Robin Zon, MD
If your oncology practice is suffering from the rising costs of equipment and facilities, staffing costs are going up, and administration expenses are through the roof, you're not alone. More than half (54%) of practices are struggling with these pressures, according to ASCO's 2017 State of Cancer Care in America report released in March.1
Much of that pressure is due to the money being spend on quality-reporting activities, which cost 1000 practices $15.4 billion, according to a 2016 study, ASCO said.2
It isn't just the costs of running an oncology practice that physicians and administrators are grappling with. Oncologists are finding themselves chained to their electronic health reporting (EHR) systems and their desks because of copious amounts of administrative work. ASCO reported that 49% of physician time is now dedicated to EHR and administrative activities, whereas time spent with patients represents a mere 27% of a physician's day.
These strains on practice time and finances are making it increasingly harder for practices to survive. “Increasing administrative duties and expenses will continue to challenge practices, especially small independent practices,” said Robin Zon, MD, chair-elect of the ASCO Government Relations Committee, in comments about the annual report. Zon said ASCO remains committed to working with independent oncology practices by providing educational activities and other assistance to help them manage rapidly changing conditions in the sector.
Among physician-owned practices, certain factors constitute significantly greater pressures than they do for other types of providers, including academic and hospital- or health system-owned practices (Figure 1). In 2016, practice and facility expenses, drug expenses, and competitive pressures were powerful stressors for physician-owned practices, the ASCO report said. For hospital-based practices, however, EHR systems and staff- ing issues were the chief problems. And academic centers were more likely to cite facility and practice expenses, staffing issues, and payer pressures. Overall, after facility and practice expenses, drug pricing was the most frequently cited pressure, followed by EHR implementation.
Different types of practices face similar problems but in different proportions.
The ASCO report, now in its fourth year, also discussed many achievements in the war on cancer, such as new drugs and recently approved indications for established therapies. Last year, 5 new drugs and biologic therapies were added to the armamentarium of the more than 200 FDA-approved cancer fighting drugs, ASCO said. In addition, indications were expanded for 13 cancer therapies, and diagnostic tests that included liquid biopsy for lung cancer mutations and next-generation sequencing to identify patients with advanced ovarian cancer who would be eligible for a particular cancer treatment were approved.
Looming challenges to cancer care delivery posed by the rising incidence of cancer and the growing US population were another important element of the report. There are not enough oncologists to go around, the report noted and, although practices are now using advanced practice providers (APPs) to bridge the gap, many nononcologist providers have indicated they feel unprepared to incorporate the needs of patients with cancer into their medical activities.
Many cancer centers that responded to the 2016 ASCO Oncology Practice Census said they were using APPs to perform care functions normally performed by doctors: 334 (75%) of 443 centers. The number of APPs em- ployed by those respondents included 3022 nurse practitioners and 1157 physician assistants. ASCO said it is working to more clearly understand the roles of these supplemental practitioners and plans to submit results of the study for publication sometime this year.
One problem that may add to the difficulty of providing sufficient care is the graying of the oncology workforce (Figure 2). In many states, between 18% and 29% of oncologists are ≥65 years, the report said. This is true throughout the Southwest and the Northeast, but is even more apparent in such states as New York, Montana, New Mexico, and West Virginia.
The graying of oncologists, indicated by darker colors on the above map, creates a more urgent recruitment problem for practices. Source: ASCO.
Oncologists are also more likely to be found in urban centers, the report said. Whereas 19% of the US population lives in rural America, only 6% of oncologists do. “Montana and Oklahoma are the most extreme examples, with each having high levels of rural residents [(44% and 33%, respectively)] and no oncologists with rural practice sites,” ASCO said. ASCO suggested that telehealth may be one answer to the problem of getting care to the regions of the United States that most need access. ASCO said that 46 (27%) of 170 practices surveyed were already using telehealth to provide oncological guidance in remote communities. “Although the survey findings indicated modest use of telehealth in oncology, several participating practices indicated high satisfaction with their programs,” the report said. Telehealth was de ned as encompassing 2-way video, e-mail, smart phones, and wireless tools.
Zon said that telehealth is not the only answer to extending care to underserved communities, although some of the innovative efforts that practices have developed to answer this need are hampered by the same pressures that are afflicting the oncological community in more affluent areas, she said. “Some oncology practices have satellite clinics that provide care in otherwise underserved or rural communities. However, these clinics are under stress, as cost and administrative burdens rise, and some have had to close. We are hopeful that innovative payment models will better support team-based care and other creative solutions that remove access barriers for individuals in rural and underserved areas.”
Women practitioners seem poised to take on a larger role in oncology across the United States, according to the report. Overall, women represented just 32% (n = 3859) of oncologists in 2016, but under the age of 40 they were 46% (n = 739). The majority of pediatric oncologist/hematologists in 2016 were women (52%).
Minorities also remain underrepresented in oncology practice, the report said. Although 18% of the US population is Hispanic, just 5.8% (n = 519) of oncologists are Hispanic. Blacks represent 13% of the US population, but among practicing oncologists, only 2.3% (n = 400).
“The oncology workforce should reflect the underlying population of patients with cancer,” ASCO said, noting that it has established an action plan to improve diversity.
Although genetic testing is becoming a much larger element of practice in targeted medicine, ASCO findings suggest that only a small proportion of oncology practices are employing on-site genetic counselors. The report stated that 29 (24%) of 122 practices surveyed said they have genetic counselors on staff and 67 (55%) provide referrals.
Whereas practices are under many pressures, patient access to care could undergo significant change based on the outcome of the Republican-led effort to replace the Affordable Care Act (ACA), ASCO said. From the act’s inception in 2010 through early 2016, “20 million fewer people were uninsured because of the ACA, and the rate of uninsured Americans dropped to an all-time low of 8.6%,” the report said. “The long-term success of the ACA is uncertain given the motions to repeal and replace.” This year marks the implementation of the Medicare Access and CHIP Reauthorization Act (MACRA), which introduces the Oncology Care Model and incentive-based payment systems designed to lower costs and improve quality of care and outcomes, and ASCO remarked that physicians will undergo a period of financial risk and uncertainty related to this rollout. “Although MACRA encourages movement away from fee for service into new payment models and alternative payment models (APMs), the rules for these payment pathways remain poorly defined, and only a limited number of oncology-specific APMs are available for oncologists who want to move to this payment pathway.”
- ASCO. The state of cancer care in America, 2017: a report by the American Society of Clinical Oncology. J Oncol Pract. doi: 10.1200/JOP.2016.020743.
- Casalino LP, Gans D, Weber R, et al. US physician practices spend more than $15.4 billion annually to report quality measures. Health Aff. 2016;35(3):401-406. doi: 10.1377/hlthaff.2015.1258