I listened...It should be on it's own thread or the ROCR thread.
First and foremost, the work put in by Beckta is remarkable. The tracking down of original source material, the analysis...it is just an enormous amount of work and is testimony to his diligence, intellect and willingness to do work that begets little credit. Amazing actually. The guy needs to sleep.
It was a little long and granular for messaging purposes, but appropriate for creating a source of reference material or starting points for a professional investigative journalist. I believe that Beckta can be a remarkable force for change in the field. He needs to package something in 30 to 45 minutes. He has the tools to be a major public intellectual regarding healthcare.
My takes: (
Caveat...there is no mid career radonc who is more of a nobody (or out of the loop) than me. Not an ASTRO member for 10 years, assiduously avoided travel and most presentations even during residency and work at a relatively small community hospital away from major metros. I know none of the important players personally, but have had some contact with some ASTRO leaders in the distant past.)
1. Starting with 21c was appropriate, but the soft peddling of the Dosoretz narrative felt strategic to me. I have never met any Dosoretz or Connie Mantz, and they may be lovely people, but I think the sum total of the 21c experience to outside radiation oncology has to be a cautionary tale of PP excess. I find the narrative that expansion begot inclusion of poor behavior subsidiaries outside of corporate influence probably not tenable. My practice took over a small rural clinic run by 21c during their peak expansion period. Physics oversight was very centralized. Practice was clearly very corporately motivated (but not bad). There was an emphasis on maximizing revenue and the contract that they were able to extract from a vulnerable rural hospital would be considered predatory by most smaller practices (and was not sustainable). They did not work to grow the practice, so much as to extract revenue from it. The numerous lawsuits, known political behavior and lack of consequences at the top speak for themselves.
2. The trial Humana/Century bundled model from 2013 is really interesting and from a distance speaks to Mantz's remarkable initiative. As someone completely outside the fold, I am amazed at the integration of at first 21c and then Genesis into academic radiation oncology. You will find Mantz as an author on fairly high profile (for radonc 🤣) database work, DEI work, prostate outcomes work, combined XRT/IO work and value based care work. There is no doubt that the folks at 21c were wicked smart, strategic and understood the full value of creating and maintaining close relationships with big player academia.
The limited term Humana bundled payment trial should be put in context of both how big 21c was at that time and the long known narrative that radical payment changes are impending. (I liken it a little bit to climate change prognosticators who know big bad change is coming but inevitably pay a political price when trying to act within a specific time frame). The limited model provided fodder for academic and policy work and almost certainly was not very meaningful financially.
I agree that Mantz should be pretty forthcoming about this. "We ran this model back in fiscal year 2013 and these are the numbers" type of thing. There are lots of ways to dismiss damaging numbers and the strategic point I'm sure Mantz would make is that the numbers would look different today and more importantly the model must be measured relative to what the alternative is going to be.
That Mantz filed a patent (for a product that will assign a quantitative assessment of clinical reasonableness) is not surprising but is kind of disgusting to me. The fact is, if you have detailed knowledge of a regulatory environment, your opportunity to patent a "product" is remarkable. You don't need a prototype, and this feels like laying claim to an intellectual property "space" by an insider creating that space. I'm a little surprised that Beckta was not offended by the product itself and he astutely noted that guidelines essentially function as such a product in the present day.
When you think of the ramifications of such a product, they are pretty horrifying. It is another step in taking away the most powerful and uniquely human tool for making high touch decisions...the narrative. Narrative will be the tool I bludgeon @RealSimulD with when we get on an Evicore call.
3. The ending was strong, but the people that matter don't give AF and I'm starting to suspect that ASTRO may have some effective political operatives. The end run around CMS is the point and CMS itself is a bit denigrated by most. Congress making changes on medical payment models in a lame duck session is more palatable to the populist right than having experts decide how to budget. A republican congress and president may well financially starve or actively diminish the regulatory portions of the executive branch as part of their brand. (See Carson and Zinke under Trump).
4. As
@sirspamalot says, "It's all about the money". The shear wealth, number of LLCs and related political contributions of Dosoretz are remarkable and may warrant a podcast themselves. The big academics are just institutionalists at rich institutions. ROCR if of course a model that will preferentially benefit the rich.
Interesting as Mantz himself is an author on a paper regarding the disproportionate impact of APM on rural clinics....now, that is virtue signaling.
