Oncologists: Future of rural cancer care seen as 'dire'
For many rural Americans, access to quality cancer care in the future could be threatened as the growing demand for services outstrips the supply of oncologists and the cost of care continues to soar, according to a report issued by the American Society of Clinical Oncology and published online March 11 in the Journal of Oncology Practice via Medscape Medical News.
It is projected that the number of new cancer cases in the U.S. will increase by 42 percent by 2025. During the same period, the number of oncologists will increase by only 28 percent, which will lead to a projected shortage of 1487 oncologists.
At the same time, cancer is slated to become the leading cause of death. And it is projected that the annual associated costs will rise from $104 billion in 2006 to more than $173 billion by 2020.
Although demands on oncologists will increase, many practices will be under great financial pressure, in part because of the sequester and recent cuts to Medicare physician payments.
The report examines how oncologists are dealing with the rising demand for their services, the economic pressures that are affecting small independent practices, and changes in healthcare delivery systems. It recommends specific steps that can be taken to preserve patient access, improve quality of care, and slow the trend of rising healthcare costs.
Speaking at a Congressional briefing, ASCO president Clifford Hudis, M.D., noted that “side-stepping the issue of being for or against the so-called Obamacare,” there will be a projected 25 million more people who will gain insurance.
The nature of cancer care improves when people have insurance because they tend to be seen sooner and will presumably be seen for longer periods of time and have longer therapy, all of which increase the workload for providers, Hudis said.
In addition, the number of cancer survivors is projected to rise from 13.5 million to 18.0 million in the coming years, Hudis said, and all of these people will need ongoing care from cancer care providers.
Although these are “good problems to have, they are problems that we need to plan for if we are going to meet the challenges,” said Hudis, of Memorial Sloan-Kettering Cancer Center in New York City.
Too few rural oncologists
Uneven access to care, particularly in rural areas, is likely to become more acute in the coming years. The vast majority of oncologists are concentrated in urban areas and in certain geographic locations.
One in five Americans live in rural areas, but only one in 33 oncologists are practicing in these regions, said Carolyn Hendricks, M.D., a medical oncologist in private practice in Bethesda, Md. Thus, on average, a patient living in Massachusetts has more than five times as many physicians to choose from as a patient living in Wyoming.
According to the report, almost 97 percent of physicians practice in urban areas or urban clusters. More than 70 percent of the counties analyzed had no medical oncologists at all.
In addition, the survival of small community-based practices is under threat, which is a dire situation.
The Community Oncology Alliance followed 1,338 clinics and oncology practices for six years. Last year, the COA reported that 43 of these practices had begun sending patients elsewhere for treatment, 288 clinics had closed, and 407 practices were struggling financially.
Small and mid-sized practices (no more than six physicians), which are concentrated in the South and West, serve more than a third of new patients, according to the ASCO report. These independent community practices, in particular, are under tremendous financial pressure.
Hendricks said she is in a solo practice that specializes in breast cancer. Although she loves her work, she expressed frustration that she might not be able to continue because of financial pressures.
Much of this has to do with falling reimbursement rates and the system of drug reimbursement. A typical community cancer clinic must spend a considerable amount of money to purchase chemotherapeutic agents that are then administered on an outpatient basis.
The pharmaceutical manufacturer and the wholesale distributor set drug costs.
“We purchase the drugs on credit and then we scramble,” she said.
A new business model that does not depend on purchasing and billing for oncology drugs is needed. “I have worked hard to increase practice efficiency, but quality care is very time-intensive,” Hendricks added. “Small practices like mine will benefit from lifting the sequestration.” In fact, the ASCO reports notes that almost two thirds of small oncology practices (with only one or two physicians) have reported that they are likely to merge, sell, or close within the year.
In small towns and rural communities, “these smaller practices are the backbone of cancer care,” said Hudis. They allow patients to receive high-quality personalized treatment close to home.
Shortage of oncologists
The projected shortage of 1,487 oncologists will likely present challenges for patients seeking quality cancer care. An average oncologist sees about 300 new patients each year. Extrapolating, this means that almost 450,000 new patients could have difficulty getting the care they need, Hudis explained.
Among the factors contributing to the projected shortfall are the aging oncology workforce and impending retirements.
Currently, one of every five oncologists is older than 64 years. In 2008, the number of oncologists older than 64 years exceeded the number younger than 40 for the first time, according to the report. The projection is that this gap will widen.
A number of oncologists are also experiencing “burnout,” Hendricks said. At the congressional briefing, she referenced a recent ASCO survey that found that although oncologists are generally highly satisfied with their career choice, as a group they experience symptoms of burnout.
About half (44.7 percent) of the respondents reported at least one symptom of burnout, which is a syndrome that includes emotional exhaustion and/or “depersonalization,” as reported by Medscape Medical News.
Although oncologists feel a great deal of satisfaction taking care of cancer patients, increased workloads and administrative burdens “have driven them to make decisions to leave their practices,” she reported during the briefing.
“A significant number have reported that they are likely to reduce the number of hours spent in clinical care, leave their current positions, and/or retire before age 65, which would significantly exacerbate the anticipated shortage,” Hendricks said.
Ever increasing costs “have created an urgent need” to improve the value of patient care, according to the report. Even though healthcare costs are rising throughout the system, they are more pronounced in cancer care.
The rising costs come through many ways, affected by the price of new therapies and a healthcare system that incentivizes the use of tests, treatments, and services can be unnecessary, ineffective, or avoidable.
The emergence of novel therapies, which are sometimes administered in combination regimens, is helping to drive costs up. Many of these new therapeutics cost up to $100,000 for a course of treatment, making them prohibitively expensive even for patients with insurance, the report said.
The oncology community is working to improve the quality and value of cancer care, but action by Congress and other policymakers is urgently needed to improve patient access to care.
“There are three very specific steps we can take now” to address the challenges in cancer care, said Hudis.
The first is to develop and test healthcare delivery and payment models that preserve the viability of small community practices and support, reward, and encourage high-quality care, he said.
The second is to end this “never-ending cyclical threat” to community practices—and to all practices—caused by sequester-related cuts to Medicare physician payments, Hudis said.
“The sequester was a very specific challenge for us,” Hudis said. “We need to repeal what should be called the ‘unsustainable’ growth rate formula.” The sustainable growth rate formula, Medicare’s current reimbursement system, has become a source of tremendous instability within healthcare.
Congressional committees have introduced the SGR Repeal and Medicare Provider Payment Modernization Act of 2014, which would eliminate the flawed SGR system, provide special support for practices in underserved areas, and support a number of innovative healthcare payment, delivery, and quality initiatives.
The third step is to embrace and support physician-led quality initiatives, such as ASCO’s Quality Oncology Practice Initiative and the CancerLinQ learning health system currently in development, Hudis said.