Keith Lerro, MD
Keith Lerro, MD, is the sole oncologist at his Wilson, North Carolina practice and often puts in seven day weeks. That is despite the fact that his practice, Regional Oncology Medical Center, employs no fewer than six administrators to manage business accounts, interact with payers, and arrange care and payment for underinsured patients. In 2003, a practice of Regional’s size could have gotten by with one or two administrators, Lerro estimates. But things have changed.
Many doctors in oncology are pushing themselves to similar extremes. Longer workdays have become a fact of life. Physicians interviewed for this article said they are spending less and less time with patients and more time on the phone with payers, more time in late night business meetings, and more time filling out electronic health records (EHR). Their personal time also has evaporated as the complexity of running an independent practice has grown. Doctors said they no longer have enough time for relaxing activities that ease the stress of putting in so many work hours.
Lerro said that he may owe his longevity in this now-grueling profession to the business exposure he received at his former practice, Southeastern Medical Oncology, also of Wilson. When he was there, he voluntarily attended business meetings because he was interested in that side of practicing oncology. Little did he realize that the knowledge he was acquiring would be critical for sustaining his current practice. Without that knowhow, he would have been underequipped for managing today’s reporting quality measures and more restrictive payment policies of insurers. “The evolution of the mandates and the shrinking margins have forced many private practices out of business,” he said. “Many of them were reasonably well run, but they just couldn’t survive.”
Working With Payers Is One of the Biggest Challenges
Now, working with payers consumes more of the workday than ever before, oncologists said. In addition, much more concentration, skill, and knowledge are needed to work successfully with payer policies and government regulations. Even after putting in additional time and effort, oncologists find it difficult to get approvals for the treatments they think are most appropriate. “The role of the physician has shifted into being a mediator between the insurance company and the patient,” Lerro said. “The doctor cannot treat the patient based on his own evidence-based review of the literature. He needs to know all of the treatment options possible and choose the one that the insurance company will pay for and the patient’s copay can handle.”
Source: Shanafelt, Gradishar et al, 2014.
Part of the additional effort that has to be invested comes in the form of actually confronting payers over denials that seem unjustified based on evidence and standards of care, according to Myron Bednar, MD, a medical oncologist at Hunterdon Hematology and Oncology in Flemington, New Jersey, who said he is spending much more time on paperwork, phone calls, and case reviews with payer representatives. “Even when we follow [National Comprehensive Cancer Network] guidelines, we get pushback or denial from insurance companies, and we have to present our cases through peer-to-peer meetings or by written letter to get approval,” he said.
Bednar said one heartbreaking example of this involved a fruitless, eightweek struggle to get a payer to cover a promising, off-label treatment for a stage IV breast cancer patient. The patient had failed multiple treatment options and was unable to obtain insurance coverage for a targeted agent, which had been approved for kidney cancer and was predicted to work based on the gene sequencing of the woman’s tumor. Eventually, after the payer wouldn’t budge on its coverage decision, Bednar was able to get the treatment through a program from the pharmaceutical company. The patient is responding well to the drug several months later, but Bednar stated the case is an example of how meetings, letters, and phone calls are not always successful and take time away from patient care.