7 Threats to Cancer Care

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


September 10, 2014

In This Article

Poor Access in Rural Areas

Key Fact:

A 2014 report by ASCO found that more than 70% (2067) of US counties analyzed had no medical oncologists at all.[6]

Dr. Yu: Twenty percent of the US population lives in what are considered rural communities. But only 3% of oncologists work in those rural communities, so you have a big disconnect there. In my practice, last night we had our quarterly meeting where all of the oncologists get together with administrators. The discussion came to radiation -- in this case, brachytherapy -- and the advantages to patients with partial breast radiation or other brachytherapies or strategies that shorten the duration of therapy.

In California (even in some parts of the San Francisco Bay area), once you get an hour and a half away from downtown San Francisco, patients don't necessarily have a good radiation facility within a mile of where they live. They have to travel, and traveling daily for weeks on end is a big issue. Some patients have said, "I don't want radiation therapy, which is too much to do. I'm not going to follow your recommendation."

Dr. Crews: One of the worries with the mergers that are happening is that smaller practices predominantly are the ones that are closing, and typically these smaller practices are in rural areas. So there's a huge concern about what happens to these patients in terms of their access to cancer care and prevention strategies.

I'm in Washington State. In my current practice we're part of a network, the Northwest Network of PeaceHealth, and we have two hospitals in somewhat rural locations that can only be accessed by air or water. One of them is in Ketchikan, Alaska, and the other is on San Juan Island. We have started cancer programs at both of these hospitals. To address that remoteness, we're partnering significantly with primary care physicians to help manage patients. We're using telemedicine, which has been very innovative and exciting to do, and we're looking at ways that we can have advanced practice clinicians in those locations fill the gap when the oncologist can't be there.

I think you have to be creative. The rural areas are going to continue to be a challenge as practices merge and as practices close, and access to care is very important. No cancer patient wants to have to drive two hours to get care; it's just very burdensome for them. But there are ways to think creatively about using nontraditional providers to help give them that care in the community.

One of the concerns that I have, though, is about some of the recent CMS changes regarding direct supervision, which require or define who can manage administration of chemotherapy, which is unfortunate for these rural areas. To provide patients with what they need in these rural settings, we need to be more creative than saying there has to be an oncologist there at the time of administration. I think we're doing a disservice to those patients with these rules.

Mr. Farber: Not to make it even worse, but one more thing to throw into the calculation is that you might have patients who live close to a medical oncologist, but that medical oncologist may not be in network of any insurance plan in that area or any insurance plan offered through, let's say, an insurance marketplace. One of the disturbing trends we have seen with the advent of the insurance marketplaces is the exclusion of a number of oncologists or hospitals from in-network in a lot of the plans.


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