Patients with cancer are living longer thanks to new treatments, but the US oncology care system is burdened by growing administrative responsibilities, difficulties obtaining payment, and runaway costs.
Richard Schilsky, MD
Patients with cancer are living longer thanks to new treatments, but the US oncology care system is burdened by growing administrative responsibilities, difficulties obtaining payment, and runaway costs, ASCO said in its 2015 report: The State of Cancer Care in America. Such turbulence is “creating uncertainties about the system’s capacity to continue to provide high-quality care,” ASCO noted in the report.
Among the concerns: an aging oncology workforce, practices under pressure to close or merge, oncologist burnout, the threat of rising cancer rates, and insufficient government funding for clinical research.
“This year’s examination of current data and trends clearly shows that oncology practices in all settings continue to experience tremendous pressures and volatility in the marketplace,” the report said. “At the same time, advances in both cancer treatment and health information technology are spurring exciting innovations in oncology care.”
Replacing an Aging Workforce
For the first time, there are more oncologists over the age of 64 than under the age of 40, said Richard Schilsky, MD, chief medical officer for ASCO, in an interview with OncLive. The report predicts a 45% rise in cancer cases in coming years, creating a “looming mismatch” between the demand for services and the supply of oncologists.
The median age of oncologists remains at 52, the same as last year, while those 40 or younger amount to just 16% of the workforce, and 19.8% are closing in on retirement, being 64 or older, ASCO reported.
However, the proportion of women in medical oncology is on the rise at more than 30% of oncologists this year, just slightly below the 32.6% of women in medicine. Women oncologists are younger on the whole than male oncologists, with a median age of 46 versus 56 years. The report notes that 48% of those in oncology fellowships are women, a figure that is higher than for women in medical training programs overall (46%).
The figures on diversity show a wide gap between the proportion of African-American oncologists and the black population, 2.3% versus 13% respectively. “The rate is not much better in training programs, where only 4% of oncology fellows are African American,” ASCO said. Hispanic practicing oncologists amount to just 3% of the total, whereas Hispanics make up 17% of the US population and 5.8% of oncology fellows, the report said.
ASCO said it has instituted a mentoring program for underserved communities in the belief that “increasing ethnic and racial diversity in the cancer care workforce has the potential to advance cultural competency and expand access to quality care.”
However, pilot efforts to reach underserved cancer patient populations in Nebraska and Iowa are seeing results, the report said.
Whether to Merge or Close
Pressures forcing practices to close or merge with larger institutions are a particular threat to rural practices, where 18 % of the US population lives but only 5% of oncologists practice, Schilsky said.
“Ten to 15% of small oncology practices report that they’re likely to merge or close or sell themselves to larger healthcare systems in the coming year, and that is a significant issue, particularly for people who live in the more rural parts of the country,” he said.
One-quarter of practices said they were likely to become affiliated with a community hospital over the next year, similar to what was reported by oncologists in the 2013 census.
New Health Threats Will Increase Need for Oncology Care
The report identifies new threats to the nation’s health from rising obesity and e-cigarettes, both of which threaten to send cancer incidence rates higher.
The report noted recently uncovered links between obesity and cancer risk, including endometrial, esophageal, postmenopausal breast and colon cancers, “with as many as 84,000 cases attributed to obesity each year. If trends continue unabated, obesity may lead to an excess of more than 500,000 cancer cases by 2030.” The report also noted a link between obesity and worse outcomes for breast, prostate, and colon cancer, among others.
Similarly, the report says a question mark hovers over the cancer risks of e-cigarette use, which is rising and which, ASCO says, has not yet been sufficiently studied and may encourage more people to try tobacco smoking.
Practices in State of Flux
ASCO said nurse practitioner and physician assistant numbers are rising rapidly and their use in practices of various sizes is expected to rise: 52% of oncology practices reported employing advance practice nurses—mostly nurse practitioners—and/or physician assistants. These practices employ 2752 advanced practice nurses and 1136 physician assistants, though most practice in academic settings, according to the report.
“This may change, because a majority of physician-owned practices indicated they are somewhat likely or very likely to hire advance practice nurses and or physician assistants in the coming year,” the report said.
The report said the need for payment reform is an urgent priority, particularly with regard to incentivizing high value, patient centered care. “The current system under which Medicare reimburses physicians for patient care has not been able to keep up with the upward cost curve,” the report said. Most practices (72%) in the ASCO survey reported they continue to work in a fee-for-service (FFS) environment, 8% use capitation, 9% care-bundling, and 11% other non-FFS alternative payment models.
“Of practices considering or implementing novel models, 36% reported that they had implemented or were considering a pathway adherence program and 30% were considering medical home programs emphasizing care coordination.”
“This emergence of variable pathway programs raises concern about a lack of standardization of pathway programs, which when combined with new payer requirements may result in increased administrative burdens for many oncology practices,” ASCO said in the report.
ASCO said 89% of practices report using electronic health records (EHR), and 6% said they would likely implement an EHR in the next 6 months. Increasing numbers of oncologists report frustration with EHRs, blaming them for “decreased productivity.”
Another drain, they said, was the need to obtain preauthorization for insurance coverage of certain drugs: 89% said it delayed or interrupted patient care, 72% said it decreased patient satisfaction, and 64% said it complicated medical decision making. Nearly 70% said their initial preauthorization requests were rejected by insurers, necessitating appeals and additional requests.
As many as 50% of oncologists asked reported burnout issues, though 80% said they like the work and would choose oncology again, Schilsky said.
For some practices, the 340B Drug Pricing Program that requires drug suppliers to provide discounts to certain hospitals was identified as “the greatest pressure your practice is experiencing currently,” ASCO said. Hospitals have the ability to make a significant margin on 340B drug purchases, paying far less than the levels at which insurers compensate, resulting in an extreme pricing advantage over small oncology practices.
Clinical Trials Losing Steam
ASCO noted that insufficient funding for the NIH and NCI is threatening to stall recent progress in medical advancement. In tandem with the publication of their report, ASCO officials are addressing Capitol Hill legislators to seek $32 billion in additional FY2016 funding for the NIH and an extra $5.3 billion for the NCI, Schilsky said. “If we’re going to keep up the progress, obviously the funding has to keep pace at least with inflation and be predictable and sustainable.”
A majority of practices, 57%, said they would likely increase participation in clinical trials to investigate the value of new cancer treatments. Among them, 27% said they would likely begin federal trials and 39% said they would initiate private, clinical trials.
Affordable Care Act Adds to Patient Workload
In 2014, nearly 8 million Americans registered through new insurance exchanges and millions more are obtaining insurance through expanded private and governmental programs, the report said. However, it said access to cancer care will “remain a challenge because of low-physician reimbursement, high drug copays and lack of access to clinical trial participation.”
“Some young uninsured individuals are choosing to pay fines rather than pay for insurance. Furthermore, a growing number of plans, including Medicaid expansion programs and state health exchanges, are pursing cost containment measures such as tiered pricing, narrow networks and restricted formularies, practices that may disproportionately affect patients facing costly cancer treatment.”
ASCO Requests Several Policy Changes
Besides asking for more money for the NIH and the NCI, ASCO is calling upon Congress to standardize care benefits between Medicare and Medicaid, and make sure that all publicly funded insurance plans allow for coverage of a suite of basic oncology services considered essential.
ASCO is also asking that Medicaid funding be provided for clinical trials and for the Sustainable Growth Rate formula to be repealed and replaced with an alternative model for oncology practices that will incentivize quality and not simply boost the volume of activity and billing.
The group also wants Congress to allow for multiple care delivery models to be tested so that optimal pathways to payment and successful treatment outcomes can be weighed against each other.