. But, perhaps, it could in a few smaller or maybe midsize cities.

 

[drowsy12]

PE will never succeed just owning some rad onc centers, or rad onc docs. If PE could not just look at rad onc as a thing unto itself, and that it needs an upstream referral chain… and then go and buy that upstream referral chain PLUS the rad oncs and rad onc centers… rad onc would be lucrative for PE. (Don’t let PE hear this, but rad onc has the best profit margin of any medical specialty.) However it will be hard/impossible for PE to accomplish this “vertical integration” in most cities. But, perhaps, it could in a few smaller or maybe midsize cities.

I am talking about PE in hospitals with rad onc, not PE of free standing centers, to be clear

freestanding is dead. no one will touch them.

 

[elementaryschooleconomics]

I am talking about PE in hospitals with rad onc, not PE of free standing centers, to be clear

freestanding is dead. no one will touch them.

Oh then we're talking about very different things then - I'm still absolutely correct about "never" hahahaha

Because for PE to infiltrate RadOnc like Emergency Medicine we'd have to unwind what has already happened to get back to single-specialty RadOnc practices who could even "sell out" to PE.

There's so, so few single specialty RadOnc practices left.

But yeah, multi-specialty groups that include RadOnc are always under threat from...well, everything I guess.

Wolves in the tall grass as far as the eye can see!

 

[RickyScott]

I am talking about PE in hospitals with rad onc, not PE of free standing centers, to be clear

freestanding is dead. no one will touch them.

If you are talking abt large academic centers vs HCA/steward etc, the large acedimic systems have huge advantages in cancer.

 

[MidwestRadOnc]

(Don’t let PE hear this, but rad onc has the best profit margin of any medical specialty.)

yeah, that’s true. Yet many independent freestanding centers struggle to stay open or even lose money. What’s up? I’ve had the idea of a cyberknife-only center catering to self referrals ala Gil Lederman (except without the ahh reputation). Terrible idea from a pure financial standpoint if you’re practicing ethically?

 

[Bequerel]

yeah, that’s true. Yet many independent freestanding centers struggle to stay open or even lose money. What’s up? I’ve had the idea of a cyberknife-only center catering to self referrals ala Gil Lederman (except without the ahh reputation). Terrible idea from a pure financial standpoint if you’re practicing ethically?

I really think old used cheap linac with electrons in an area with a bunch of old people to treat OA and do your own punch biopsies on old patients for skin cancer is a way

 

[MidwestRadOnc]

I really think old used cheap linac with electrons in an area with a bunch of old people to treat OA and do your own punch biopsies on old patients for skin cancer is a way

Interesting question what the best way is for an entrepreneurial rad onc to run a solo operation.

I could actually do this now as there is not a dermatologist in the town I work in. Anyone get trained and credentialed to do biopsies and basically run a one stop skin clinic? I don’t own the machine but it would be an interesting idea to present to leadership. I recently had a patient with a squam on her arm I referred out to derm because it seemed like the right thing to do.

 

[medgator]

Interesting question what the best way is for an entrepreneurial rad onc to run a solo operation.

I could actually do this now as there is not a dermatologist in the town I work in. Anyone get trained and credentialed to do biopsies and basically run a one stop skin clinic? I don’t own the machine but it would be an interesting idea to present to leadership. I recently had a patient with a squam on her arm I referred out to derm because it seemed like the right thing to do.

Have seen derms own linacs and HDR

 

[elementaryschooleconomics]

I really think old used cheap linac with electrons in an area with a bunch of old people to treat OA and do your own punch biopsies on old patients for skin cancer is a way

This is in the realm of something I'm going to attempt if the world doesn't destroy itself over the next decade.

That's a...big "if" at the moment though.

 

[udrag14]

PE will never succeed just owning some rad onc centers, or rad onc docs. If PE could not just look at rad onc as a thing unto itself, and that it needs an upstream referral chain… and then go and buy that upstream referral chain PLUS the rad oncs and rad onc centers… rad onc would be lucrative for PE. (Don’t let PE hear this, but rad onc has the best profit margin of any medical specialty.) However it will be hard/impossible for PE to accomplish this “vertical integration” in most cities. But, perhaps, it could in a few smaller or maybe midsize cities.

Imagination my friend.

Let's paint a picture where CMS allows fully virtual direct or no supervision.

PE comes in and make a teledoc center in a couple major cities. They negotiate with centers..."hey you can't find a doctor...we will give you a doctor from top 5 residency. we will only take professional, you take all techinical. We just will do 100 percent virtual."

They hire shift work rad onc telemed only who cover 30 or 40 patients. Pay them maybe 2 or 3k a day 1099 with no benefits. They just do their shift and leave. Add AI for increasing contour efficency and standardization.

This is what owning a center looks like in the future. They will just concentrate the professional side down to bare minimum while killing the job market.

 

[radoncle]

Imagination my friend.

Let's paint a picture where CMS allows fully virtual direct or no supervision.

PE comes in and make a teledoc center in a couple major cities. They negotiate with centers..."hey you can't find a doctor...we will give you a doctor from top 5 residency. we will only take professional, you take all techinical. We just will do 100 percent virtual."

They hire shift work rad onc telemed only who cover 30 or 40 patients. Pay them maybe 2 or 3k a day 1099 with no benefits. They just do their shift and leave. Add AI for increasing contour efficency and standardization.

This is what owning a center looks like in the future. They will just concentrate the professional side down to bare minimum while killing the job market.

I think you’re overestimating the enthusiasm of rural centers to have full remote coverage. Every hospital wants a face of their program and every hospital wants their patients to be seen in person at least most of the time. They want someone who is going to “be part of the local community” and who will build the practice. We have CMS approval of virtual supervision currently and hospitals aren’t embracing this. There are plenty of Radiation Oncologists who would be eager to do full-time remote clinical work if this were truly an option.

 

[RickyScott]

Imagination my friend.

Let's paint a picture where CMS allows fully virtual direct or no supervision.

PE comes in and make a teledoc center in a couple major cities. They negotiate with centers..."hey you can't find a doctor...we will give you a doctor from top 5 residency. we will only take professional, you take all techinical. We just will do 100 percent virtual."

They hire shift work rad onc telemed only who cover 30 or 40 patients. Pay them maybe 2 or 3k a day 1099 with no benefits. They just do their shift and leave. Add AI for increasing contour efficency and standardization.

This is what owning a center looks like in the future. They will just concentrate the professional side down to bare minimum while killing the job market.

So the pe business model here is to ignore technical fees and go after some of the proffesional salary? To some extent, this will happen but not from pe. Hospitals with more than one center will just hire one doc.

 

[elementaryschooleconomics]

I think you’re overestimating the enthusiasm of rural centers to have full remote coverage. Every hospital wants a face of their program and every hospital wants their patients to be seen in person at least most of the time. They want someone who is going to “be part of the local community” and who will build the practice. We have CMS approval of virtual supervision currently and hospitals aren’t embracing this. There are plenty of Radiation Oncologists who would be eager to do full-time remote clinical work if this were truly an option.

Correct.

This is my exact scenario.

Obviously, I'm about as pro "Virtual Direct" as anyone could be.

When I first came to my solo, 5-day-a-week job, I had dreams of convincing the hospital of letting me do one day/week as virtual/WFH.

Within...maybe a week? Maybe two weeks? I realized it wouldn't be something I could even admit I was thinking about.

This is incredibly weird to say - and even weirder to experience - but you become a local celebrity. Quickly. Very quickly.

As in, less than a month after coming here, my spouse gave our last name to check in for a haircut. Some random lady sitting in the waiting room overhears it and starts talking about seeing me on some random advertisement the hospital had put me in. That means this lady - who was not a patient - had to see the advertisement, read it enough to memorize my name, and then immediately recognize my name out in "the wild", weeks later, to correctly identify my spouse.

People know my car, and will tell me their sister saw me in the Home Depot parking lot the other day. Which means the sibling/friend/whatever not only recognized my vehicle, but then talks about my vehicle/where I've been.

By maybe...the third month, ~75% of my new patient consults would tell me that I had seen/treated a family member or friend of theirs.

I cannot emphasize enough how important this additional awareness/skillset is for the hospital and the community. This is a sharp, sharp, sharp sword.

You know how we all know "bad" doctors, but it's hard for non-doctors to tell? And we all know bad doctors with good bedside manner so patients love them, right?

This is the first time I've seen random, low-health literacy people in the community know who the "bad" doctors are, and ask me to make sure I send them elsewhere if they need that kind of specialist.

A lot of my patients have dial-up internet. Or no internet. I don't ever have to worry about people finding out their test results before I do because, at most, 10% of my patients use the hospital portal. Most don't even know what that is if you ask them.

It would not be received well if the "young, new, hotshot doctor" who took over for the community pillar that was the prior RadOnc who retired "worked from home" every week.

Now obviously, if my hospital - or the rural hospital category in general - couldn't recruit a permanent RadOnc, then yeah, having some sort of locums/TeleRadOnc setup would basically be their only choice. Patients would still come here, but you can bet a billion dollars a lot of people would choose to drive a little further for the linac being run by the in-person permanent RadOncs.

I will definitely, one day, push for some level of "virtual" workday setup.

Mentally, I've sort of earmarked 2030 to start that conversation.

 

[udrag14]

I think you’re overestimating the enthusiasm of rural centers to have full remote coverage. Every hospital wants a face of their program and every hospital wants their patients to be seen in person at least most of the time. They want someone who is going to “be part of the local community” and who will build the practice. We have CMS approval of virtual supervision currently and hospitals aren’t embracing this. There are plenty of Radiation Oncologists who would be eager to do full-time remote clinical work if this were truly an option.

I think you are underestimating how many rural program want stability and save some money.

If they need to pay 750k for a 5 year on site versus 400k for 5 year off site, which would they pick?

Admins just care about the bottom line. If they can keep more money, they will pick that option.

 

[udrag14]

So the pe business model here is to ignore technical fees and go after some of the proffesional salary? To some extent, this will happen but not from pe. Hospitals with more than one center will just hire one doc.

I think they will love to have techinical, but you don't need it. You just underpay/overwork your doctor staff.

 

[MidwestRadOnc]

I think they will love to have techinical, but you don't need it. You just underpay/overwork your doctor staff.

Why didn’t genesis care succeed with global?
I guess there’s less risk with taking a percentage off pro only if the labor supply is there. But it would have to be a pretty lean operation on a large scale.

 

[fiji128]

I think you are underestimating how many rural program want stability and save some money.

If they need to pay 750k for a 5 year on site versus 400k for 5 year off site, which would they pick?

Admins just care about the bottom line. If they can keep more money, they will pick that option.

I don't think this is true. It might be if the offsite number is around $150/$200k though.

 

[radoncle]

I don't think this is true. It might be if the offsite number is around $150/$200k though.

Agreed. In smaller community settings, word gets around quickly when a doctor leaves or if a program doesn’t have a doctor. Referral volume declines when there’s no face to send patients to especially in fields like rad onc that rely almost exclusively on referrals from other physicians.

Additionally, hospitals are very slow to accept change. It’s highly unlikely most places will be comfortable not having an onsite physician at least part/most of the time.

 

[MidwestRadOnc]

There are some hospitals that understand it’s better to have a single well liked doctor there less than 5 days a week than have rotating locums.

There are also many stupid administrators that only care about bottom line. Dumb enough to staff through something like bridge oncology? I don’t know. Would be interested where this is being used if anywhere right now.

And everything in between.

I would not consider a rural position at this point unless it was understood I could cover remotely 1-2 days a week. I’m sorry for those of you stuck in these positions pre 2020 rule change. I agree it’s going to be a hard sell to change that pattern without threatening to leave and meaning it.

 

[elementaryschooleconomics]

There are some hospitals that understand it’s better to have a single well liked doctor there less than 5 days a week than have rotating locums.

There are also many stupid administrators that only care about bottom line. Dumb enough to staff through something like bridge oncology? I don’t know. Would be interested where this is being used if anywhere right now.

And everything in between.

I would not consider a rural position at this point unless it was understood I could cover remotely 1-2 days a week. I’m sorry for those of you stuck in these positions pre 2020 rule change. I agree it’s going to be a hard sell to change that pattern without threatening to leave and meaning it.

Yup.

It's easy to forget that at the individual level, $400k vs $750k is a lot.

However, anyone who has seen behind the curtain and knows how much revenue a single RadOnc generates for a hospital knows ~$250k is an absolute pittance. Unless you're at one of the odd sites where there's just enough population to justify having a linac, but you you rarely break ~10 on beam...$250k is <5% of your value to the hospital.

That being said, I absolutely have encountered brain-dead admin who are willing to torch $30 million in revenue over <$1 million in contract disputes.

American healthcare is not an actual free market. It's a bizarre amalgamation of regulation, regulatory capture, inertia...and so on.

There's a reason we're still stuck with fax machines.

But there is a baseline understanding at most hospitals that have remained solvent for any length of time that having a stable/established physician is lucrative; a rotating locums cast or onboarding a new doc every couple years is not.

(sadly, that understanding does not trickle down financially to the stable/established doctors...)

 

[elementaryschooleconomics]

I would not consider a rural position at this point unless it was understood I could cover remotely 1-2 days a week. I’m sorry for those of you stuck in these positions pre 2020 rule change. I agree it’s going to be a hard sell to change that pattern without threatening to leave and meaning it.

I also want to comment on this particular aspect simply because I want to continue to harp on the nuance in the "lifestyle" thing:

First, to reiterate a bigger point - this rural doc/local celebrity thing is an excellent example of why it's insanely cruel to wave away oversupply and call it a mechanism to "fix maldistribution". It's not fair to the doc (and their family) who wanted to be in a big city, but now gets recognized in the McDonald's drive-thru (the only food place open after 8PM). It's not fair to the community, who will have yet another doc leave after a short time as soon as they can get a job in the place they really wanted to be. I see this almost every day right now with PCPs. OBVIOUSLY, the whole country is hurting for PCPs, so I assume I'm not alone in experiencing this, but many of my patients are getting re-assigned to a new PCP (usually an APP) yearly (or faster) because there's so much turnover. It's...causing a lot of anxiety and issues.

But: as bizarre as being a "local celebrity" is, and as annoying as it can be to literally only have a single business/restaurant capable of hosting a professional function (or that there's no movie theater closer than 45 minutes away, etc, etc, etc) - if you're built to enjoy these environments (I can live in a shack if the woods if you give me the internet and Amazon Prime), there are few things more professionally rewarding than being able to witness the massive, positive impact you can have on a huge geographic region.

The double-edged sword is razor thin, but this may be one of the last frontiers of being the "classic" stereotype of a small-town doctor, and NOT just a cog in a machine.

I just wanted to clarify that point, because I don't plan on leaving this whacky, insane job anytime soon - but I also wouldn't recommend it to most people.

Swords. Edges. You get the point (pun intended, hehe).

 

[drowsy12]

Count me in on not wanting to be in a rural location. But those locations have multiple more med oncs and surgeons to justify the rad oncs existence, what’s so unique about us as rad oncs that we don’t want to do it, even when there are financial incentives?

Are we just that much more worldly? (/s)