Community Oncology in US Continues to Disappear

Nick Mulcahy

April 30, 2018

Non-hospital-affiliated, community-based oncology practices remain under duress in the United States, according to a 2018 report from the Community Oncology Alliance (COA).

Since 2008, 1653 community oncology clinics or practices have closed, been acquired by hospitals, undergone corporate mergers, or struggled financially, reveals the latest COA practice impact report.

Currently, there are about 2000 community practices or clinics in the United States, said Ted Okon, the COA's executive director. Community practices and clinics range from large groups, such as Florida Cancer Specialists, which has 80 sites, to small, one-clinic practices. The COA has not determined the exact number of community-based practices and related clinic sites.

However, the COA does count clinic closings. During the past 2 years, an average of 3.5 community oncology practices have closed per month.

But the overall toll is higher. Each month since 2008, an average of 13.8 practices have been affected by closings, hospital acquisitions, or corporate mergers, the COA says.

Since 2008, a total of 658 practices have been acquired by hospitals, which the COA says is a "dramatic shift" of community cancer care into the more expensive hospital setting.

There's been "a clear and negative dismantling" of the community-based cancer care system during the past decade, said Okon in a press statement.

The table below lists events of concern in the new report. Some terms, such as "clinics closed," "struggling financially," and "acquired by hospital," are self-explanatory. The term "sending patients elsewhere" means the clinic is referring Medicare and Medicaid patients to other providers because of low government reimbursement. "Merged and acquired" means that two or more practices have merged or that a large nonhospital entity, such as US Oncology, acquired a practice.

Table. Increasing Troubles (Cumulative Totals)

Year 2010 2012 2014 2016 2018
Clinics closed 172 241 313 380 423
Struggling financially 323 442 395 390 359
Sending patients elsewhere 44 47 46 45 45
Acquired by hospital 224 392 544 609 658
Merged or acquired 102 132 149 157 168
Totals 865 1254 1447 1581 1653


Since the last COA report in 2016, there has been an 11.3% increase in the number of community cancer clinics that have closed and an 8% increase in the number of consolidations into the hospital setting.

However, the report also reveals that the trend has slowed.

Although the total number of relevant events, such as closings, jumped by nearly 400 from 2010 to 2012, only 72 such events occurred from 2016 to 2018.

"There are glimmers of light that the darkest times are hopefully over," Okon told Medscape Medical News.

Some Bright Spots

These trends are "reflective of the push-pull of misguided public policies on cancer care," the COA says in its report.

Community-based practices have "enormous" operating pressures, says the COA, because of the ongoing 2% sequester payment cut to Medicare enacted by the Centers for Medicare & Medicaid Services (CMS) in 2013.

At the same time, community oncology practices have become desirable acquisitions by hospitals because of a lawful misuse of 340B Drug Pricing Program. Through the program, hospitals and hospital-owned practices make significant profits by exploiting extra payments intended to benefit poor patients in need, as reported by Medscape Medical News.

A recent study of the program published online in January in the New England Journal of Medicine concluded that "the 340B Program has been associated with hospital-physician consolidation in hematology-oncology and with more hospital-based administration of parenteral drugs in hematology-oncology."

Despite these problems, Okon says that "community oncologists are more upbeat than I have seen in a while."

Community oncologists are more upbeat than I have seen in a while. Ted Okon, COA

Oncologists are optimistic about a number of things, he said. For example, there is the growing awareness of the misuse of the 340B program, and awareness of problems associated with pharmacy benefit managers is increasing. Also, multiple community-based practices are participating in — and benefiting from — the Oncology Care Model, which is an experimental payment model involving both CMS and private payers. The model financially rewards clinical efficiency and thoroughness.

Despite these good signs, Okon is worried about physician demographics and their impact on the number of community oncology practices. "I am concerned about the trend of retiring oncologists. There is an increasing demand but a diminishing supply among all oncologists," he said.

Follow Medscape senior journalist Nick Mulcahy on Twitter: @MulcahyNick

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