MDACC no longer accepting consults if patients might be treated elsewhere

[OTN]

Had a patient call MDACC for a second opinion. Was told by an NP in the radiation department that "It is not our habit to consult patients who do not plan on getting their radiation here." As she could not guarantee to them she would be treated in Houston, they did not accept her consult.

On another note, MDACC received $212 million in tax dollars from the state of Texas last year, on top of hundreds of millions of dollars from the federal government for research: https://www.mdanderson.org/documents/about-md-anderson/about-us/facts-and-history/quick-facts.pdf

---

Members don't see this ad.

 

[fiji128]

One of the nice things about being at a bottom feeding community practice is I rarely get second opinion consults. Personally, I know I would get quite frustrated as doc if I had to see a ton of patient's that wanted my expertise but had no attention of being treated at my facility.

 

[yesmaster]

What if a patient plans on getting radiotherapy at MDACC, but after they visit, they get a second opinion at another practice and opt elsewhere? Does MDACC send them a bill for $300k for the proton therapy they "promised" to receive?

 

[OTN]

One of the nice things about being at a bottom feeding community practice is I rarely get second opinion consults. Personally, I know I would get quite frustrated as doc if I had to see a ton of patient's that wanted my expertise but had no attention of being treated at my facility.

I actually agree- it would be frustrating to give one's opinion a lot and not treat. However...that's the gig.

 

[seper]

That's foolish of MDACC. I work at a sort of "destination cancer hospital" too and love to see second opinions who will not come to me for treatments. I get to show off my knowledge of data, impress patients and residents.

 

[yesmaster]

Personally, I know I would get quite frustrated as a doc if I had to see a ton of patient's that wanted my expertise but had no attention of being treated at my facility.

Personally, I hate this proceduralist attitude. It's important for patients to understand their options and feel comfortable with a treatment plan, and if that involves talking to multiple doctors, that's totally fine. I say this partly from seeing myself and family go through "procedure mill" type practices for other, not oncologic conditions. Proceduralists who want to do lots of procedures and nothing else tend to be perfunctory in their counseling/consultations.

I don't dislike MDA, but I feel like there's a push to get as many patients onto the proton conveyor belt as possible. Certainly, the financial incentives are set up to push proton utilization at the institutional and faculty level.

 

[evilbooyaa]

Yeah this should be publicly known, IMO. Can't really call yourself an oncology mecca without doing a second opinion consult here and there. I mean... they certainly have enough physicians for it already, right?

 

[ramsesthenice]

I actually agree- it would be frustrating to give one's opinion a lot and not treat. However...that's the gig.

Yep. It can be frustrating but if your institution accepts state money to further their mission of caring for residents of that state you are on shaky ethical ground to deny citizens your "expertise."

 

[RickyScott]

Personally, I hate this proceduralist attitude. It's important for patients to understand their options and feel comfortable with a treatment plan, and if that involves talking to multiple doctors, that's totally fine. I say this partly from seeing myself and family go through "procedure mill" type practices for other, not oncologic conditions. Proceduralists who want to do lots of procedures and nothing else tend to be perfunctory in their counseling/consultations.

I don't dislike MDA, but I feel like there's a push to get as many patients onto the proton conveyor belt as possible. Certainly, the financial incentives are set up to push proton utilization at the institutional and faculty level.

I am so suspicious of proton research from mdacc

 

[OTN]

I am so suspicious of proton research from mdacc

I have heard first-hand accounts of data fudging on the esophageal trial to try and make it favorable for protons.

 

[medgator]

Had a patient call MDACC for a second opinion. Was told by an NP in the radiation department that "It is not our habit to consult patients who do not plan on getting their radiation here." As she could not guarantee to them she would be treated in Houston, they did not accept her consult.

On another note, MDACC received $212 million in tax dollars from the state of Texas last year, on top of hundreds of millions of dollars from the federal government for research: https://www.mdanderson.org/documents/about-md-anderson/about-us/facts-and-history/quick-facts.pdf

Not to mention being a premier pps exempt center committing financial toxicity at a massive scale...

Then again, consults/cognitive work doesn't rake in the dough

 

[Mandelin Rain]

If true, this is patently absurd and if you are a physician working for MDACC you should be both embarrassed and disappointed in your institution and yourself for allowing such a thing to happen.

 

[Lamount]

The responses here surprise me a little. I figured people in PP would be happy about this sort of thing, as it makes it less likely that MDACC will be ‘poaching’ patients.

Working at an academic center, I see some second opinions. I don't explicitly try to convince patients to forgo local treatment for our center (except for a very few cases where they were getting inappropriate treatment... like fractionated RT for stage I lung), but I have had a number of patients ask to have their treatment with us -and I don't refuse unless it is palliative.

 

[Mandelin Rain]

I think it's just understanding that the primary function of our jobs as physicians is to serve patients, no matter what that looks like or what it pays.

Maybe MDACC just isn't that committed to serving cancer patients.

 

[OTN]

The responses here surprise me a little. I figured people in PP would be happy about this sort of thing, as it makes it less likely that MDACC will be ‘poaching’ patients.

Working at an academic center, I see some second opinions. I don't explicitly try to convince patients to forgo local treatment for our center (except for a very few cases where they were getting inappropriate treatment... like fractionated RT for stage I lung), but I have had a number of patients ask to have their treatment with us -and I don't refuse unless it is palliative.

To me it's just more of a signal that MDACC is going to do everything they can to keep patients at their facility, so I don't think we can expect the poaching to decrease.

I have had physicians in their department lie directly to patients about me and my ability to treat them safely and effectively. Not surprisingly, when I call these docs to have a little dialogue about how I treat patients, suddenly their concerns were nowhere to be found.

 

[Mandelin Rain]

Hot take: MDACC residents struggle in private practice and I'd think very hard before hiring one.

 

[StIGMA]

This should be the policy at every MDACC network member. To really emphasize how ridiculous this policy is.

Cancer Network Partners

See a full list of partner members, certified members, associate members and affiliates of the MD Anderson Cancer Network.

www.mdanderson.org

 

[yesmaster]

I figured people in PP would be happy about this sort of thing, as it makes it less likely that MDACC will be ‘poaching’ patients.

MDA isn't saying "get treated in your community", it's saying "don't just come here for the 2nd opinion, stay for treatment, too".

More poaching is the goal, not less.

 

[BobbyHeenan]

You think this is a function of more people requesting lots of Zoom/Telehealth second opinions overwhelming the consult service?

 

[fiji128]

I would say at the end of the day none of this has anything to do with patients/good medicine. I'm sure its just a business calculation centered on generating the most amount of revenue for the least cost.

 

[fiji128]

You think this is a function of more people requesting lots of Zoom/Telehealth second opinions overwhelming the consult service?

Very well could be.

 

[OTN]

You think this is a function of more people requesting lots of Zoom/Telehealth second opinions overwhelming the consult service?

So hire more radoncs. Plenty running around.

 

[ramsesthenice]

You think this is a function of more people requesting lots of Zoom/Telehealth second opinions overwhelming the consult service?

Overwhelming? I doubt it. More likely its a run of the mill calculated decision. Our system doesn't pay us to think. It pays us to do. Someone (or many someones) has decided the ROI isn't there to spend time talking to people for comparatively negligible rates. I personally think routinely declining consults/second opinions is a crappy position to take, but it is perferrable to the practice of trying to convince anyone and everyone that they "need" to stay for treatment. As I implied above, my main beef with this position is the fact they get state funding.

 

[medgator]

Overwhelming? I doubt it. More likely its a run of the mill calculated decision. Our system doesn't pay us to think. It pays us to do. Someone (or many someones) has decided the ROI isn't there to spend time talking to people for comparatively negligible rates. I personally think routinely declining consults/second opinions is a crappy position to take, but it is perferrable to the practice of trying to convince anyone and everyone that they "need" to stay for treatment. As I implied above, my main beef with this position is the fact they get state funding.

And they get paid more than everyone else to deliver the same photons

 

[ramsesthenice]

And they get paid more than everyone else to deliver the same photons

Endowments don't grow on their own. Wait a minute...yes they do. Never mind.

 

[Radonc 2013]

You think this is a function of more people requesting lots of Zoom/Telehealth second opinions overwhelming the consult service?

I'm not sure how long state licensing requirements for out of state providers were or will be exempted due to COVID. If these policy changes that allow for out of state physicians to provide telemedicine consultations become permanent, it will be a game changer for large cancer centers. Their reach will become much more significant, and more opportunities to convince patients to make the trip for treatment. If I'm MDA, I'm never turning down an opportunity to pitch someone. I would do the opposite and advertise heavily and promote telemedicine visits in states that allow for out of state telemedicine visits in an attempt to capture more patients.

 

[fiji128]

You run into diminishing returns at some point. Is doing telemedicine on 25 out of state consults to maybe get one patient in the door worth it? I'd say probably not.

 

[yesmaster]

To be fair, UT’s $32 billion endowment is from oil & gas money.

 

[Radonc 2013]

You run into diminishing returns at some point. Is doing telemedicine on 25 out of state consults to maybe get one patient in the door worth it? I'd say probably not.

I would be interested to see what kind of conversion rate you would be looking at. I'm sure much lower than the people that actually travel to MDA, but even the patients seen by telemedicine are showing some degree of interest in possibly traveling for their care. The downstream revenue generated by the single patient in terms of surgery, chemotherapy, radiation, imaging, and labs could be substantial. Especially if they are able to charge more for the same treatments...it sounds like the economics are vastly different than my lowly community cancer center.

 

[RickyScott]

This should be the policy at every MDACC network member. To really emphasize how ridiculous this policy is.

Cancer Network Partners

See a full list of partner members, certified members, associate members and affiliates of the MD Anderson Cancer Network.

www.mdanderson.org

I would be interested to see what kind of conversion rate you would be looking at. I'm sure much lower than the people that actually travel to MDA, but even the patients seen by telemedicine are showing some degree of interest in possibly traveling for their care. The downstream revenue generated by the single patient in terms of surgery, chemotherapy, radiation, imaging, and labs could be substantial. Especially if they are able to charge more for the same treatments...it sounds like the economics are vastly different than my lowly community cancer center.

Consult price alone at mdacc can be thousands

 

[thecarbonionangle]

As someone who not uncommonly sees multiple out of state, second/third opinion consults (path reviewed at multiple places, multiple rad oncs have weighed in), i can also say that it can be extremely annoying for me. The amount of work involved is significantly more than a usual consult. there is tons of imaging to get, tons of reports to chase down, fighting with other places to send you notes in time. A good amount stay because I got that effect on people but a good amount basically just waste your time.
I see no way around it, however. It is painful but necessary.

 

[Mandelin Rain]

As someone who not uncommonly sees multiple out of state, second/third opinion consults (path reviewed at multiple places, multiple rad oncs have weighed in), i can also say that it can be extremely annoying for me. The amount of work involved is significantly more than a usual consult. there is tons of imaging to get, tons of reports to chase down, fighting with other places to send you notes in time. A good amount stay because I got that effect on people but a good amount basically just waste your time.
I see no way around it, however. It is painful but necessary.

Cuts into dat Twitter time tho. Hire another NP.

 

[evilbooyaa]

You run into diminishing returns at some point. Is doing telemedicine on 25 out of state consults to maybe get one patient in the door worth it? I'd say probably not.

I do think that spamming telehealth availability to everywhere in the country is somewhat unlikely in terms of panning out in terms of ROI, but the concept of them not approving second opinions from within the same STATE that their facility is open in? Bonkers.

If I was them I would be pushing that every single patient within a 4-5 hour radius come see me. Then, those that have the financial means to actually come for a consult on-site (would not offer tele-health because that makes it 'too easy' for any tom, dick, or harry to get a consult), see the awesome buildings, campus, and get suckered into pouring their life savings into a hotel (preferably an on-campus one) for their 5-9 weeks of prostate/breast/H&N/whatever proton radiation. Offering too much tele-health is a loser in terms of patient retention.

People think Princeton, and go meh. Then they see the Princeton campus, and go "omg I want to come here". I've never been to MDACC, but I'm sure it's quite visually appealing. Gotta get people in to see the prettiness.

I was thinking about this a bit more since my initial reply. I wonder if what you probably ran into is a NP who is "overworked" and "salaried, doesn't get a production bonus" try to have an out to do work. Easy to claim something as 'institutional policy' when it's just somebody going rogue. I wonder if somebody can actually ask MDACC if this is a real thing.

 

[Mandelin Rain]

I was thinking about this a bit more since my initial reply. I wonder if what you probably ran into is a NP who is "overworked" and "salaried, doesn't get a production bonus" try to have an out to do work. Easy to claim something as 'institutional policy' when it's just somebody going rogue. I wonder if somebody can actually ask MDACC if this is a real thing.

This though did occur to me.

 

[Palex80]

I had a patient ask for a second opinion in MGH once for a skull base tumor. It was a pricey, but she wanted to have the consult, it was all done virtual and the patient clearly stated that she was merely asking for a second opinion from a famous well-known center for proton therapy in skull base tumors but would not undergo treatment there, since she could not afford it.
She liked the consult alot and I found the written report quite detailed and very well formulated (although I do suspect they propably copy-paste those for all the skull base tumor patients they see for consults).

Anyways, I do not see why doing consults as a second opinion center without treating the patents will a) not work as a business model (there are obviously enough patients that would like to have their plan of therapy written out by the MDACC, irrelevant of the price tag - as long as it's not absourdly high) and b) enhance your fame and reputation.

 

[dieABRdie]

I was thinking about this a bit more since my initial reply. I wonder if what you probably ran into is a NP who is "overworked" and "salaried, doesn't get a production bonus" try to have an out to do work. Easy to claim something as 'institutional policy' when it's just somebody going rogue. I wonder if somebody can actually ask MDACC if this is a real thing.

Or an NP who's immediate superior administrator knows they can be more effective in bossing around a nurse practitioner rather than an academic attending physician. They're most likely being pressured to sift out the "unproductive" visits. Its highly unlikely this is the work of a radiation oncologist.

 

[w00tz]

Financially, I don't see how this benefits them. I can't imagine an admin saying "let's turn away potential patients", unless they are swimming in patients right now, but I don't think they are? I guess we will see if this works out for them or actually decreases their numbers.

Side note - second opinions can be draining, IMO. Not only do you have to say everything you normally say, then sometimes the patient asks you to compare and contrast stuff from other docs, and you have to sell the patient on your practice.

I'm just imagining a standard prostate consult, which tends to be very long. At MDACC, they offer photons, protons, brachy, brachy boost?, clinical trials, discussing ADT, surgery which going over all of those can take forever already. Add to the clinical stuff, trying to schmooze the patient to get the patient treated at your center. You have to kick up the attentiveness a few notches to build that rapport. Convince them that moving to Houston for treatments will be better for them than getting it where they are from. After the consult, you anxiously wait for the patient's response while they deliberate. May not be a huge deal for some people, but I am somewhat introverted so that extra schmooze doesn't come naturally. But when I know a patient is getting a second opinion, the gauntlet has been thrown and the pressure is on to get the patient. All that ends up being pretty draining to me, but I'm also in PP. Not sure if there is that same pressure at MDACC/academics.

 

[RadOncDoc21]

Financially, I don't see how this benefits them. I can't imagine an admin saying "let's turn away potential patients", unless they are swimming in patients right now, but I don't think they are? I guess we will see if this works out for them or actually decreases their numbers.

Side note - second opinions can be draining, IMO. Not only do you have to say everything you normally say, then sometimes the patient asks you to compare and contrast stuff from other docs, and you have to sell the patient on your practice.

I'm just imagining a standard prostate consult, which tends to be very long. At MDACC, they offer photons, protons, brachy, brachy boost?, clinical trials, discussing ADT, surgery which going over all of those can take forever already. Add to the clinical stuff, trying to schmooze the patient to get the patient treated at your center. You have to kick up the attentiveness a few notches to build that rapport. Convince them that moving to Houston for treatments will be better for them than getting it where they are from. After the consult, you anxiously wait for the patient's response while they deliberate. May not be a huge deal for some people, but I am somewhat introverted so that extra schmooze doesn't come naturally. But when I know a patient is getting a second opinion, the gauntlet has been thrown and the pressure is on to get the patient. All that ends up being pretty draining to me, but I'm also in PP. Not sure if there is that same pressure at MDACC/academics.

I would assume they may have it easier. I find the secret to a second opinion is to kindly tell them that their doc for the most part is doing the right thing and it’s “acceptable” but it’s not the MDACC way which is the only way!

 

[jeebus69]

Hot take: MDACC residents struggle in private practice and I'd think very hard before hiring one.

Really? First hand experience?

 

[ramsesthenice]

Hot take: MDACC residents struggle in private practice and I'd think very hard before hiring one.

I’ve heard people say stuff like this before for both private and academics. My personal guess is it’s an over simplification with a few issues at play:

1) they put out a ton of residents. By default, they are probably going to put out more duds than smaller programs simply because of volume.

2) enough places are enamored with MDACC that their top grads get the pick of the litter when it comes time to find a job. Unless you work in a super desirable market your sample is probably biased towards their less competitive grads that got outcompeted for the top positions.

3) confirmation bias. Lots be honest, a lot of us are jaded by centers like MDA calling themselves authorities, claiming to be expert experts, and getting away with charging insane rates most of us can’t get away with. We want to find things they are not good at. We may know someone who struggled a bit or heard of someone who did and latched on to it like scripture.

It’s hard for me to believe that all or even most of their former residents make subpar PP attendings.

 

[RickyScott]

I’ve heard people say stuff like this before for both private and academics. My personal guess is it’s an over simplification with a few issues at play:

1) they put out a ton of residents. By default, they are probably going to put out more duds than smaller programs simply because of volume.

2) enough places are enamored with MDACC that their top grads get the pick of the litter when it comes time to find a job. Unless you work in a super desirable market your sample is probably biased towards their less competitive grads that got outcompeted for the top positions.

3) confirmation bias. Lots be honest, a lot of us are jaded by centers like MDA calling themselves authorities, claiming to be expert experts, and getting away with charging insane rates most of us can’t get away with. We want to find things they are not good at. We may know someone who struggled a bit or heard of someone who did and latched on to it like scripture.

It’s hard for me to believe that all or even most of their former residents make subpar PP attendings.

Have no experience with mdacc grads, but my guess is confirmation bias. Everybody probably expects the world of the grads, so when a bad apple is encountered, it is shocking. I would hope that anyone smart enough to be there would be adaptable. Could see a situation where someone is too rigid and enthralled in the “mdacc way” that they can’t adapt to a different practice pattern, but would have to think that this is not typical. Mdacc residents are also treated much better than places like mskcc etc., so it is also possible that some are overly entitled?

 

[TheWallnerus]

This explains their new logo.

 

[anondoconda]

Anon MDA person here; we get a lot of confusion about this.


To clarify, OP is correct (kind of) that we don’t to 2nd opinions for “Rad Onc only” or “surgery only” or “just chemo, no RT” for many services for non-metastatic dz.

Patients have to come and do multi specialty eval (surg Onc/med Onc/Gyn onc/radonc) in order to receive a 2nd (or 1st, or any) opinion.

So if a patient declines to see our Radoncs, surgery won’t give opinion; same for us.

This loses us “standalone” Rad Onc 2nd opinions, but ensures multispeclaity evaluation (which is our hallmark).

 

[OTN]

Anon MDA person here; we get a lot of confusion about this.


To clarify, OP is correct (kind of) that we don’t to 2nd opinions for “Rad Onc only” or “surgery only” or “just chemo, no RT” for many services for non-metastatic dz.

Patients have to come and do multi specialty eval (surg Onc/med Onc/Gyn onc/radonc) in order to receive a 2nd (or 1st, or any) opinion.

So if a patient declines to see our Radoncs, surgery won’t give opinion; same for us.

This loses us “standalone” Rad Onc 2nd opinions, but ensures multispeclaity evaluation (which is our hallmark).

So my patient who already had her breast surgery and was happy with her medical oncologist wasn’t allowed to see a radonc, but instead would have had to see all three specialties?

“Multispecialty evaluation” is not a hallmark of MDACC. The vast majority of large private practices and academic centers do the same, ours included. Single-specialty groups are disappearing.

Forcing patients to undergo needless evaluation seems like fraud to me, but I also don’t get EKGs on all my patients before they start XRT, so what do I know?

 

[anondoconda]

So my patient who already had her breast surgery and was happy with her medical oncologist wasn’t allowed to see a radonc, but instead would have had to see all three specialties? “Multispecialty evaluation” is not a hallmark of MDACC. The vast majority of large private practices and academic centers do the same, ours included. Single-specialty groups are disappearing. Forcing patients to undergo needless evaluation seems like fraud to me, but I also don’t get EKGs on all my patients before they start XRT, so what do I know?

So my patient who already had her breast surgery and was happy with her medical oncologist wasn’t allowed to see a radonc, but instead would have had to see all three specialties? “Multispecialty evaluation” is not a hallmark of MDACC. The vast majority of large private practices and academic centers do the same, ours included. Single-specialty groups are disappearing. Forcing patients to undergo needless evaluation seems like fraud to me, but I also don’t get EKGs on all my patients before they start XRT, so what do I know?

 

[anondoconda]

Oh, and we won’t see non-emergent non-metastatic patients get seen without internal path review, so that’s a typical rate limiting step as well.

 

[RadOncDoc21]

So my patient who already had her breast surgery and was happy with her medical oncologist wasn’t allowed to see a radonc, but instead would have had to see all three specialties?

“Multispecialty evaluation” is not a hallmark of MDACC. The vast majority of large private practices and academic centers do the same, ours included. Single-specialty groups are disappearing.

Forcing patients to undergo needless evaluation seems like fraud to me, but I also don’t get EKGs on all my patients before they start XRT, so what do I know?

Seems like fraud because it is but again, health care is a billion dollar business. They know what they are doing and if the customers (patients) are willing to pay up, then the system (insurance companies, etc) will continue to allow it. As docs, we are all just pawns in this deadly game.

 

[medgator]

So my patient who already had her breast surgery and was happy with her medical oncologist wasn’t allowed to see a radonc, but instead would have had to see all three specialties?

“Multispecialty evaluation” is not a hallmark of MDACC. The vast majority of large private practices and academic centers do the same, ours included. Single-specialty groups are disappearing.

Forcing patients to undergo needless evaluation seems like fraud to me, but I also don’t get EKGs on all my patients before they start XRT, so what do I know?

Best part is when they try to repeat imaging studies there because they have the "best" scanners and it's hard to get outside studies. Have seen that behavior before.... Not hard to get studies on CD and have the patient hand carry them but that would be cost effective medicine

 

[jeebus69]

Lol wait so she liked her surgeon and her med onc but needed a second radonc opinion after seeing you? I don’t think the problem is with MDACC. Hot take! But hey, trashing mdacc is fun we all enjoy it.

I actually love seeing second opinion consults. Once the pathology is corrected, staging is completed, and the patient is referred to any necessary additional services, often times the treatment changes. Ultimately I find that the patients are grateful. PP docs have a giant Napoleon complex against academic medical centers and it’s manifested in pointless threads like this.

 

[medgator]

Lol wait so she liked her surgeon and her med onc but needed a second radonc opinion after seeing you? I don’t think the problem is with MDACC. Hot take! But hey, trashing mdacc is fun we all enjoy it.

I actually love seeing second opinion consults. Once the pathology is corrected, staging is completed, and the patient is referred to any necessary additional services, often times the treatment changes. Ultimately I find that the patients are grateful. PP docs have a giant Napoleon complex against academic medical centers and it’s manifested in pointless threads like this.

Plenty of time to do that with 5-10 under beam and a resident, huh? Some of those busier 10-15 pt services even have a PA i hear.

Disclosure: i have a great working relationship with some of the larger centers nearby, but certain academic centers, including the Anderson, are known to hardsell pts on staying their for treatment when they would be taken care of fine in the community. Just look at the bogus Palliative network article from UPenn.

Probably the first common sense thing mda has done in awhile is to cut training spots and train less of their competition