A radiation oncology program pays for physics one of three ways, and many run two of them at once. It employs its physicists. It contracts an independent physics firm. Or it contracts the physics arm of the company that built the machine.

The last two are not the same thing. An independent firm sells you physics. The manufacturer's physics arm belongs to the company selling you linacs, software and service.

So picture the finance meeting on Thursday. One side of the slide is what the program spends employing its physics team. The other is a physics services quote. The quote is lower, and somebody has already put the difference in a box called savings.

Start with what the employed side actually costs. The AAPM's 2024 survey puts the median at $245,000 for a board-certified, primarily clinical physicist. That is salary. Benefits sit on top and are not in the survey, so use your own loaded rate. Federal data puts benefits near 30 percent of total compensation, which lands one physicist near $350,000 loaded. That is the number in the example.

I spent twenty years on the vendor side and watched the manufacturer's physics business get built from inside the company: formed, staffed, priced and sold as a service line. Take what follows as my read, not a price list. That arm gets quoted at roughly twice a $350,000 position, often for a narrower scope, and almost nobody put the two scopes side by side before comparing the number.

The comparison cuts both ways, and the question does not change: what work is covered, and what is the program still doing itself after it pays. Against the manufacturer's arm the employment budget looks small. Against an independent quote it looks large. The size of the number tells you nothing until the work behind it is written down.

An independent firm can be good value, with broader coverage and more redundancy than one employed physicist, which matters the week yours is out. Plenty of programs are not choosing at all: they contract because they have been trying to hire for a year and nobody applied. What you give up is your own team.

One thing sits on none of the three prices, and it matters most in a capital year. Your physicist is usually the most technically independent voice in an equipment decision. They read the specifications, they know what a machine does on your floor rather than in the brochure, and they tell you when the answer is no. Your radiation oncologists carry their own part of that call.

I was on the other side of this for twenty years. If you had asked me then which machine your program should buy, I would have given you an honest answer, and it would have been my machine. That is not a character flaw, it is where I sat, and it is where a vendor's physicist sits on that one question. Only that one. They hold the same board certification and the same obligations as the physicist you employ, and on QA, commissioning and clinical work it does not arise; on which machine to buy, it does. So ask it directly and write the answer down: under each option, who gives the program an independent technical read on the next machine, and who do they work for.

Providers describe their own work in public. One national firm lists clinical support on a weekly rotation, planning supervision, radiation safety officer support, annual calibrations, commissioning, and go-live. A university outreach service lists chart checks, calibrations, commissioning, shielding surveys and source exchanges. Distinct services, and nothing on either page says which are inside your quote.

Now look at what is missing from every one of those lists: who covers the physicist's leave, who carries chief physicist responsibility, who sits in the capital meeting. Add one that did not exist five years ago. When an AI tool does something it should not, somebody has to know what was bought, what it was accepted against, and what normal looks like on your machines. That is continuity rather than employment, and it is not automatic under any of the three. The employment budget has the same holes, and until those answers are written down, nobody should be subtracting one number from another.

So read the schedule attached to the quote, not the cover letter. Anything it does not list, the program is still doing itself and paying for itself.

Round numbers, made up so the arithmetic is easy to follow, the same questions asked of all three.

Employ the physicist. $350,000 loaded for the year, no transition cost. Absence and vacancy coverage is not written down anywhere, and next year's upgrade work is assumed absorbed by the current team. Both need confirming with the physics lead.

Contract an independent firm. $300,000 for the year, plus $20,000 of transition quoted separately. Whether absence coverage is included, and what it costs if it is not, has to come from the schedule, and the upgrade work is assumed to sit outside the base quote.

Contract the manufacturer's arm. $700,000 for the year, with a bench behind the site so a leave or a vacancy is the vendor's problem, and the physics owned by somebody else. Both of those are real, and for some programs worth buying. Neither is a saving.

The savings box on the slide compared the first two and said $50,000. Put the transition charge beside it and the known gap is $30,000. Add the third and it stops being a $50,000 question at all. All three leave the same row blank: the work the program still arranges itself. Fill that one in and the prices start covering the same work.

Year two gets its own line, and this is what prompted the issue. Independent physics firms are being bought. On September 2, West Physics, which says it serves over 6,000 client sites, bought Radiographic Testing Services of Albany, a few months after taking on a private equity sponsor. Nothing about that is wrong, and it tells you nothing about your renewal letter. It belongs on your comparison for a simpler reason: the firm you sign with may not be the firm you renew with, and when the owner changes, the only thing that travels with you is what the agreement says.

So write down what you can see before you sign: the escalation clause and what it is tied to, the renewal date and the notice you owe, what happens to your records, QA equipment and data when it ends, and the entity you are contracting with. Ask while you are still deciding, because afterward the terms are the terms.

None of this decides staffing. The physicist who holds the qualified medical physicist role, employed or contracted, is the program's advocate here and the one person whose job is to say what it needs. Your physicist sets the clinical requirements, with your radiation oncologists on the parts that are theirs: the machines, the procedures, the QA program, the coverage you have to have. Get that list written before any price is on the table, and measure every option against it. If the question is whether to replace that physicist with a service, get the requirements down before the decision gets framed that way.

After that comes the commercial work: who provides each requirement, where it is written, and what the program still has to arrange itself. A blank means unknown. Unknown is not zero, and it is not savings.

This issue's move. Take the options going to the finance meeting and fill in three rows: the work required, absence and vacancy coverage, and the work the program keeps. Put a source next to every answer, and give every unknown an owner and a date. Then send the provider one paragraph:

Ask your own department the same about the employed option.

Then give finance one page: the decision requested, the recommendation the evidence supports, the scope difference behind it, the unresolved facts, and the next action with a name and date. The recommendation can be conditional. “We recommend the service, and these three answers have to come back before we sign” is something finance can act on. One number minus another is not.

On the word “comprehensive”

The Pitch: "Our quote includes comprehensive physics coverage."

The Reality: That sentence tells finance nothing about what the program will still have to provide. The providers describe their services in public, and none of those descriptions say which ones a given quote includes, or who covers leave, or who holds chief physicist responsibility. Those items are either inside the quote or they are yours, and the word does not tell you which.

The schedule does, which is why the schedule is what you ask for, in writing: the work included, its limits, and who is responsible for each item the program still needs. The employed option gets the same question from your own department, and both answers go on the comparison before anyone touches the savings slide.

With Heather Turner, RT(T), PMP

Why your treatment machine is sitting empty while your waiting room is full.

Nothing frustrates an operational leader more than looking at a linear accelerator schedule with open slots while knowing you have ten patients cleared clinically who cannot get onto the table.

In today's reimbursement environment, prior authorization delays are no longer just a financial headache for the billing office; they are a major driver of unbooked machine time. When an authorization gets caught in an endless loop of payer requests for clinical records or peer-to-peer reviews, the start of treatment gets pushed back. That delay leaves an open slot on tomorrow's schedule that you cannot fill at the last minute.

When I was treating patients on the floor, I viewed prior authorization as something that happened "up front" in an office I rarely visited. But as an operational leader, I realized that authorization delays are a primary bottleneck to machine utilization. If you want to keep your LINACs full, you have to treat prior auth as a time-sensitive clinical workflow, not an administrative task.

A machine gap caused by a delayed authorization is revenue you will never recover. By bringing clinical discipline to your authorization process, you protect your patient care timeline and keep your treatment slots filled.

The two prices in front of you are not wrong. They just do not cover the same work yet. Before the meeting, put them on one page with three rows filled in: the work required, who covers absence and vacancy, and what the program keeps doing under each option. Then finance decides on the whole job instead of on part of it.

If a physics decision is going in front of finance this quarter and the two prices on the slide do not cover the same work, reply and say so. A word is enough. I read the replies myself and I answer them myself.