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Pressures on independent oncology practices have been mounting for years, as payer data-reporting requirements become more onerous and revenue from drug reimbursements decline.
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).1 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.
A Different Set of Priorities
“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.”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.
Even now, self-employed oncologists earn an average of $354,000 a year while their employed counterparts bring in $278,000, according to Medscape’s most recent compensation report.3 But the advantages of working in an independent practice have been eroding for several years. Debra Patt, MD, a vice president of Texas Oncology and chair of the ASCO Clinical Practice Committee, cited the impact of the federal 340B discount program, which greatly increased hospitals’ drug revenues and motivated them to move aggressively into oncology, as well as Medicare quality initiatives that require major investments in staffing and electronic data collection.
The options for small practices include affiliating with large providers like US Oncology (as Texas Oncology has done), joining a hospital, or adopting electronic health records or clinical pathways to improve efficiency and boost reimbursements, Patt said. However, she added that making such changes is costly and challenging for any physician.
“If you are a small to medium-sized practice, and you have all of these new reporting burdens ahead of you, and there is financial uncertainty, you may have a lower appetite to recruit,” she said. “And it’s harder to recruit to those positions because of the uncertainty in the climate ahead.”
Managing those tasks is particularly unappealing to many newly trained physicians, Patt said. “For the millennials that are now coming out of their oncology fellowship programs, they are more apt to focus on their specific area of interest, be it care delivery or research, and are less apt to take on additional functions in a practice, like to volunteer for additional administrative burdens,” she said.
That’s, in part, due to a broad cultural shift that has changed perspectives on life-work balance, said Teri Guidi, president of Oncology Management Consulting Group in Tampa, Florida. Attitudes vary, but more oncologists now want to take advantage of the fact that it is possible to have a good career without giving over their lives to their practice, she said. “The younger ones have a very different sense of what life is. Life is not 60 to 80 hours a week. It’s, ‘I don’t want to take calls more than one night in seven, and I want to be out every Thursday afternoon at four to see the kids’ soccer game,’” Guidi said. “There’s a human side to a physician’s life these days that was really not the case when I was growing up and my dad was a physician. It’s a lifestyle issue of, how hard are they willing to work?”
Learning to Cope
She also described the smaller pool of new medical oncologists as a leading reason for the staffing crunch. With fewer fresh faces to hire, organizations that need an oncologist more often need to poach one instead, thereby increasing turnover rates and creating difficulties for the practices that lose staffers. Khalid said his practice has experienced such losses even though it’s in Charleston, West Virginia’s capital and largest city. One partner, who had come to them from a fellowship at MD Anderson in Houston, was able to eliminate her school debt and leave after just four years. “She had absolutely no roots in the state,” he said. “Once the loans were paid off, life was more comfortable, and she moved off to a bigger city.”The financial pressures that make practices in small towns less attractive places to work lead to shutdowns or mergers in many cases. A COA survey last year found that one-third of community practices were in serious merger or acquisition discussions. From 2008 to 2014, some 313 clinics closed, 544 were acquired, and 149 merged, according to COA.4
Small practices that remain open and independent may have to start triaging, by seeing urgent patients more quickly and delaying routine appointments, Khalid said. They can hire a short-term physicians or extenders, such as physician assistants or nurse practitioners, as many practices do so their oncologists can focus on core medical duties. Guidi said practices will sometimes put a nurse through school so he or she can become a nurse practitioner and help keep the business going. If those options aren’t available, the remaining partners “just have to bite the bullet” and increase their patient loads, Khalid said.
Experts warn, however, that taking on more work carries a cost as well, especially given the record keeping and reporting that accompanies each additional patient. A 2014 study found that 45% of oncologists reported experiencing some degree of burnout, with higher rates for those in private practice than those in academic practice.5 Each additional hour spent with patients per week increased the risk of burnout by 2% to 4%. Studies show that burnout can lead to early retirements or career changes, which, in large numbers, could worsen or hasten the growing shortage of cancer specialists that contributes to recruitment challenges in some parts of the country.