March 2014 Edition Vol.11, Issue 3

ASCO Reports on the State of Cancer Care in America in 2014

ASCO Reports on the State of Cancer Care in America in 2014

By Lynne Lederman, PhD

On March 11, 2014, the American Society of Clinical Oncology (ASCO) released its first report on the state of cancer care in America, which focuses on demographic, economic, and practice trends that affect cancer care in the US.1,2 During a webcast3 on that date, key findings of the report and some of these solutions were discussed. Current ASCO President Clifford A. Hudis, MD, Chief of Breast Cancer Medicine, Memorial Sloan-Kettering Cancer Center, Professor of Medicine, Weill Cornell Medical College, New York, New York, said that the goal of the report was to help cancer care providers and policy makers, among others, to understand the challenges to delivering cancer care. 

If not addressed, the challenges that the US cancer care system faces could make it unsustainable. These challenges include an increasing demand for care, predicted workforce shortages, rising costs, imbalances in access to care, and an unstable practice environment. 

Dr. Hudis, said that if there was one take-away from the report, “it should be the word quality. The purpose of everything we do at ASCO is to achieve and deliver quality.” 

Here we report on some of the key findings of the report and issues that were discussed during the webcast.

Demand for Care

The demand for cancer care is expected to increase 42% by 2025, reflecting that people are living longer; ageing is a prime risk factor for cancer. By 2025, cancer will become the leading cause of death in the US. In addition, the Affordable Care Act (ACA) is expected to add 25 million newly insured people. According to Dr. Hudis, although most individuals with cancer gain access to care eventually, those with insurance are presumed to be seen sooner, and, having better outcomes, longer, which will increase the workload for healthcare providers. ASCO projects that the current number of cancer survivors, 13.7 million, will increase to 18 million in the coming years.

Workforce Shortages

The supply of medical oncologists, now numbering about 13,400 in the US, is expected to increase by 28% by 2025, leaving a projected shortage of nearly 1487 oncologists as the number of patients increases faster. Based on oncologists seeing an average of 300 new patients per year,4 this would result in almost 450,000 Americans who would face challenges in accessing cancer care. 

Oncologists over age 64 years, that is those approaching retirement age, began to outnumber oncologists under age 40 in 2008; currently almost one-fifth are over age 64 years, and ASCO predicts that this proportion will continue to increase. Medical oncologist burnout is another challenge. It is the perception by oncologists that although the field is rewarding and they enjoy patient care, increased workload and administrative burdens are driving them to the decision to leave their practice. The ASCO report included the results of a membership survey that indicated that significant numbers of medical oncologists have concerns about burnout, are likely to reduce patient care hours, leave their practice, or retire before age 65 years. This would exacerbate the workforce shortage.

Access to Care

Currently, one in five Americans lives in a rural area, but only 1 in 33 oncologists practice in a rural area, so there is a disconnect between local or regional resources and patients. Dr. Hudis observed that “we have to have a way of distributing high quality care where it needs to be rendered, not just at referral centers.” ASCO partnered with the University of Iowa to examine how cancer care is delivered in rural areas of that state. Although a network of medical oncologists who travel to rural areas was created, there is a concern that financial pressures from the sequestration could place that network at risk. Currently, there is no information as to whether patient outcomes were improved by access to the visiting consulting clinics that were set up under this arrangement, and there is no systematic national process to measure whether rural specialty care arrangements were adequate. ASCO plans to extend this analysis to other states with a low density of practicing oncologists, and will include an analysis of patient outcomes.

Additionally, blacks and Latinos have disproportionally lower rates of access to care, and the increased health care coverage related to the ACA may not rectify this. The report mentions that blacks and Latinos are underrepresented among oncologists, although whether or not this affects disparities in care is not known. 

Unstable Practice Environment and Rising Costs

Small (one or two physicians), and mid-sized (fewer than seven physicians) local oncology practices which serve about one-third of newly diagnosed patients with cancer are at risk. Nearly two-thirds of these small community practices are at risk for merger, sale, or closure in the next year, based on the ASCO 2013 membership census.5 (See Figure 2). 

It is the small and mid-sized practices, which are concentrated in the southern and western US, that provide care to over one-third of newly diagnosed patients. However, the trend is for practices to increase in size, and medical oncologists are moving to larger institutions. This is illustrated in Figure 3, showing that from 2012 to 2013, the number of large practices (7 or more physicians) has increased at the expense of smaller practices. 

Closure of practices can disrupt patient care in the middle of treatment, and require increased travel time, among other barriers to care. 

Carolyn Hendricks, MD, a medical oncologist in private practice in Bethesda, Maryland, who is the current chair of ASCO’s Quality of Care Committee, described the challenges facing her as a solo practitioner during the webcast. She employs two oncology nurses, a nurse practitioner, and a biller. She has been practicing since 2001, but has been considering closing her practice, citing the increasing cost of chemotherapy drugs and falling reimbursement as a major factor.

Hendricks points out that the pricing for chemotherapy drugs is directly related to how much drug she purchases, so that she pays more than larger practices. In 2013 she purchased $3.4 million of chemotherapy, about average for a medical oncologist; like other oncologists, she purchases chemotherapy on credit, then has to “scramble” to obtain reimbursement. She carries a huge debt that she wasn’t willing to disclose publicly, and has lost a significant amount of revenue over the last couple of years. 

She can’t see more patients, is unwilling to cut staff salaries, and is considering closing her practice. An academic medical center negotiated with her for a year and a half before withdrawing, calling the economic climate for outpatient oncology too precarious. Of the 50% of oncologists who responded to the ASCO 2013 membership census, half saw a significant impact of the Medicare sequestration, and half reported sending Medicare patients to a hospital infusion center rather than treating them in their own practice. Dr. Hendricks had to send some patients to a hospital infusion center herself when two staff members went on leave. Her patients were upset to find their out of pocket expenses higher for the infusion center compared with the office setting.

 

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