Community Oncology Clinics Still Under Siege, Says COA Report

Roxanne Nelson, BSN, RN

October 07, 2016

Since 2008, community cancer clinic closings have increased 121% and consolidation into hospitals has increased 172%, according to a new report issued by the Community Oncology Alliance (COA).

During this time period, 380 cancer clinics have shut their doors, and 609 community cancer practices have been acquired by hospitals, or at least become affiliated with them.

In addition, almost 400 practices report that they are struggling to keep their head above water because of financial distress.

"Treatment advances like oral drugs and immunotherapy have the potential to save lives," said Bruce J. Gould, MD, president and medical director of Northwest Georgia Oncology Centers in Marietta and president of COA, in a statement. "That will not matter if patients can no longer afford care or if care simply disappears from their community."

The current report is the sixth in the series that COA has issued, and it covers activity for a 9-year period beginning in January 2008 through September 2016.

Compiled from public and private sources, the paper reports on community oncology trends at both the national and state level.

Of note, the monthly rate of community oncology practice closures has increased by 87% since COA issued their last practice impact report in 2014.

Since 2008, 1581 community clinics and/or practices nationally have been affected by closures, hospital acquisitions, and corporate merger, which extrapolates to a rate of 15.1 community practices affected per month.

COA found that the states with the most clinic closures are Florida (37), Texas (36), and Michigan (34) and that the states with the most practices that are struggling financially are Michigan (43), New York (41), and California (40).

During this time frame, 157 practices have merged or been acquired, but Ted Okun, executive director of COA, pointed out that some mergers can be beneficial.

"Not all consolidation is hurting patients, and some of it is good for the community," Okun told Medscape Medical News. "Not all mergers are bad if they stay in the community."

One example is Florida Cancer Specialists, which has expanded but its care stays in the community. "They have about 200 physicians and over 100 advanced practitioners, and they operate out of about 90 locations in the state," said Okun.

Burden on Patients

But consolidation and hospital acquisition place an additional burden on the nearly 20% of Americans living in rural areas, according to the report. "In an urban area, patients have many more choices," Okun said. "But in rural areas, there may only be one cancer clinic in the community."

He noted that it's an ingrained belief that when a patient is diagnosed with cancer, they will do anything to get care, even if it means traveling long distances. But data show that the opposite is true. "Many patients can't travel, for any number of reasons," he said. "They are sick, they don't have transportation, and so on. So they may end up with no care at all."

The ever-increasing trend of closures and consolidation of community oncology clinics into the hospital setting has had "a significant and permanent impact on patient access to local, affordable cancer care," says the report.

"My guess is that clinics that are 'outposts' and at best break even or at a loss are probably the first to be closed when a hospital buys a practice," said Okun. "But in some cases these practices are very small, and when the physicians retire, they just are closed."

The COA emphasizes that the "most profound effect" has been the acquisition of community oncology practices by hospitals, which has been fueled by the 340B drug discount program.

The original intention of the 340B program was to support institutions that served high numbers of indigent patients, but instead it has created a profit motive for hospitals to acquire community oncology practices.

A Big Irony

One of the biggest ironies of the current trends is that despite efforts to curtail spending, the shift in cancer care has had the opposite effect.

As COA has previously stated, the crisis in the community oncology setting is a result of inadequate Medicare reimbursement for community-based cancer care, misguided Medicare policies that incentivize higher-cost settings, and the application of the sequester cuts to the underlying cost of cancer drugs.

Patients may pay up to 53% more when they receive hospital-based cancer care compared with the same care they would receive in a physician office setting. That cost, in turn, is shared by both the patient and the payor, most often Medicare.

"From 2014 to 2016, it cost Medicare about $2 billion more to pay for patients to receive care in the hospital," said Okun.

"The more that we see the corporatization of medicine, and the power shift from physician executives to business executives, the more it will be about numbers," he added. "The concentration is on profits and not patients."

Despite the continuing trend of practice closure and acquisition, there is one "bright spot" in the report — that more practices are working together. "They are not formally joining together but are cooperatively working on payment reform and other issues," said Okun.

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