In the Shadow of Big Centers, Community Oncologists Still Thrive

Nick Tate

March 16, 2023

New York genitourinary oncologist Jahan Aghalar, MD, left Memorial Sloan Kettering Cancer Center in 2019 for a nearby community practice with locations spread across the New York metropolitan area.

Like many oncologists who choose to work in the community setting, Aghalar craved the ability to spend more time with his patients and less on his commute into Manhattan.

"I'm happy to have my place of work so close to my home — that's been a tremendous benefit," said Aghalar, who called the move to New York Cancer & Blood Specialists (NYCBS) — a community oncology practice that has grown from a few offices in 2008 to about 100 clinics across the five boroughs, Long Island, and the surrounding region — "a no brainer." "Now I have more time to spend with my patients."

Despite the well-known, work-life advantages of community oncology, choosing this setting might seem risky given the financial strain these practices have faced over the past 15 years. Since 2008, nearly 1700 community oncology clinics or practices have closed, been acquired by hospitals, undergone corporate mergers, or struggled financially, according to a 2020 report from the Community Oncology Alliance (COA).

But the financial landscape for community practices may be shifting. In fact, according to COA, many community oncology practices have reported thriving in the shadow of bigger players.

"It is a real unfortunate misconception that you can only get the quote-unquote 'best cancer care' at a major name-brand institution in a major city — that is not true," said Nicolas Ferreyros, managing director of policy, advocacy, and communications with COA, the nonprofit that represents such practices. "The vast majority of cancers can be treated in a community oncology practice and thousands of them have been doing that very well, at high quality and much lower cost to patients and the cancer care system."

The personal touch that community centers provide is the most critical factor in the survival of these practices, according to Susan Sabo-Wagner, MSN, RN, OCN, executive director of clinical strategy for Houston's Oncology Consultants, a community-based practice with 15 offices spread across Texas.

"Sometimes patients feel as though they are just a number at those larger institutions," Wagner said. But as cancer therapy has advanced, many patients can get quality care closer to home, which means "they can pick up their kids from soccer practice, they can sit at the dinner table with their families, they can sleep next to their spouses."

But perhaps the biggest driver of the trend is financial. Many community oncology practices are doing well because they can offer patients quality cancer care at significantly lower costs — and, in some cases, may even provide higher salaries, experts said.

Financial Pros

Georgia oncologist Miriam Atkins, MD, joined a community oncology practice in Augusta 22 years ago, after 7 years at a large academic-military cancer center in San Antonio, because she craved more "control over my own destiny."

Since her move to the community setting, Atkins has enjoyed greater flexibility with scheduling patients, tailoring visit durations to the needs of each person. But perhaps the biggest surprise for her has been financial.

"My income is actually higher than my colleagues that work at big centers," said Atkins, now the president of COA. Atkins explained that oncologists may get a big salary up front but then experience cuts later. However, in a private group "you're not going to have someone come in and say, 'You're not working hard enough so we're going to cut your pay.' "

Although available salary data do not clearly delineate the differences, which could vary widely by practice, position, and location, Aghalar echoed Atkins' point, noting that, in his experience, "salaries are typically higher in community practices, but at the exchange of more clinical responsibilities."

Another factor that may make community practices more attractive for patients and employers providing health coverage: The costs of care are often significantly lower compared with larger institutions.

A 2018 analysis found, for instance, that the average monthly per-patient cancer cost at a community-based clinic is $12,548 vs $20,060 at a hospital-based outpatient practice. Data also show that hospital prices for the top 37 infused cancer drugs average 86.2% more per unit than in community offices.

"It's very real savings, and the trend is we're going to see more of this type of care," said Ferreyros, noting non–hospital-affiliated community oncology centers now deliver more than half of cancer care in the United States.

Ferreyros believes this percentage will continue to rise because self-insured employers — who encompass 65% of covered workers in the US — prize the financial savings of contracting with community practices. Locking up these contracts with employers has also helped smaller community oncology practices compete with larger centers.

"Employers are no fools," he said. "They have seen [that sending] a patient to a local hospital is a six-figure number for a cancer treatment. If you're a small employer that's self-insured, that will hit your bottom line and health costs for the year very hard."

Partnering: A New Model for Care?

While many community oncology centers remain independent, some have also benefited from partnering with their big-name competitors.

NYCBS, where Aghalar practices, has had a formal working relationship with Memorial Sloan Kettering for several years. NYCBS chief executive officer Jeffrey Vacirca, MD, said the partnership with MSK has allowed his doctors to refer patients to the renowned cancer center for procedures and treatments his clinic doesn't perform, such as bone marrow transplants and highly specialized surgeries, which gives patients and oncologists the "best of both worlds."

NYCBS oncologists this past January joined forces with a practice of MSK physicians — Memorial Medical Care, PC — to provide comprehensive cancer care services in Brooklyn's Flatbush neighborhood. Here, patients can receive their evaluation and most of their therapy from NYCBS oncologists as well as more specialized care, such CAR T-cell therapy, from MSK physicians.

Aghalar, who joined NYCBS 4 years ago after 5 years at MSK, said he was initially worried about missing out on access to the high-caliber surgeons and radiation oncologists available at MSK, when dealing with difficult situations. But the partnership has eliminated that concern.

"I would say this is an ideal model of bringing [together] the best of what community oncology can offer and what a large academic medical cancer center can offer," Aghalar said. "Of course, each setting has pluses and minuses but when we combine them, we feel we are putting ourselves and our patients in the best position they can be in."

NYCBS is not the only community oncology center to partner with comprehensive cancer centers in their area. Community oncology clinics have launched similar partnerships with other big-name cancer institutions, including MD Anderson, Fox Chase Cancer Center in Philadelphia, and the Duke Cancer Institute in North Carolina.

How does this type of partnership benefit patient care?

Jack Niederberger's experience as a patient echoes some advantages of this model.

Last August, the 20-year-old Niederberger developed a sore throat and fever he suspected was COVID-19. But when he went to his pediatrician, he tested negative for the virus and strep throat.

His bloodwork, however, turned up a more troubling possibility: his symptoms might be signs of leukemia.

"On Tuesday morning the doctor called me and said you have to get Jack to [NYCBS] right away," recalled his mother, Gayle. "I just about dropped the phone."

That Tuesday afternoon, Jack went to NYCBS, which confirmed his leukemia diagnosis. He was referred to MSK for treatment, which began days later.

"It was a whirlwind," said Gayle. NYCBS "jumped on it so fast and there was not one stone left unturned, between the two. It was seamless."

Since then, Niederberger has undergone five rounds of chemotherapy and is now in remission.

Vacirca said his case is the "perfect example" of why such partnerships are a great option for patients. More complex care really needs to happen in centers of excellence, Vacirca said, explaining why Niederberger was treated at MSK, not NYCBS. But Niederberger was still about to receive the ongoing support and care coordination from the community practice in his backyard.

"I think this model, if embraced, is the best one you'll see out there," Vacirca said. "It gives us the best of both worlds — fantastic community-based care, but with a partnership with one of best cancer hospitals in the world."

A More Personal Touch for Patients

Soon after Debra Patt, MD, PhD, MBA, left MD Anderson for a community practice in Austin, she confronted a case that confirmed that she'd made the right move.

The patient had metastatic triple negative breast cancer, a hard-to-treat form of the disease that carries an average survival rate of about a year. The woman's best and only real option was to enroll in a clinical trial for an experimental treatment.

"She had moved to Austin to get treated at our clinic because we could open a clinical trial faster than MD Anderson could — about 7 months faster," Patt noted. "We opened the trial, and she did great. Her cancer went into remission."

Although the cancer later recurred, Patt was able to treat it with an oral chemotherapy. "She was able to see her daughter get married and see her first granddaughter born," Patt recalled.

Being free of the red tape and top-down management that comes with working for a large cancer center can allow oncologists to provide more timely care. Working at a community clinic often also lets oncologists spend more time with their patients.

At MSK, "I felt [patients] were seeing me at pit stops along their journey, as opposed to me being there along with them on their journey," Aghalar recalled. "Now I have more of a hands-on involvement in the journey the patient is going on."

Another factor: Recent innovations in chemotherapy and immunotherapy drugs have made it increasingly possible to administer them in smaller clinics, said Alti Rahman, MHA, MBA, practice administrator for Oncology Consultants in Houston. "We have 12 clinics in Houston, and they are about 8-10 miles apart. So we can be close to the patients, which is important," Rahman noted.

One recent study found that, between 2010 and 2019, the share of community oncologists in practices that integrated drug dispensing increased by almost fourfold — from 7.6% to 28.3% — and reached 100% in South Dakota, 89% in Delaware, and 75% in Wyoming.

And although community oncology practices have been plagued by financial challenges, closures have leveled off in the past few years, said Ferreyros. In fact, he believes the 3740 community practices in the US have grown stronger in the face of "a lot of upheaval in the healthcare system" over the past two decades.

"I think what you're seeing now is, in a way, survival of the fittest," he said. "Practices have adapted and evolved and transformed themselves to meet the challenges of the marketplace — whether that is through innovative value-based contracts, developing partnerships and agreements with local employers, or being able to better manage their operations."

Patt agreed that market forces and financial pressures are boosting the success of community oncology practices across the country. But she believes the benefits of community-based oncology for doctors and patients alike are at the heart of the successful community oncology practices like hers.

"It's a great time to be a cancer care provider. We're very lucky to live in a time of remarkable innovations and that's an incredible privilege," she said. "And to be able to do it in a way in which you can be as effective as possible — in the community — I think is really important for doctors and patients."

Nick Tate, a contributing writer and editor for WebMD, is a bestselling author and award-winning journalist specializing in healthcare, medicine, science, and biotechnology.

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