Mission to Treat Rural Poor Is Challenged by Merger Pressure

Tony Hagen @oncobiz
Published: Sunday, Apr 26, 2015
Dr. Gladys Rodriguez

Gladys Rodriguez, MD

For Gladys Rodriguez, MD, a practicing oncologist for 24 years, the daily schedule is filled with calls to payers and hours spent at the computer typing up electronic health records. Years ago, she recalls, she had a lot more time to spend with patients.

“There are days that I have to call 10 different insurance companies to get approvals. Ten years ago, I never had to go through that,” Rodriguez, an employee of the START Center for Cancer Care in San Antonio, Texas, told Oncology Business Management. “It’s not only me. It’s everybody here. My nurse and my nurse assistant probably spend half of their time on the phone.”

START is a bustling, multi-location practice that has many of the problems identified as typical of oncology practices these days by the American Society of Clinical Oncology (ASCO) in its recent report, “The State of Cancer Care in America, 2015.” Mountains of administrative work, negotiations with payers, and difficulty recruiting adequately trained staff are common issues for the Texas clinic.

In addition, members of the practice sit down regularly to consider the pressures of the marketplace and how to remain independent, Rodriguez says. START employs 12 medical oncologists, 4 radiation oncologists, 4 phase 1 researchers, 9 general surgeons, and 2 gynecologist oncology surgeons.

START’s practice area is the city of San Antonio—which has 1.4 million inhabitants—along with the surrounding metro district and a rural expanse that extends at least 3 hours by car from the city center, encompassing Laredo and the West Texas–Mexico border town of Eagle Pass. San Antonio is growing rapidly, but many of its residents are economically disadvantaged, and the practice works with a large population of Medicare, Medicaid, and underinsured patients. Many patients traveling long distances have no transportation of their own and depend on area groups and towns to chip in for bus service to bring them to START.

Roughly half of Rodriguez’s patients are Hispanic, and 1% are undocumented. Some come from as far away as Mexico. “There are some programs in San Antonio that provide care for breast cancer patients even if they are undocumented, and we see a lot of those patients,” Rodriguez says.

START has a robust clinical trials program with about 40 drugs in phase 1 testing. The trials program allows patients to receive treatment that may not be available at other practices, broadening the availability of new treatments and options for care, while pro bono activities and patient foundations help to fund medications and care for indigent patients. Rodriguez says that one of the reasons START physicians prize their independence is that a larger, acquiring organization might not allow them as much latitude in treating their patients as they currently enjoy.

But oncology practices throughout Texas always seem to be in talks with acquirers, and the danger is that a practice which currently poses no sizable threat to START’s operations could become an adversary through a merger. An alternate scenario—and one no less worrying—is that a large health organization will, rather than take over a local practice, “just hire people from the outside and start their own program,” Rodriguez says.

Many independent practices throughout the country are reacting to these pressures by raising the white flag. ASCO reported that 7% of respondents to its annual survey indicated a likelihood that their practices would close; and the Berkeley Research Group has reported that, based on its own survey, 33% of community oncology practices are in serious acquisition talks with hospitals, or in merger talks with other practices.

Table 1. How Oncologists Spend Their Time

aSource: Shanafelt T,Gradishar W, Kosty M, Satele D, Chew H, Horn L. Burnout and career satisfaction among US oncologists. J Clin Oncol. 2014;32(7):678-686,http://jco.ascopubs.org/content/32/7/678.full.pdf+html. Published March 1, 2014. Accessed April 22, 2015.



“The solo practitioners are fading away, not because people don’t like to be by themselves,” Rodriguez says. “It’s just that because of the cost of medications, the infrastructure you have to provide, the chemotherapy in your office, because of all the reporting you have to do, it’s almost impossible to meet all of those requirements and still be able to provide the care. And because of that, the number of people who will be able to go to a rural place and try to practice by themselves is very limited.”


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