What is a normal patient volume?

[drowsy12]

‘Now a fair case based model will let the docs do more for a given patient. They just won't get paid more for it.’

Yeah and bottom line I think this contributes in part to why some will always be against bundled payment models. Just like PA companies will always be against it haha

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[medgator]

Above examples are good.

Of course single patients will be harmed. Now, would cancer or toxicity outcomes be changed in a statistically significant way? Maybe not over the whole population?

I think most docs should strive for personal quality (not metric meeting) and personalized medicine. In other words, they should try to maximize outcomes for the individual patient while being cognizant of cost and futility.

Inflexible guidelines take the above option away.

Now a fair case based model will let the docs do more for a given patient. They just won't get paid more for it.

Yep. Case rates/payment bundles are where it is at. The protonistas will cry bloody murder but F em. The free market is taking care of them already

 

[evilbooyaa]

I want a guideline that if you’re over age 60 and have a stage one favorable breast cancer, the insurance company doesn’t have to pay for more than 5 RT fractions and will only pay for IMRT if you’re doing partial breast. Would save money versus all current guidelines AND be a quality measure that’s being implemented.

Putting patients at higher risk for late toxicity (if not doing 5Fx PBI) compared to 15Fx WBI or PBI???? As the only option for patients? C'mon man.

 

[MidwestRadOnc]

The compensation methodology with regards to modality and fractionation (5 fraction sbrt vs. 6 fraction IMRT vs. 8 fraction 3D with DCA and CBCT) is such a clown show. It's like we as a specialty in conjunction with CMS looked at the IRS and the tax code and said oh that makes far too much sense, hold my beer.

 

[medgator]

The compensation methodology with regards to modality and fractionation (5 fraction sbrt vs. 6 fraction IMRT vs. 8 fraction 3D with DCA and CBCT) is such a clown show. It's like we as a specialty in conjunction with CMS looked at the IRS and the tax code and said oh that makes far too much sense, hold my beer.

Bundles would have fixed it long ago....

 

[MidwestRadOnc]

Bundles would have fixed it long ago....

It also would do away with the South Florida fractionation/modality police cottage industry/racket. Watching those ladies have to start earning an honest living would be so satisfying.

 

[TheWallnerus]

Putting patients at higher risk for late toxicity (if not doing 5Fx PBI) compared to 15Fx WBI or PBI???? As the only option for patients? C'mon man.

I mean if *I am* paying for care, no, I wouldn’t pay any rad onc for more than 5 fractions in older women with favorable breast cancer. I wouldn't necessarily amend my guideline to only allow 5-fraction PBI, but it would definitely be less toxicity than "15fx WBI or PBI." And 5fx in general is equivalently (or less) toxic as 15 fx WBI; it doesn't put women at risk for higher toxicity. It is not logical to embrace 15fx PBI or WBI without equal embracement of 5fx PBI (or WBI)... if one accepts that premise, payors paying for more than 5 fractions (again, for certain patient groups) would also not be logical.

Not to be (too) sensationalistic, but I feel like embracing 5 fractions as the standard (for the right groups) is existential for us.

"We conclude that 26 Gy in five daily fractions for breast radiotherapy is an effective regimen for tumour control. There is no evidence or scientific rationale to argue against it for any subgroup. With regards to adverse effects, it is as well tolerated as moderate hypofractionation over 3 weeks of daily radiotherapy. Furthermore, it is convenient for patients and less burdensome for radiotherapy departments. We recommend that 26 Gy in five daily fractions for all indications of whole-breast, partial-breast and chest wall radiotherapy be adopted as the standard of care."

 

[evilbooyaa]

I mean if *I am* paying for care, no, I wouldn’t pay any rad onc for more than 5 fractions in older women with favorable breast cancer. I wouldn't necessarily amend my guideline to only allow 5-fraction PBI, but it would definitely be less toxicity than "15fx WBI or PBI." And 5fx in general is equivalently (or less) toxic as 15 fx WBI; it doesn't put women at risk for higher toxicity. It is not logical to embrace 15fx PBI or WBI without equal embracement of 5fx PBI (or WBI)... if one accepts that premise, payors paying for more than 5 fractions (again, for certain patient groups) would also not be logical.

Not to be (too) sensationalistic, but I feel like embracing 5 fractions as the standard (for the right groups) is existential for us.

"We conclude that 26 Gy in five daily fractions for breast radiotherapy is an effective regimen for tumour control. There is no evidence or scientific rationale to argue against it for any subgroup. With regards to adverse effects, it is as well tolerated as moderate hypofractionation over 3 weeks of daily radiotherapy. Furthermore, it is convenient for patients and less burdensome for radiotherapy departments. We recommend that 26 Gy in five daily fractions for all indications of whole-breast, partial-breast and chest wall radiotherapy be adopted as the standard of care."

"We, who are working in a system that is incapable of caring for its patients in a timely fashion due to general incapability of the NHS to appropriately care for its population without doctors striking on a daily basis, and are thus under significant pressure to get patients done as quickly as possible, have evaluated that 26Gy in 5 fractions once daily over a week is non-inferior in terms of local recurrence, which the trial we ran was powered for.
The trial, which was not powered to detect toxicity differences, showed no statistically significant differences in grouped toxicities. In multiple individual toxicities that may be of interest to individual patients on an individualized basis, there is a statistically significant worsening of late toxicity metrics that we measured between 26Gy in 5 fractions and 40Gy in 15 fractions. While this may be of interest to individual patients, we have buried these data deep within the supplement and announced that all toxicities are 'equal' between 26Gy in 5 fractions and 40Gy in 15 fractions, as we work in a system that is currently crumbling in terms of financial pressures, and we are motivated to get patients done as quickly as possible. We decide to buck the trend of personalized medicine, including shared decision making, that is being presented on a global scale and instead proceed with cookie cutter assembly line medicine for our early stage breast cancer patients."

If I have a prostate cancer patient who wants conventional fx even for prostate alone and it gets denied, I would p2p and then appeal, including complaint to insurance commissioner. And that's to give a patient the autonomy to pick the treatment with the lowest global toxicity rate, driven by a decrease in acute GI toxicity by picking conventional. Same thing with prostate SBRT ever becoming something beyond 'A' standard of care.

Similarly, if I have an early stage breast cancer patient who wants 40/15 for mod hypo for tangents alone and it gets denied in favor of 5fx, I would do similarly. And that difference is for LATE toxicity.

 

[TheWallnerus]

"We, who are working in a system that is incapable of caring for its patients in a timely fashion due to general incapability of the NHS to appropriately care for its population without doctors striking on a daily basis, and are thus under significant pressure to get patients done as quickly as possible, have evaluated that 26Gy in 5 fractions once daily over a week is non-inferior in terms of local recurrence, which the trial we ran was powered for.
The trial, which was not powered to detect toxicity differences, showed no statistically significant differences in grouped toxicities. In multiple individual toxicities that may be of interest to individual patients on an individualized basis, there is a statistically significant worsening of late toxicity metrics that we measured between 26Gy in 5 fractions and 40Gy in 15 fractions. While this may be of interest to individual patients, we have buried these data deep within the supplement and announced that all toxicities are 'equal' between 26Gy in 5 fractions and 40Gy in 15 fractions, as we work in a system that is currently crumbling in terms of financial pressures, and we are motivated to get patients done as quickly as possible. We decide to buck the trend of personalized medicine, including shared decision making, that is being presented on a global scale and instead proceed with cookie cutter assembly line medicine for our early stage breast cancer patients."

If I have a prostate cancer patient who wants conventional fx even for prostate alone and it gets denied, I would p2p and then appeal, including complaint to insurance commissioner. And that's to give a patient the autonomy to pick the treatment with the lowest global toxicity rate, driven by a decrease in acute GI toxicity by picking conventional. Same thing with prostate SBRT ever becoming something beyond 'A' standard of care.

Similarly, if I have an early stage breast cancer patient who wants 40/15 for mod hypo for tangents alone and it gets denied in favor of 5fx, I would do similarly. And that difference is for LATE toxicity.

I have never heard you be so cynical

We are lucky the insurance companies allow 21 fractions for stage one breast cancer for now. There is zero data that is superior to 15 or 16 fractions, and you would have to make not-honest arguments to try and argue that 21 fractions won’t have more toxicity versus 15 or 16. Even allowing for (specious!) arguments that 26/5 is more toxicity than 40/15, in essence 20-21 fractions is chosen by the vast majority of American rad oncs. Toxicity arguments can cut both ways.

Before I die, I do believe we will see an American insurance company try and “enforce” 5 fraction (especially in old women with stage one).

 

[CaesarRO]

"We, who are working in a system that is incapable of caring for its patients in a timely fashion due to general incapability of the NHS to appropriately care for its population without doctors striking on a daily basis, and are thus under significant pressure to get patients done as quickly as possible, have evaluated that 26Gy in 5 fractions once daily over a week is non-inferior in terms of local recurrence, which the trial we ran was powered for.
The trial, which was not powered to detect toxicity differences, showed no statistically significant differences in grouped toxicities. In multiple individual toxicities that may be of interest to individual patients on an individualized basis, there is a statistically significant worsening of late toxicity metrics that we measured between 26Gy in 5 fractions and 40Gy in 15 fractions. While this may be of interest to individual patients, we have buried these data deep within the supplement and announced that all toxicities are 'equal' between 26Gy in 5 fractions and 40Gy in 15 fractions, as we work in a system that is currently crumbling in terms of financial pressures, and we are motivated to get patients done as quickly as possible. We decide to buck the trend of personalized medicine, including shared decision making, that is being presented on a global scale and instead proceed with cookie cutter assembly line medicine for our early stage breast cancer patients."

If I have a prostate cancer patient who wants conventional fx even for prostate alone and it gets denied, I would p2p and then appeal, including complaint to insurance commissioner. And that's to give a patient the autonomy to pick the treatment with the lowest global toxicity rate, driven by a decrease in acute GI toxicity by picking conventional. Same thing with prostate SBRT ever becoming something beyond 'A' standard of care.

Similarly, if I have an early stage breast cancer patient who wants 40/15 for mod hypo for tangents alone and it gets denied in favor of 5fx, I would do similarly. And that difference is for LATE toxicity.

Did you make up that quote or is it an actual quote? It's awesome

 

[evilbooyaa]

I have never heard you be so cynical

We are lucky the insurance companies allow 21 fractions for stage one breast cancer for now. There is zero data that is superior to 15 or 16 fractions, and you would have to make not-honest arguments to try and argue that 21 fractions won’t have more toxicity versus 15 or 16. Even allowing for (specious!) arguments that 26/5 is more toxicity than 40/15, in essence 20-21 fractions is chosen by the vast majority of American rad oncs. Toxicity arguments can cut both ways.

Before I die, I do believe we will see an American insurance company try and “enforce” 5 fraction (especially in old women with stage one).

I am very selective about who needs a boost and who doesn't. I understand that that is rare nationwide but I would not want an insurance company to make that decision for me or my patients, ever.

Did you make up that quote or is it an actual quote? It's awesome

Off the top of my head

 

[SneakyBooger]

If I have a prostate cancer patient who wants conventional fx even for prostate alone and it gets denied, I would p2p and then appeal,

Skip the P2P, go straight to appeal. P2P just wastes time.

 

[evilbooyaa]

Sometimes the p2p works! Appeal is so painful. I get that's a feature not a bug. But if I can get somethig over turned in a 30-60 second phone call... If the p2p is informational only then I report them to state insurance commissioner.

 

[seper]

Sometimes the p2p works! Appeal is so painful. I get that's a feature not a bug. But if I can get somethig over turned in a 30-60 second phone call... If the p2p is informational only then I report them to state insurance commissioner.

LOL it’s never informational. They always say “just do the right thing and order 30 Gy / 10 for that painful bone met, Dr. Ebidooya”

 

[Mandelin Rain]

LOL it’s never informational. They always say “just do the right thing and order 30 Gy / 10 for that painful bone met, Dr. Ebidooya”

You Buggin Out.

 

[evilbooyaa]

LOL it’s never informational. They always say “just do the right thing and order 30 Gy / 10 for that painful bone met, Dr. Ebidooya”

"I may or may not agree with you, but this is a call just for me to demonstrate to you how completely powerless I have allowed an insurance company to make me feel, that even if I feel you're doing the best thing for the patient, I am physically unable to allow going beyond the guidelines which benefit nobody but the insurance company. I should probably quit this job and go get a real one, but I am either geographically limited or too **** at being a Rad Onc for anyone to hire me doing honest clinical work"

 

[thecarbonionangle]

I find the general arguments for PA unconvincing. i overall think people are being hurt and it is basically a game of delay. The general argument is always a variation cherry picking a few examples of egregious behavior to support screwing way more people. Think of another example, let us say a government entity violating people’s rights to catch a few people, say an extreme frisk program. Maybe you catch a guy with a stolen gun, lock up a ton of people with some weed, rarely you catch something terrible. You say look we caught the guy with the child porn so screwing 99 percent of you was worthwhile. Yeah i don’t buy it. Any system is a leaky bucket which comes with a baseline level of abuse. People giving me the classic florida example changes nothing. Every time i have to speak to some of these “academic” shills or community doing P2P, i get in a bad mood. I avoid it as much as I can because it is a waste of time generally.

Recently had a case 3 weeks went by, denied SOC for a curable cancer. denial reason was no comparison plan. Except comparison plan was submitted with initial appeal. They clearly did not even look at it. resubmitted again and again refused P2P. This time we sent a very strongly worded appeal and it was inmediately approved with no explanation. Nothing was achieved or any grift was prevented. Patient had a ton of anxiety. Med onc was not happy. Tumor grew. great job PA folks. i am sure someone somewhere was helped.

 

[Mandelin Rain]

I find the general arguments for PA unconvincing. i overall think people are being hurt and it is basically a game of delay. The general argument is always a variation cherry picking a few examples of egregious behavior to support screwing way more people. Think of another example, let us say a government entity violating people’s rights to catch a few people, say an extreme frisk program. Maybe you catch a guy with a stolen gun, lock up a ton of people with some weed, rarely you catch something terrible. You say look we caught the guy with the child porn so screwing 99 percent of you was worthwhile. Yeah i don’t buy it. Any system is a leaky bucket which comes with a baseline level of abuse. People giving me the classic florida example changes nothing. Every time i have to speak to some of these “academic” shills or community doing P2P, i get in a bad mood. I avoid it as much as I can because it is a waste of time generally.

Recently had a case 3 weeks went by, denied SOC for a curable cancer. denial reason was no comparison plan. Except comparison plan was submitted with initial appeal. They clearly did not even look at it. resubmitted again and again refused P2P. This time we sent a very strongly worded appeal and it was inmediately approved with no explanation. Nothing was achieved or any grift was prevented. Patient had a ton of anxiety. Med onc was not happy. Tumor grew. great job PA folks. i am sure someone somewhere was helped.

Preach. Routine three week delays in necessary/SOC radiation therapy. Or you can give substandard care. Your choice.

All because some other guy who has nothing to do with you or your patients is prescribing too many fractions for bone Mets.

Quick idea: if you find someone is routinely billing relatively extraordinary amounts per specific ICD codes, say top decile, start reviewing his/her cases for those ICDs and leave the rest of us alone to take care of business. It’d literally take a spreadsheet.

 

[drowsy12]

I find the general arguments for PA unconvincing. i overall think people are being hurt and it is basically a game of delay. The general argument is always a variation cherry picking a few examples of egregious behavior to support screwing way more people. Think of another example, let us say a government entity violating people’s rights to catch a few people, say an extreme frisk program. Maybe you catch a guy with a stolen gun, lock up a ton of people with some weed, rarely you catch something terrible. You say look we caught the guy with the child porn so screwing 99 percent of you was worthwhile. Yeah i don’t buy it. Any system is a leaky bucket which comes with a baseline level of abuse. People giving me the classic florida example changes nothing. Every time i have to speak to some of these “academic” shills or community doing P2P, i get in a bad mood. I avoid it as much as I can because it is a waste of time generally.

Recently had a case 3 weeks went by, denied SOC for a curable cancer. denial reason was no comparison plan. Except comparison plan was submitted with initial appeal. They clearly did not even look at it. resubmitted again and again refused P2P. This time we sent a very strongly worded appeal and it was inmediately approved with no explanation. Nothing was achieved or any grift was prevented. Patient had a ton of anxiety. Med onc was not happy. Tumor grew. great job PA folks. i am sure someone somewhere was helped.

You need to talk to your hospital admin if they are stopping you from treating before PA for standard curative cases. That’s ridiculous too.

 

[medgator]

You need to talk to your hospital admin if they are stopping you from treating before PA for standard curative cases. That’s ridiculous too.

They don't want to lose money either. Do you think your salary appears out of thin air?

 

[medgator]

Preach. Routine three week delays in necessary/SOC radiation therapy. Or you can give substandard care. Your choice.

All because some other guy who has nothing to do with you or your patients is prescribing too many fractions for bone Mets.

Quick idea: if you find someone is routinely billing relatively extraordinary amounts per specific ICD codes, say top decile, start reviewing his/her cases for those ICDs and leave the rest of us alone to take care of business. It’d literally take a spreadsheet.

CMS supposedly does this to look at fraudulent billing. Look at 2+SDs away from the middle and start investigating further

 

[drowsy12]

They don't want to lose money either. Do you think your salary appears out of thin air?

I think there's a difference between not doing stuff that won't get paid and then waiting for PA for every case before starting, when you know you will get paid. the latter is what bothers me. I have heard of situations where you can't even SIM until PA comes through. ludicrous. I understand some of you may not have a choice. sucks to be in that situation.

 

[ramsesthenice]

Yesterday I was asked for a letter of necessity for a pelvic IMRT case that finished treatment November 19….2022?!? Seriously, WTF? Does the overhead for all of this justify realized savings for these companies? It must, or they wouldn’t do it. But it seems like the net profits could probably be higher with a smaller footprint that focused on legit questionable practices.

 

[medgator]

I think there's a difference between not doing stuff that won't get paid and then waiting for PA for every case before starting, when you know you will get paid. the latter is what bothers me. I have heard of situations where you can't even SIM until PA comes through. ludicrous. I understand some of you may not have a choice. sucks to be in that situation.

I get it. Usually the CT sim code doesn't need auth, the problem is once that process is started, a lot of stuff just gets automatically done and before you know it, you have a 6-8 week imrt pt under beam with no auth.

Patients are really their best advocate in terms of dealing with and facilitating the PA process to get done as quickly as possible

 

[Neuronix]

I think there's a difference between not doing stuff that won't get paid and then waiting for PA for every case before starting, when you know you will get paid. the latter is what bothers me. I have heard of situations where you can't even SIM until PA comes through. ludicrous. I understand some of you may not have a choice. sucks to be in that situation.

"When you know you will get paid."

We've had our share of denials that are then not appealable because we did not follow the insurers prior auth process. So we really can't guarantee we're getting paid until we get the prior auth (and not even then really...).

I have what seems to be a growing number of patients where I cannot sim until prior auth is obtained, 5+ business days not unusual.

 

[drowsy12]

Fair enough. However I would argue that some of these major hospitals, especially if PPS exempt, can easily eat the charge on 8/1 palliatives, esp if inpatient

But sure that’s not your choice. But if it was me I have pushed back and treated. My admins and hospital are pretty reasonable.

I’ve seen some of my friends at both normal community hospitals ranging to PPS exempt places have diff experiences with their beauracracy tho

 

[Oldmen]

Quick question. What should be the ideal percent (%) of total collection (TC) for a RadOnc, suppose your salary is based on percentage of TC in a community hospital or private practice?

 

[MidwestRadOnc]

Quick question. What should be the ideal percent (%) of total collection (TC) for a RadOnc, suppose your salary is based on percentage of TC in a community hospital or private practice?

The math some out to about 22% of total collections being PC. With no buy in shoot for 25, but realize 20 + benefits is fair.

What percentage do you think academic rad oncs are getting at PPS exempt academic centers?

Unusual that a hospital would split collections with you vs. play the RVU game. If they are gonna bill and collect and give you the PC I’d say you hit the jackpot.

 

[MidwestRadOnc]

Also for what it’s worth the average wRVU rate that approximates PC is around mid 60s. Anything above mid 70s you’re probably getting some of the TC. (Assuming the hospital pays out the wRVU on a true eat-what-you kill basis vs. periodic true-ups done at times that benefit them and not you).

This is based on my personal experience at multiple centers. If anyone else has different numbers I’d be interested.

 

[Oldmen]

Also for what it’s worth the average wRVU rate that approximates PC is around mid 60s. Anything above mid 70s you’re probably getting some of the TC. (Assuming the hospital pays out the wRVU on a true eat-what-you kill basis vs. periodic true-ups done at times that benefit them and not you).

This is based on my personal experience at multiple centers. If anyone else has different numbers I’d be interested.

This is helpful

 

[Mandelin Rain]

smaller footprint that focused on legit questionable practices.

Especially with the UA companies being chronically "understaffed" (sarcastic air quotes) and requiring 14 days for review and then 7 days to schedule a peer to peer.

This should be illegal. It's a delay tactic for cancer care. Obviously that sweet insurer lobby money will keep the grift going.

 

[evilbooyaa]

I have moved a number of posts about Ozempic to their own thread. Don't talk about Ozempic in this thread again or warnings will be distributed.