7 Threats to Cancer Care

Gabriel Miller; Peter P. Yu, MD; Jennie R. Crews, MD; Matthew Farber


September 10, 2014

In This Article

Payment Problems

Key Facts:

In the 2013 Medscape Physician Compensation Report, oncology reported the greatest decrease in income among the specialties, with a 4% drop; however, in the 2014 survey, oncologists reported a 4% increase.

One out of every three respondents to the ACCC's 2013 Trends in Community Cancer Centers survey were involved in a merger, acquisition or affiliation of cancer programs during the previous year.[2]

Dr. Yu: One issue is that we are not a procedure-based practice. We deal mostly with cognitive services, which means our income is largely derived from E/M codes, which just don't pay well. We did have a procedure of sorts with chemotherapy, but the margins for that have eroded rapidly, and now, in fact, it has become a risk factor. So with the rising price of drugs and shrinking margins, it really becomes not a potential revenue source but a potential practice killer. With the expense of chemotherapy drugs, insurance denial, and patients not being able to handle the copays, you could be financially sunk pretty quickly. The financial pressures tie into payment reform and reimbursement mechanisms, so that is a part of the problem.

The broad context is to move away from reimbursement structures that reward just doing more, getting paid for doing more, and to put more emphasis on accountability for outcomes and for reducing costs by [telling practices] that the way to preserve your margin is not by increasing volume; it's by reducing the cost of your care delivery and focusing there. Another thing that ASCO feels is important is to encourage or incentivize the use of nonphysician providers to deliver care. Physicians are the best trained, the most knowledgeable members of the cancer care team, and need to be used appropriately. So we should be making the big decisions. We should be seeing the patients when there is a problem and having one-on-one, meaningful discussion with them. But others can do the things that are more clerical or more routine. A reimbursement system that pays only when the doctor sees the patient, and not when someone else does something, is not encouraging us to be efficient in doing what we want to do and letting us not do the things that we don't want to do.

Dr. Crews: One of the biggest impacts with healthcare reform has been limiting where patients can go, and that's driven by the insurance companies. We're having a lot of issues with one predominant insurer in this region limiting patients going to the premier university system in the state. That's where we send most of our patients for second opinions and specialized care. That's been a huge issue with reform; patients could have decreased access to sites of care.

Mr. Farber: Salaries of medical oncologists, if we are going to take that subset, have either been flat or declining in recent years. We have definitely seen that trend happening, and I think it goes back to before the recent shift in some of the payment methodologies. I think it really goes back to the Medicare Modernization Act of 2003 and that part of the system, because there were some significant changes specifically around how Medicare reimburses for care and how Medicare reimburses for drugs. All of that put a lot of financial pressure on how practices compensated their physicians' time. When you add to that these newer payment methodologies, it just continues to put pressure on that. Things like treatment pathways and episodic care, accountable care organizations, oncology medical homes -- these are all ways to weed out any excess and unnecessary tests in the systems in an effort to provide better-quality care at lower cost. There are some studies showing that it is working from an overall cost standpoint to the healthcare system, but at the same time, we are still trying to understand what the implications are to our practices. For example, for a practice to become a true oncology medical home as it's being defined now, there are quite a few upfront staff and personnel costs that a practice has to invest in -- things like having 24-hour triage services available or being open on weekends. There is significant cost to that and there has to be payment justifications in order to do that. You can't expect the practice to be able to do that without increased reimbursement on the part of the payers.


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