Nanda Vrindavanam, MD
When Nanda Vrindavanam, MD, was looking for a new job last year, he kept an open mind about the type of setting where he would end up. But having worked at a physician network in Cincinnati for 13 years, the idea of switching to a hospital was very attractive.
“I had done a lot of administrative work where I was. That was taking up a lot of my time, and there weren’t enough returns from that work,” he said. “Every day, it was personnel issues, it was just the regular workflow issues within the practice, and then on top of that, you have the larger administrative problems, like, how is reimbursement going to change? It was pretty stressful. You start thinking, why not just work as an employed physician, where you don’t have to deal with all of that? I just have to see my patients.”
Pressures on independent oncology practices have been mounting for years, as payer data-reporting requirements become more onerous and revenue from drug reimbursements decline. Many physicians still enjoy the control and higher pay that working for yourself often provides, but as Vrindavanam’s experience suggests, some practices are finding that those advantages are no longer enough to attract and retain the physicians they need to stay in business, and grow.
Recruitment challenges are a subset of the larger problems faced by small and midsize practices. In 2015, an ASCO survey found that the number of practices with five or fewer oncologists dropped to 41% from 64% the previous year, while those with more than 12 oncologists more than doubled to 36% (Figure)
Community oncology is dividing as larger, sophisticated, often urban practices adapt to new healthcare realities and flourish, while smaller ones struggle to remain independent.
Pressures are particularly acute on practices in remote or rural parts of the country, like West Virginia. The state has the oldest practitioners in the country, on average, and a low number of oncologists per resident, despite having very high cancer rates.2
Four community practices have closed in West Virginia in recent years and four others were acquired by hospitals, leaving 10 still operating, according to the Community Oncology Alliance (COA). “They do try to hire, but it’s difficult,” said Ahmed Khalid, MD, president of the West Virginia Oncology Society. “Those independent practices that are still in existence—some of those that I know are in the process of getting bought by nearby hospitals.”
Other factors may also be contributing to the difficulties some providers have maintaining and expanding their medical staffs, such as a growing need for physicians and an insufficient number of oncology and hematology fellowships. Competition means job hunters can be choosy, allowing them to prioritize the proximity of family, the amenities of urban life, or an easier work schedule when they decide which positions to accept.
During Vrindavanam’s search, he encountered a number of practices, both independent and at hospitals, that were struggling to hire doctors, he said. They included providers throughout Illinois, in midsize Ohio cities, and in Texas border towns. A number of practices in Iowa kept calling him for months. A hospital in Myrtle Beach, South Carolina, made him a good offer a few months ago, but he and his wife visited and concluded they would not “fit” there. She noted a lack of different kinds of restaurants in the small city, he said.
After a national search, he finally settled on Austin Cancer Center in Texas, where he has family nearby. Although not a hospital, the practice is growing rapidly, has an administrative staff to handle nonmedical duties, treats fewer Medicare and more private-insurance patients than his old practice, and is located in a hip, booming city.
“The payer mix was a big thing,” Vrindavanam said. “The work itself is very good, because for the majority of my time, the work is about seeing patients, and making sure everything is done well and that they’re satisfied. I have a choice of whether I want to pick up any administrative duties and what kind of work I want to do. It’s a nice way to do it.”
A Different Set of Priorities
Working in small private practices has long had benefits for entrepreneurial oncologists. The hours may be long and the responsibilities broad, but they could build a practice from the ground up, personally manage patient care, earn excellent pay, and sell the business when they retired.