The Enemy

[BobbyHeenan]

This is truly embarrassing that this woefully underpowered study is published in Lancet Oncology

Surprised more haven’t been commenting how icky this study is

I've got a $20 bill that says the "peer reviewers" have a proton unit on their campus too.

How in the world can you look at that data and say that proton hypofrac seems like a good idea in these cases?

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[Lamount]

It is totally false that PA is always profit motivated. I work for a self insured hospital and have treated a number of staff, and sometimes have to deal with the PA. The insurance company is deploying PA as a performative gesture to employers.the hospital is paying the bill.

It is actually in the insurance company’s financial interest that the bill/radiation services are priced as high as possibe since the employer (hospital) is the one actually paying the bill and United is just taking a percentage.

It is amazing how many docs don’t understand the differing “insurances” out there. The majority of Americans recieve insurance through self insured employers. Why is this so hard to understand?

This is an important point... but I don't think it is the whole story. My understanding is... insurers are competing with each other to service any given employer. Thus, while the insurers get me money if they always say "yes" to claims, they could be undercut by a competitor -correct me if I am wrong.

 

[sirspamalot]

This is an important point... but I don't think it is the whole story. My understanding is... insurers are competing with each other to service any given employer. Thus, while the insurers get me money if they always say "yes" to claims, they could be undercut by a competitor -correct me if I am wrong.

When hospitals own insurance plans... Things get weird. I was in a meeting with multiple hospital systems once who had contracted PA.. self insured.

Ever seen a snake eating it's tail?

 

[RickyScott]

This is an important point... but I don't think it is the whole story. My understanding is... insurers are competing with each other to service any given employer. Thus, while the insurers get me money if they always say "yes" to claims, they could be undercut by a competitor -correct me if I am wrong.

Exactly, it is like radiation departments offering hypofract. They offer PA to compete with each other as a service for employers to manage costs. Of course, it is in the insurance companies financial interest that costs aren’t managed.

 

[sirspamalot]

Ok, I'm confused. Insurance companies themselves ALWAYS as an organism want to maximize retaining premiums and mitigate payout. Unless they are owned by a self insured say hospital, in which case, paying out benefits the underlying hospital owner. Lets flesh this out.

There are 2 basic ways that PA makes money: case PMPM cost flat service fee, and alternatively, buying risk and thru actuarial 2 year look back, figuring out that applying PA will result in greater premium retention than what the insurance company has been doing. You might get a 5% service fee for flat, but make 30% with risk buying.

If the hospital system self insures, and it also owns an insurance plan, then you are a snake eating your own tail. They can reduce spend to some degree, but in the end, they are shifting the win from the hospital back to their own plan. Truly though, what they are doing, is just cramming down the cost of their self insureds as employees, while stiffing the public to whom they sell their plan to on a bigger scale. Sure, it hurts the hospital.

But guess which one makes more money overall? Lets see... get a plan with 500,000 premium paying members.. the hospital will do "Well enough" even with some PA pain.. but the plan will reap fat stacks.

 

[RickyScott]

Ok, I'm confused. Insurance companies themselves ALWAYS as an organism want to maximize retaining premiums and mitigate payout. Unless they are owned by a self insured say hospital, in which case, paying out benefits the underlying hospital owner. Lets flesh this out.

There are 2 basic ways that PA makes money: case PMPM cost flat service fee, and alternatively, buying risk and thru actuarial 2 year look back, figuring out that applying PA will result in greater premium retention than what the insurance company has been doing. You might get a 5% service fee for flat, but make 30% with risk buying.

If the hospital system self insures, and it also owns an insurance plan, then you are a snake eating your own tail. They can reduce spend to some degree, but in the end, they are shifting the win from the hospital back to their own plan. Truly though, what they are doing, is just cramming down the cost of their self insureds as employees, while stiffing the public to whom they sell their plan to on a bigger scale. Sure, it hurts the hospital.

But guess which one makes more money overall? Lets see... get a plan with 500,000 premium paying members.. the hospital will do "Well enough" even with some PA pain.. but the plan will reap fat stacks.

The best way for insurance companies to earn a profit is not to be in the “insurance” business. Their most profitable service line is to coordinate the payments of self funded employers (which provide health care to the majority of Americans). No risk and pure predictable profit.
When a Walmart employee has radiation, Walmart is paying the bill. United/Aetna is just managing and coordinating everything for a transactional percentage. To compete with other insurances, they offer PA services, but there is no profit motive for the PA. They are not saving the insurance company money; in fact they are costing it potential profit.

 

[sirspamalot]

But you see, thats simply not true.

If the actuarial wizards do a 2 year look back at Walmarts radiology spend, apply PA limitations, and see they can cut cost by 22%, they'll offer to buy the risk pool for 5-10% off which is an incentive for Walmart to sell it.

Then, they go make 10-15% or more when they roll forward over 2 years, applying PA, rather than a measly 2-5% service contract.

We're talking millions per pool, and hundreds of pools. Big money.

With the largest PA approaching 500 physicians on staff, the majority being FT, you don't carry that payroll unless you got the cheddar to cover it.

 

[RickyScott]

But you see, thats simply not true.

If the actuarial wizards do a 2 year look back at Walmarts radiology spend, apply PA limitations, and see they can cut cost by 22%, they'll offer to buy the risk pool for 5-10% off which is an incentive for Walmart to sell it.

Then, they go make 10-15% or more when they roll forward over 2 years, applying PA, rather than a measly 2-5% service contract.

We're talking millions per pool, and hundreds of pools. Big money.

With the largest PA approaching 500 physicians on staff, the majority being FT, you don't carry that payroll unless you got the cheddar to cover it.

Pretty easy to verify health insurance companies major service lines and products.

 

[communitydoc13]

If the actuarial wizards do a 2 year look back at Walmarts radiology spend, apply PA limitations, and see they can cut cost by 22%, they'll offer to buy the risk pool for 5-10% off which is an incentive for Walmart to sell it.

What happens then? Is PA functionally insuring these patients or are they just changing the terms of their contract with Walmart in a way that seems beneficial to both parties. (What this means to the patient is more stringent review of services and criteria for said services).

Is PA functionally taking contracts based on flat service fees, then based on their analysis, choosing to functionally run the policy after their audits for a period of time?

Can they do this? What is keeping them from changing their behavior after purchasing the risk?

 

[deleted1111261]

Okay “PA” as a generalization is interesting

We have not “bought” any plans.

I love the speculation, tho. I can see the very large companies considering an overlap.

How much do you think PA companies charge for their services? I was surprised at how little.

 

[RickyScott]

I really don’t think spams assertion that population risks are packaged and sold is a major part of health insurance. I have been told repeatedly by people who work in the industry that the most common model is the employer straight up pays the bill and this is also supported by the academic. literature.

 

[sirspamalot]

You can believe whatever you want. The fact is, straight up, that risk purchasing resulted in the highest payouts.

Case management is like "we'll make it up on volume." Low margins, zero risk, big volume.

If your actuarial analysis says you can cut 30% and you buy for 10%, you make 20% on the big fat X pool. Simple.

THE ONLY safety net is the ability to appeal and pushback for when things go wrong. And things DID GO WRONG at times, and insureds relationships with senators got utilized, and people got spanked and fined/sued. Oh well.

By adhering to "guidelines" and trying hard to make those guidelines seem reasonable, PA can make plenty of money in the nooks and crannies of thousands of case types. Of course, there is so much grey in guidelines (e.g. 2B or not 2B) that PA can always tilt whatever way they want. They see all, you see nothing but the case in front of you.

In the earlier years, PA got so overwhelmed with caseload (sales team YAY execution team WE'RE DYING OVER HERE) that mass auto-approvals to "catch up" occurred.

Whistleblower made it known, and big auto approvals was declared as FRAUD. But but.. people got what they wanted you say. YES but the fraud was telling insco that reviews would be done and they were not.

Oh well, pay the fine, move along.

PA stops a few bad docs, for sure. And the focus should be on those bad apples. Hello gold card! But the nitty gritty is where the money is at..and PA is a master at that. Billions say so. Maybe care improves for a small # of patients too, but at what cost to the thousands of inappropriate denials, delay in care, etc? I can only wonder but my gut says the abacus on that don't shift to the positive. Maybe for radiation oncology it really does help in the net net, but for many other areas, I'm less convinced. Has there ever been a study published that shows net benefit? Bueller? Anyone? Anyone?

Appeal anything that remotely doesn't sit right with you, but know that your time and exhaustion eventually will wear you down. You do it for free. Its like the casino, you've already lost no matter how hard you try.

 

[winstonfoot5]

Lawsuit raises antitrust and kickback allegations around cancer patient referrals

Oncologists in Philadelphia are alleging Jefferson Health system is violating federal antitrust and kickback laws by creating a “concerted campaign to eliminate” the group’s “presence in the oncology marketplace.”

www.statnews.com

STAT+
Lawsuit raises antitrust and kickback allegations around cancer patient referrals
Bob Herman
By Bob Herman Sept. 8, 2023


Oncologists in Philadelphia are alleging Jefferson Health system is violating federal antitrust and kickback laws.

A large independent group of oncologists in Philadelphia is suing the area’s dominant hospital system, Jefferson Health, alleging the system is violating federal antitrust and kickback laws by creating a “concerted campaign to eliminate” the group’s “presence in the oncology marketplace.”

The lawsuit resurfaces longstanding concerns associated with hospitals buying up physician groups and then forcing those physicians to refer patients to the hospitals’ own facilities, even if that’s not in a patient’s best interest. Hospitals have increasingly acquired physician groups over the past 15 years, and in the process have entrenched monopoly positions for certain types of care by preventing patients from “leaking” to competitors.

Obtaining more market share and negotiating power isn’t the only incentive for hospitals to scoop up physicians. Oncology, in particular, is a lucrative specialty for hospitals to own. Revenue is immediately boosted because hospitals are able to charge more for the cancer doctors’ services in a hospital-owned clinic, even though those same services would be significantly cheaper in an independent clinic. Hospitals that participate in a federal drug discount program, known as 340B, also are able to buy expensive chemotherapy drugs for cheap while still billing insurers full freight.

Alliance Cancer Specialists, a group of 36 oncologists, said those factors are exactly at play in its part of Philadelphia. ACS alleged its longstanding relationship with Jefferson deteriorated in recent years after it rebuffed Jefferson’s acquisition attempt. Jefferson allegedly started demanding that its own hospitalist physicians only refer cancer patients to oncologists who are employed by Jefferson instead of sending them to ACS.

“The physicians who received this message reasonably understood it to mean that under all circumstances, only referrals to [Jefferson’s] hospital-employed physicians are acceptable,” according to the lawsuit.

Top medical leaders at Jefferson then hinted to its physicians “their continued employment was conditioned upon their referrals” only to Jefferson’s cancer doctors, the lawsuit alleged. Jefferson also tied the incentive compensation of its physicians to whether cancer patients were retained “in-house,” according to the suit, which is based on ACS’ alleged interactions with Jefferson as of last month

ACS said Jefferson most recently threatened to terminate the privileges of its oncologists at a handful of Jefferson’s hospitals by Sept. 16 — meaning those doctors could no longer treat or admit patients at those specific facilities.

Trending Now: How a supplement company became a haven for health misinformation
A spokesperson for Jefferson Health would not confirm whether the system sent a letter stating that it will revoke the privileges of ACS doctors. The system does not comment on pending litigation. However, “we intend to vigorously defend our position,” the spokesperson said.

Federal law specifically outlaws hospitals paying for referrals. The federal government has intervened in several cases over the past few years, including some that involve cancer care.

 

[NotMattSpraker]

Sorry to perseverate but the non-inferiority margin was 10%. Control arm expected to be 10% they would accept a doubling of complications (20%) and conclude non-inferiority. WTF?

It's not perseverating. I read this paper twice because I couldn't believe what I was reading.

People can critique the design for sure, but its not that wildly out of the realm of "biased design" in my opinion. It was a trial clearly set up to show benefit of protons. Others have done that. See lymphoma. Certainly we can all poke the 10% margin but these are the things people have to do in order to get activation and funding to complete radiation trails.

The issue for me is the discussion and the quotes in the news article. No one made them do that. Everyone should come down hard on these authors for the way they are interpreting their obviously biased design. It is egregious.

I walked away thinking about all the yelling that proton evangelists do about insurance approval tainting their trials. With result interpretations like this paper, Im not sure they deserve insurance approval honestly.

This is the first randomized proton trial for the top cancer treatment indication in the US. We should all be embarrassed and concerned about how future trials will be reported. Also, probably a little jealous of European investigators. It's become clear that the business of medicine has severely compromised our ability to operate scientifically as physicians.

 

[elementaryschooleconomics]

This is the first randomized proton trial for the top cancer treatment indication in the US. We should all be embarrassed and concerned about how future trials will be reported. Also, probably a little jealous of European investigators. It's become clear that the business of medicine has severely compromised our ability to operate scientifically as physicians.

This is the first randomized proton trial for the top cancer treatment indication in the US. We should all be embarrassed and concerned about how future trials will be reported. Also, probably a little jealous of European investigators. It's become clear that the business of medicine has severely compromised our ability to operate scientifically as physicians.

Just wanted to...reiterate that a bit.

 

[TheWallnerus]

This is the first randomized proton trial for the top cancer treatment indication in the US. We should all be embarrassed and concerned about how future trials will be reported. Also, probably a little jealous of European investigators. It's become clear that the business of medicine has severely compromised our ability to operate scientifically as physicians.

Just wanted to...reiterate that a bit.

Rereiterating.

 

[grenz]

This is the first randomized proton trial for the top cancer treatment indication in the US. We should all be embarrassed and concerned about how future trials will be reported. Also, probably a little jealous of European investigators. It's become clear that the business of medicine has severely compromised our ability to operate scientifically as physicians.

Just wanted to...reiterate that a bit.

What does everyone think about the potential utility of making public records requests for proton centers owned by a public university hospital? See if there’s discussion about spinning study results?

 

[elementaryschooleconomics]

What does everyone think about the potential utility of making public records requests for proton centers owned by a public university hospital? See if there’s discussion about spinning study results?

I have it on good authority *exaggerated winking* that some people may have started doing just this awhile ago, and that reviewing the records for disclosure takes forever.

 

[temujim]

Sorry to perseverate but the non-inferiority margin was 10%. Control arm expected to be 10% they would accept a doubling of complications (20%) and conclude non-inferiority. WTF?

Probably what happened is authors got funding (Mayo, small bits from NCI, etc), not nearly enough to run a reasonable study, and turned to the statistician and said make it work. Then crossed their fingers they wouldn't have to answer uncomfortable questions. No dice, so looks kind of silly. But hey, Lancet Oncology.

 

[grenz]

I have it on good authority *exaggerated winking* that some people may have started doing just this awhile ago, and that reviewing the records for disclosure takes forever.

Takes forever but ultimately we get the records? Nice

 

[Gfunk6]

It's not perseverating. I read this paper twice because I couldn't believe what I was reading.

People can critique the design for sure, but its not that wildly out of the realm of "biased design" in my opinion. It was a trial clearly set up to show benefit of protons. Others have done that. See lymphoma. Certainly we can all poke the 10% margin but these are the things people have to do in order to get activation and funding to complete radiation trails.

The issue for me is the discussion and the quotes in the news article. No one made them do that. Everyone should come down hard on these authors for the way they are interpreting their obviously biased design. It is egregious.

I walked away thinking about all the yelling that proton evangelists do about insurance approval tainting their trials. With result interpretations like this paper, Im not sure they deserve insurance approval honestly.

This is the first randomized proton trial for the top cancer treatment indication in the US. We should all be embarrassed and concerned about how future trials will be reported. Also, probably a little jealous of European investigators. It's become clear that the business of medicine has severely compromised our ability to operate scientifically as physicians.

Lawsuit raises antitrust and kickback allegations around cancer patient referrals

Oncologists in Philadelphia are alleging Jefferson Health system is violating federal antitrust and kickback laws by creating a “concerted campaign to eliminate” the group’s “presence in the oncology marketplace.”

www.statnews.com

STAT+
Lawsuit raises antitrust and kickback allegations around cancer patient referrals
Bob Herman
By Bob Herman Sept. 8, 2023


Oncologists in Philadelphia are alleging Jefferson Health system is violating federal antitrust and kickback laws.

A large independent group of oncologists in Philadelphia is suing the area’s dominant hospital system, Jefferson Health, alleging the system is violating federal antitrust and kickback laws by creating a “concerted campaign to eliminate” the group’s “presence in the oncology marketplace.”

The lawsuit resurfaces longstanding concerns associated with hospitals buying up physician groups and then forcing those physicians to refer patients to the hospitals’ own facilities, even if that’s not in a patient’s best interest. Hospitals have increasingly acquired physician groups over the past 15 years, and in the process have entrenched monopoly positions for certain types of care by preventing patients from “leaking” to competitors.

Obtaining more market share and negotiating power isn’t the only incentive for hospitals to scoop up physicians. Oncology, in particular, is a lucrative specialty for hospitals to own. Revenue is immediately boosted because hospitals are able to charge more for the cancer doctors’ services in a hospital-owned clinic, even though those same services would be significantly cheaper in an independent clinic. Hospitals that participate in a federal drug discount program, known as 340B, also are able to buy expensive chemotherapy drugs for cheap while still billing insurers full freight.

Alliance Cancer Specialists, a group of 36 oncologists, said those factors are exactly at play in its part of Philadelphia. ACS alleged its longstanding relationship with Jefferson deteriorated in recent years after it rebuffed Jefferson’s acquisition attempt. Jefferson allegedly started demanding that its own hospitalist physicians only refer cancer patients to oncologists who are employed by Jefferson instead of sending them to ACS.

“The physicians who received this message reasonably understood it to mean that under all circumstances, only referrals to [Jefferson’s] hospital-employed physicians are acceptable,” according to the lawsuit.

Top medical leaders at Jefferson then hinted to its physicians “their continued employment was conditioned upon their referrals” only to Jefferson’s cancer doctors, the lawsuit alleged. Jefferson also tied the incentive compensation of its physicians to whether cancer patients were retained “in-house,” according to the suit, which is based on ACS’ alleged interactions with Jefferson as of last month

ACS said Jefferson most recently threatened to terminate the privileges of its oncologists at a handful of Jefferson’s hospitals by Sept. 16 — meaning those doctors could no longer treat or admit patients at those specific facilities.

Trending Now: How a supplement company became a haven for health misinformation
A spokesperson for Jefferson Health would not confirm whether the system sent a letter stating that it will revoke the privileges of ACS doctors. The system does not comment on pending litigation. However, “we intend to vigorously defend our position,” the spokesperson said.

Federal law specifically outlaws hospitals paying for referrals. The federal government has intervened in several cases over the past few years, including some that involve cancer care.

I attended the COA (Community Oncology Alliance) annual meeting earlier this year and one of the Oncs from Alliance Cancer Specialists was a speaker. Even after Jefferson employed their own Oncologists and Hospitalists, the Jefferson employed Hospitalists would still refer to the private group over their "own" Oncologists. Reasons included:

1. The private group would show up very quickly and reported patient satisfaction was higher than the Jefferson Oncologists
2. The Jefferson group would very liberally send physician extenders to see patients (even giving them first crack for consults). This was a major point of dissatisfaction for the referring Hospitalists and their patients.

At one point, Jefferson Health re-configured their EMR to force in-house referrals go to the hosptial-employed Oncologists and would demand a written "reason" if this were not done. In response, the Hospitalists stopped using the EMR to refer inpatients to the private group and would instead use text/phone.

 

[deleted1111261]

This is a really complex situation!

I've been in the employed docs shoes. 250 breast surgeries done in our hospital. 0 go to the hospital radonc department. All patients are told to drive 5 miles to the private group's radiation center. They get discharged and pass our department on the way out. "Doesn't the hospital have radiation?" "Oh, they are on a different EMR and it will just be easier to drive over to our center." The hospital has given privileges to the surgeon and her team to operate there. The hospital has purchased very nice equipment + bells and whistles (4D CT, DIBH, prone board, SGRT) that the other center does not have. The employed Radonc is excellent (okay, it was me, but presume it is an excellent RO). Yet, every patient gets sent out to the facility in which the surgeon has ownership in. On top of this, the private group didn't take any call at any of the hospitals. I had to do all their inpatient work when their patients were admitted.

Our leadership at the time feared the very case that just was posted, above. Yet, rolling over completely in the face of the surgeon's financial interest in the competing center doesn't make sense either and that was part of me being unhappy. I wanted to fight and fight hard.

I'm not pulling for the hospital here. But, it is disheartening that I have to worry about this type of lawsuit, while the competing team can do whatever they want.

So, I understand the view that the hospital is usually the devil. But, the hospital is made up of employed doctors that just want to take care of patients and not have to find financial entanglements to make it happen. Don't get me wrong - I think the competing group is fine and I have some friends amongst them and refer residents to apply there - I think they are great. It's just an odd situation to be in.

 

[NotMattSpraker]

I've been dealing with a similar situation, but its more friendly. Im also the employed dude in this scenario.

I can see both sides of this for sure. I tend to feel bad for whatever side is doing higher quality care

Im gearing up to do ACRO advocacy day in 1 week. I have learned a ton about the economics of freestanding practice. It has to be really tough for them in many markets. It must feel extra rigged if you are fighting with a PPS center in a competitive city.

 

[thecarbonionangle]

I heard of a set up which is in the opposite end of that situation, a private group without admitting priviledges who dumps their inpatients on another hospital group. They think this is a great set up because they do not want to take call but i have always wondered how this is fair? When patient is discharged they take the patient back. Seems messed up.

 

[deleted1111261]

I heard of a set up which is in the opposite end of that situation, a private group without admitting priviledges who dumps their inpatients on another hospital group. They think this is a great set up because they do not want to take call but i have always wondered how this is fair? When patient is discharged they take the patient back. Seems messed up.

This is what I’m describing and what I experienced. I sent em back, tho. I never kept them.

 

[sirspamalot]

Anyone who thinks healthcare is ABOUT healthcare is a doctor/nurse/cog in the machine. And terribly naive.

Its always about the benjamins. Always. And the big bois play to win, DGAF, and they have zero responsibility relative to the healthcare worker.

Sad, really.

 

[RickyScott]

Anyone who thinks healthcare is ABOUT healthcare is a doctor/nurse/cog in the machine. And terribly naive.

Its always about the benjamins. Always. And the big bois play to win, DGAF, and they have zero responsibility relative to the healthcare worker.

Sad, really.

That’s fine. The problem comes when institutions and organizations, like Astro, claim that they are 100% focused on science and the patient, but are totally centered on dollars and special interests. They put forth initiatives in name of pt care like ROCR that are really designed to prompt rural pts into traveling to expensive university systems.

 

[sirspamalot]

Agree 100%. If I could give you 5 upvotes, I would. Seriously. ROCR is a joke, ASTRO (FASTRO? NO! F ASTRO!) isn't our friend, and ACRO while valiant isn't moving the needle much. Personally, I like Dr. Mantz as a person, but his arguments are unpersuasive and his association with distasteful (Ok, dishonest, unscrupulous, whatever) entities is unpalatable.

Without massive ACRO backing by every single nonacademic or self loathing academic radonc, the sandwich will continue to be the same. Remember what I said about chicken salad?

Speaking of sandwiches what happened to our new improved incoming ASTRO president who vowed to hear the cries of pain from SDN radoncs?

"Sorry, but the ASTRO President is currently unavailable. If you'd like to leave a message, knowing no one will ever call you back, please press 1. If you'd like to leave an angry message we won't listen to and will be autodeleted, please press 2. If your dues are due and you'd like to make a payment through our autopay system, please press 3. If you'd like to speak to a representative (chortles), please press 0. "

You press 0, cue the puke-music loop

STOP PAYING ASTRO DUES, JOIN ACRO

 

[RadOncDoc21]

Agree 100%. If I could give you 5 upvotes, I would. Seriously. ROCR is a joke, ASTRO (FASTRO? NO! F ASTRO!) isn't our friend, and ACRO while valiant isn't moving the needle much. Personally, I like Dr. Mantz as a person, but his arguments are unpersuasive and his association with distasteful (Ok, dishonest, unscrupulous, whatever) entities is unpalatable.

Without massive ACRO backing by every single nonacademic or self loathing academic radonc, the sandwich will continue to be the same. Remember what I said about chicken salad?

Speaking of sandwiches what happened to our new improved incoming ASTRO president who vowed to hear the cries of pain from SDN radoncs?

"Sorry, but the ASTRO President is currently unavailable. If you'd like to leave a message, knowing no one will ever call you back, please press 1. If you'd like to leave an angry message we won't listen to and will be autodeleted, please press 2. If your dues are due and you'd like to make a payment through our autopay system, please press 3. If you'd like to speak to a representative (chortles), please press 0. "

You press 0, cue the puke-music loop

STOP PAYING ASTRO DUES, JOIN ACRO

He’s busy remember? He definitely hasn’t been around once we got passed the BS meter.

 

[NotMattSpraker]

Probably what happened is authors got funding (Mayo, small bits from NCI, etc), not nearly enough to run a reasonable study, and turned to the statistician and said make it work. Then crossed their fingers they wouldn't have to answer uncomfortable questions. No dice, so looks kind of silly. But hey, Lancet Oncology.

Looks like it was Mayo (unclear source), a K12 award, and a P30 grant. The K12 award is actually an interdisciplinary womens health grant, I chuckled haha. Its probably impossible to know the committee that designed this one.

I have applied for institutional trial funding through a couple mechanisms and the experience/priorities can be different. Caveat I've never done this at Mayo.

At the cancer center level, Ive had weird feedback from multi-D reviewers because most don't understand radiotherapy well but they hear about protons! The best feedback I ever got was actually from patient reviewers.

I've also applied for departmental proton funding for a phase 1 trial of lattice reirradiation. This is reviewed by Rad Oncs only. People like to rip my former employer on here, but the funding review process was exactly what you'd want. They'd fund good scientific trials that encouraged proton treatment on IITs. Another one was like short course re-irradiation for pelvis. I've reviewed for this mechanism as well and Id bet that this trial design would've gotten destroyed in that review at least.

I'd love to hear the discussion around why it wasn't proton-photon! PI had to answer to someone Im sure.

Maybe they thought it would be too hard to accrue at a place where people travel internationally to receive protons?

 

[TheWallnerus]

This is truly embarrassing that this woefully underpowered study is published in Lancet Oncology

It was powered enough to find some significantly worse toxicities for proton hypofract

 

[SneakyBooger]

I'm slow. I mean like a snail slow. It takes me 2 hrs to watch 60 Minutes.

Looking at that Mayo Clinic study I see more acute toxicity with hypofractionation. Yet, I was forced many many years ago to believe that radbio would predict less acute toxicity and more late toxicity with hypofractionation.

I see the same findings with prostate hypofractionation.

I think I was deceived!

 

[sirspamalot]

I'm slow. I mean like a snail slow. It takes me 2 hrs to watch 60 Minutes.

Looking at that Mayo Clinic study I see more acute toxicity with hypofractionation. Yet, I was forced many many years ago to believe that radbio would predict less acute toxicity and more late toxicity with hypofractionation.

I see the same findings with prostate hypofractionation.

I think I was deceived!

How big cc and how bad AUA before you cry uncle and offer standard instead of hypo?

 

[fiji128]

Lawsuit raises antitrust and kickback allegations around cancer patient referrals

Oncologists in Philadelphia are alleging Jefferson Health system is violating federal antitrust and kickback laws by creating a “concerted campaign to eliminate” the group’s “presence in the oncology marketplace.”

www.statnews.com

STAT+
Lawsuit raises antitrust and kickback allegations around cancer patient referrals
Bob Herman
By Bob Herman Sept. 8, 2023


Oncologists in Philadelphia are alleging Jefferson Health system is violating federal antitrust and kickback laws.

A large independent group of oncologists in Philadelphia is suing the area’s dominant hospital system, Jefferson Health, alleging the system is violating federal antitrust and kickback laws by creating a “concerted campaign to eliminate” the group’s “presence in the oncology marketplace.”

The lawsuit resurfaces longstanding concerns associated with hospitals buying up physician groups and then forcing those physicians to refer patients to the hospitals’ own facilities, even if that’s not in a patient’s best interest. Hospitals have increasingly acquired physician groups over the past 15 years, and in the process have entrenched monopoly positions for certain types of care by preventing patients from “leaking” to competitors.

Obtaining more market share and negotiating power isn’t the only incentive for hospitals to scoop up physicians. Oncology, in particular, is a lucrative specialty for hospitals to own. Revenue is immediately boosted because hospitals are able to charge more for the cancer doctors’ services in a hospital-owned clinic, even though those same services would be significantly cheaper in an independent clinic. Hospitals that participate in a federal drug discount program, known as 340B, also are able to buy expensive chemotherapy drugs for cheap while still billing insurers full freight.

Alliance Cancer Specialists, a group of 36 oncologists, said those factors are exactly at play in its part of Philadelphia. ACS alleged its longstanding relationship with Jefferson deteriorated in recent years after it rebuffed Jefferson’s acquisition attempt. Jefferson allegedly started demanding that its own hospitalist physicians only refer cancer patients to oncologists who are employed by Jefferson instead of sending them to ACS.

“The physicians who received this message reasonably understood it to mean that under all circumstances, only referrals to [Jefferson’s] hospital-employed physicians are acceptable,” according to the lawsuit.

Top medical leaders at Jefferson then hinted to its physicians “their continued employment was conditioned upon their referrals” only to Jefferson’s cancer doctors, the lawsuit alleged. Jefferson also tied the incentive compensation of its physicians to whether cancer patients were retained “in-house,” according to the suit, which is based on ACS’ alleged interactions with Jefferson as of last month

ACS said Jefferson most recently threatened to terminate the privileges of its oncologists at a handful of Jefferson’s hospitals by Sept. 16 — meaning those doctors could no longer treat or admit patients at those specific facilities.

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A spokesperson for Jefferson Health would not confirm whether the system sent a letter stating that it will revoke the privileges of ACS doctors. The system does not comment on pending litigation. However, “we intend to vigorously defend our position,” the spokesperson said.

Federal law specifically outlaws hospitals paying for referrals. The federal government has intervened in several cases over the past few years, including some that involve cancer care.

Of course every hospital engages in this anti trust anti completive behavior. It's core to the whole underlying business model. The discovery from the private practice group lawyers should be awesome if they can afford it. Most likely the matter will just settle out of court with a nice pay day for the Alliance Cancer Specialists group. It would be great if it all went public in a trial.

 

[yesmaster]

Sometimes the independent physician group loses the lawsuit and they have to pay their legal fees plus the legal fees of the hospital system.

 

[SneakyBooger]

How big cc and how bad AUA before you cry uncle and offer standard instead of hypo?

I discuss with all patients standard and hypo and let them choose...

 

[sirspamalot]

Sometimes the independent physician group loses the lawsuit and they have to pay their legal fees plus the legal fees of the hospital system.

Ah yes.. the New Mexico 7 year misadventure. Lost at trial, lost at appeal. Tough tough loss. Many millions spent with attorneys (the only ones who always win).

Sorry bruh.

These cases have a fairly high bar, and the difference between legitimate hard nosed competition versus anticompetitive/monopoly claims is sometimes very hazy. But this lawsuit never had gravitas and should not have been filed, because butthurt alone isn't enough to win.

And remember kids, the Courts DGAF about whether something is ethical (Supreme Court laughs out loud) its just a matter of cold stark (pun intended) law. Emotion/Decency/Ethics play zero role in Appellate Court and above. That **** is for Juries who are made up of humans who might give one.

Don't believe me? "However, the Sherman Act does not incorporate professional ethical rules. "

 

[RickyScott]

I discuss with all patients standard and hypo and let them choose...

Most of my pts don’t choose hypo. Treated 3 docs in last 2 years and none wanted to hypo.

 

[sirspamalot]

Most of my pts don’t choose hypo. Treated 3 docs in last 2 years and none wanted to hypo.

Curious. Did you discuss the financial differences?

On another note:

Most of my prostate hypo patients getting P/SV/LN do really well, but then you get "that one guy" who struggles w/GU and being as he's near the end, I'm hopeful that he'll resolve within a few weeks (Ditropan, Aleve help a little).

Not sure what made him "different" than others with moderate size/score but hey, I also had one woman recently with ridiculous full field skin erythema with short course breast.. Absolutely nothing unusual about her dosimetry. My machine passed all its checks, all other patients including similar Rx have always done fine.

Never seen anything like it. Wasn't a topical or other causative agent. No history of sun sensitivity. ATM mutant? I really really don't know. It looked terrible but fortunately wasn't painful for her. I'll be curious to see what her cosmesis looks like at follow up.

Sometimes, there will be a one off... we just have to live with it. Perplexing.

 

[medgator]

Curious. Did you discuss the financial differences?

On another note:

Most of my prostate hypo patients getting P/SV/LN do really well, but then you get "that one guy" who struggles w/GU and being as he's near the end, I'm hopeful that he'll resolve within a few weeks (Ditropan, Aleve help a little).

Not sure what made him "different" than others with moderate size/score but hey, I also had one woman recently with ridiculous full field skin erythema with short course breast.. Absolutely nothing unusual about her dosimetry. My machine passed all its checks, all other patients including similar Rx have always done fine.

Never seen anything like it. Wasn't a topical or other causative agent. No history of sun sensitivity. ATM mutant? I really really don't know. It looked terrible but fortunately wasn't painful for her. I'll be curious to see what her cosmesis looks like at follow up.

Sometimes, there will be a one off... we just have to live with it. Perplexing.

You mean gi? I had to put one 28fx guy on break for A week for diarrhea. Data suggests it's a gi not gu issue with hypo

 

[RickyScott]

Curious. Did you discuss the financial differences?

On another note:

Most of my prostate hypo patients getting P/SV/LN do really well, but then you get "that one guy" who struggles w/GU and being as he's near the end, I'm hopeful that he'll resolve within a few weeks (Ditropan, Aleve help a little).

Not sure what made him "different" than others with moderate size/score but hey, I also had one woman recently with ridiculous full field skin erythema with short course breast.. Absolutely nothing unusual about her dosimetry. My machine passed all its checks, all other patients including similar Rx have always done fine.

Never seen anything like it. Wasn't a topical or other causative agent. No history of sun sensitivity. ATM mutant? I really really don't know. It looked terrible but fortunately wasn't painful for her. I'll be curious to see what her cosmesis looks like at follow up.

Sometimes, there will be a one off... we just have to live with it. Perplexing.

The docs don’t give a f abt the financial issues. Whenever I bring this up, no one wants the cheaper treatment.

 

[temujim]

The docs don’t give a f abt the financial issues. Whenever I bring this up, no one wants the cheaper treatment.

Other than the self pays, which patient does? Very few have skin in the game. That's why I don't get some of the self-policing rad onc does with protons, etc. The field is a rounding error. Just lean into that Cloward-Piven strategy.

 

[SneakyBooger]

Curious. Did you discuss the financial differences?

Yes. I explained that given I am a salaried physician that should they choose hypo fractionation I will make more money with respect to the effort needed. I explained their insurance corporation will also make more money.

 

[deleted1111261]

Yes. I explained that given I am a salaried physician that should they choose hypo fractionation I will make more money with respect to the effort needed. I explained their insurance corporation will also make more money.

Love this, hahaha!

44 is all good. Didn’t evicore drop their resistance ?

 

[TheWallnerus]

Love this, hahaha!

44 is all good. Didn’t evicore drop their resistance ?

United hasn’t

 

[SneakyBooger]

Yes. I explained that given I am a salaried physician that should they choose hypo fractionation I will make more money with respect to the effort needed. I explained their insurance corporation will also make more money.

And patients continue to choose standard fractionation.

 

[grenz]

I have it on good authority *exaggerated winking* that some people may have started doing just this awhile ago, and that reviewing the records for disclosure takes forever.

Maybe to avoid hipaa complications, these people can target it to communications pertaining to the U Maryland marketing

 

[BobbyHeenan]

Maybe to avoid hipaa complications, these people can target it to communications pertaining to the U Maryland marketing

That's actually a really interesting idea.

Marketing : Hey Dr. X, what do you think about this? *shows wildly inappropriate proton ad*
Doc: looks great, thanks.

Yikes.

 

[evilbooyaa]

I heard of a set up which is in the opposite end of that situation, a private group without admitting priviledges who dumps their inpatients on another hospital group. They think this is a great set up because they do not want to take call but i have always wondered how this is fair? When patient is discharged they take the patient back. Seems messed up.

If that was happening to me I would not give the patient back to their team that dumped them when they became problematic.

 

[evilbooyaa]

This is a really complex situation!

I've been in the employed docs shoes. 250 breast surgeries done in our hospital. 0 go to the hospital radonc department. All patients are told to drive 5 miles to the private group's radiation center. They get discharged and pass our department on the way out. "Doesn't the hospital have radiation?" "Oh, they are on a different EMR and it will just be easier to drive over to our center." The hospital has given privileges to the surgeon and her team to operate there. The hospital has purchased very nice equipment + bells and whistles (4D CT, DIBH, prone board, SGRT) that the other center does not have. The employed Radonc is excellent (okay, it was me, but presume it is an excellent RO). Yet, every patient gets sent out to the facility in which the surgeon has ownership in. On top of this, the private group didn't take any call at any of the hospitals. I had to do all their inpatient work when their patients were admitted.

Our leadership at the time feared the very case that just was posted, above. Yet, rolling over completely in the face of the surgeon's financial interest in the competing center doesn't make sense either and that was part of me being unhappy. I wanted to fight and fight hard.

I'm not pulling for the hospital here. But, it is disheartening that I have to worry about this type of lawsuit, while the competing team can do whatever they want.

So, I understand the view that the hospital is usually the devil. But, the hospital is made up of employed doctors that just want to take care of patients and not have to find financial entanglements to make it happen. Don't get me wrong - I think the competing group is fine and I have some friends amongst them and refer residents to apply there - I think they are great. It's just an odd situation to be in.

Unfortunately that is the reality of being at the end of a referral chain. Referral to a center 5 miles away is not a big deal, especially if your Rad Onc system is actually on a separate EMR from the hospital that you work for. That sounds like a systems issue, not really an issue of the breast surgeon in question.