Health Policy
Original Contribution
Results of the 2013 American Society of Clinical Oncology National Oncology Census By Amy Hanley, Karen Hagerty, MD, Elaine L. Towle, CMPE, Michael N. Neuss, MD, Therese M. Mulvey, MD, and Anupama Kurup Acheson, MD
Results: The Census collected 530 useable responses in
Abstract Purpose: The American Society of Clinical Oncology (ASCO) National Oncology Census (Census) provides a mechanism for ASCO to systematically gather and analyze information about current practice structures and potential changes at a time when practices are working to adapt to increasing administrative and financial pressures. The Census is conducted annually and reports on new and trending data.
Methods: The 2013 Census was launched on May 30, 2013, as a national survey of oncology practices. The survey required practices to answer 11 questions and provided additional optional questions.
Introduction The American Society of Clinical Oncology (ASCO) National Oncology Census (Census) originated as a mechanism to systematically gather and analyze information about current oncology practice structures and potential changes at a time of growing administrative and financial pressures. Specific information regarding oncology practice structure is necessary to understand how practices are adapting as they aspire to provide high-quality cancer care to the patients they serve. Absent this basic information about oncology practices, policy solutions and other interventions may be inadequate to respond to the anticipated shortage of oncologists or may inadvertently address the wrong issues. ASCO’s goals for the Census are to collect demographic data on as many US oncology practices as possible, including information on services offered, practice size, staffing characteristics, organizational structure, and affiliations; to learn how oncology practices are adapting to administrative and financial pressures with relation to these demographic characteristics; and to develop the capacity to monitor these characteristics on an ongoing basis. All this is being done to allow ASCO to tailor its advocacy, educational products, and practice support efforts appropriately to best meet the needs of its members and the larger oncology practice community as they care for patients in a shifting health care delivery landscape.
2013 compared with 632 respondents in 2012. Practices reporting in 2013, however, represented a total of 8,011 physicians compared with only 5,018 in 2012.
Conclusion: The pace of policy change in oncology practice is changing the landscape of how practices are organized. A greater number of practices with more than seven physicians responded in 2013, which could indicate overall growth in the size of oncology practice. Practices reported increased affiliations with hospitals through a variety of contractual mechanisms. In subsequent census efforts, ASCO will have the capability to match 2013 respondents to future respondents, allowing for increased precision in comparison of longitudinal data.
of optional questions were also included. ASCO emailed the survey to all US members and, through a variety of communications channels, encouraged participation by the entire oncology community. Nonrespondents were emailed and called to solicit involvement. The census was closed on August 30, 2013. ASCO received 685 responses to the census. Responses were excluded if physicians were not involved in direct patient care (n ⫽ 5), outside the United States (n ⫽ 23), and locum tenens or retirees (n ⫽ 12). Multiple responses from the same practice were included when it was clear that the responses represented separate sites of service. One hundred fifteen responses were identified as duplicates and removed from analysis. Additionally, practices that responded “greater than 100 physicians” or “greater than 30 physicians” were rounded to 100 or 30 respectively. Final analysis included 530 respondents. Rural-Urban Commuting Area Codes were used to place responders into “metropolitan” or “nonmetropolitan” categories. Additionally, five-digit zip codes were used to map responders. We report the census regions as West, Midwest, South, and Northeast. Data were compared with that of 2012 to identify any shifts. Because of differences in data collection methodology, direct comparisons of data from 2012 and 2013 respondent practices is not possible at this time.
Methods
Results Practice Demographics
The ASCO 2013 Census was launched on May 30, 2013. The brief survey required practices to answer 11 questions. A series
For the 2013 survey, we received 530 useable responses compared with 632 responses in 2012. Although the number of
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American Society of Clinical Oncology, Alexandria, VA; Oncology Metrics, a division of Altos Solutions, Los Altos, CA; Vanderbilt Ingram Cancer Center, Nashville, TN; Southcoast Hospital Group, Fall River, MA; Providence Oncology and Hematology Care Clinic, Portland, OR
Hanley et al
No. of Practices
250
2012 2013
200 150 100 50
West
South
Midwest
Northeast
Figure 1. Practices responding, by census region, in 2012 and 2013.
practices reporting decreased, the number of physicians included in the data reports increased. The reporting practices included a larger number of physicians, both in total (2013: n ⫽ 8,011; 2012: n ⫽ 5,018) and by average practice size (2013: 15 physicians per practice; 2012: nine physicians per practice). Reporting practices were grouped into the following groups: those with one to two physicians, those with three to six physicians, and those with seven or more physicians. Overall, more practices with seven or more physicians responded in 2013 (Appendix Fig A1, online only). Therefore, we analyzed practice size as a percentage of responses from each year to demonstrate where shifts in the size of practices may be occurring. There was an increase in the percentage of practices reporting seven or more physicians from 29% in 2012 to 42% in 2013. There were corresponding decreases in the percent of practices reporting between three and six (from 37% to 30%) or between one and two physicians (from 34% to 28%). Figure 1 shows the distribution of practice responses across the four census regions for both 2012 and 2013.1 The number of practices responding from each region decreased this year, except for the West, where the number slightly increased. We analyzed a more detailed breakdown of responding practice size by census region (Fig 2). With the exception of the Northeast, practices with seven or more physicians represented the largest number of practices reporting for each region. Even in the Northeast, practices with seven or more physicians were re-
West
South ≥ 7 physicians 3-6 physicians 1-2 physicians
Northeast
Midwest 0
20
40
60
Staffing
80
No. of Practices Figure 2. 2013 practice size and distribution by census region.
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Practices reported a mean of 9.8 full-time equivalent certified oncology nurses per practice, an increase from 6.7 in 2012. We again analyzed the responses with and without including academic cen-
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ported with just one less occurrence than the leading reporting group, those with three to six physicians. These results contrast quite strongly with the 2012 respondents; groups of seven or more physicians did not lead reporting in any of the census regions. In 2012, practices of three to six physicians led the reporting in all regions except the Northeast, where physician groups of one to two had a slight edge. Compared with 2012, this year’s survey responses represented more academic centers; these responses may have biased the overall study results. There was a doubling in the percentage of respondents to this year’s survey describing the practice as an academic practice (2012: 9.5%; 2013: 20.2%). In 2012, of the 599 practices providing information on this variable, 57 selfreported as an academic practice; in 2013, 107 practices of the 530 reporting used this descriptor. We therefore analyzed the responses regarding practice size with and without academic centers. Omitting academic centers from the analysis causes no change in the 25th percentile, and the 50th percentile (median) remained relatively stable at five physicians per practice versus four when omitting the academic centers. However, there was a significant shift in both the mean and the 75th percentile, suggesting that heavier reporting from academic centers for this year’s data does bias the overall number in favor of larger practice sizes. Of the 8,011 physicians represented in the survey, 4,635 were in academic practice and 1,782 reported they were in private community practice. Of those in private community practice, the average practice size was approximately seven physicians. Ninety private community practices reported having one to two oncologists in their practice; 91 practices consisted of three to six physicians. Seventy-two practices reported seven or more oncologists in the practice. We analyzed practice size by census region, focusing on only the practices that self-reported as private community practice. Groups of one to two oncologists dominated in the South; this was the only region where these small practices led the way in practice structure (Fig 3A). In the other three census regions, within private community practices, groups with three to six oncologists were most prevalent (notably, in the Midwest Region groups of seven or more oncologists were equally common; Fig 3B). Respondents were asked to indicate medical specialties represented in their practice (eg, gynecology oncology, surgical oncology). Compared with 2012, there was an increase in the percent of practices reporting multiple specialties. This could reflect increased survey participation by academic practices, an increasing consolidation of existing practices, or both. Practices similarly reported their operating structure. There was a slight decrease in the percentage of practices describing themselves as private community practice. Likewise, there was a small decrease in those reporting as private integrated group practices.
2013 ASCO Census
80
90 80
60
70 50 40 30
Uninsured/self-pay Private/commercial Medicaid Medicare
60 50 40 30
20
20 10
10
0
0 Other
B
Midwest Northeast
South
40
Midwest Northeast South West
35
No. of Practices
West
30 25
2013
Figure 5. Payer mix (mean), comparing 2012 with 2013.
centers are omitted from the analysis. Compared with 2012 data, it does seem to indicate that practices are increasing the number of nurse practitioners and physicians assistants.
20 15
Payer Mix
10
Despite the change in demographics between respondents in the 2012 and 2013 surveys, payer mix remained largely the same. Although there were increases in the percentage of uninsured/selfpay (3% to 6%) and Medicaid (7% to 10%) payers, they were not statistically significant (Fig 5). Approximately half of practices (52%) indicated that they were unlikely to experience changes in the number of Medicare patients they treat. Almost a fifth (18%) indicated they were very or somewhat likely to decrease the proportion of Medicare patients, whereas 25% were very or somewhat likely to increase the number of Medicare patients. Respondents indicate similar percentages for each of the other payer types. For Medicaid, 47% of practices anticipate no change, 18% anticipate a decrease, and 28% anticipate an increase. For privately insured, 57% of practices anticipate no change, 17% anticipate a decrease, and 22% anticipate an increase. For uninsured, 48% of practices anticipate no change, 28% anticipate a decrease, and 17% anticipate an increase.
5 0 1-2 physicians
3-6 physicians
≥ 7 physicians
Figure 3. (A) Practice size by census region. (B) Census distribution by practice size.
ters (Fig 4). The results of this analysis showed little change: a 25th percentile and median that tracked fairly closely together, with differences in the mean and 75th percentile that suggest skewing of the data by larger academic centers. However, the difference in full-time equivalent certified oncology nurses per practice was less striking than the difference in the number of physicians. We also compared the numbers from 2012 and 2013 for nurse practitioners and physician assistants (Appendix Figs A2 and A3, online only). The comparison responses for number of practitioners by type across 2 years of the census shows a change in the 25th and 50th percentiles, but there are larger differences for both professions in the mean and 75th percentiles when larger academic 12
No. of Certified Oncology Nurse FTEs
2012
10
2012 2013 (all) 2013 (omits acad. ctrs)
8 6 4 2 0
25th percentile
50th percentile (median)
Mean
75th percentile
Figure 4. Full-time equivalent (FTE) certified oncology nurses per practice. acad ctrs, academic centers.
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Delivery and Payment Models New to the 2013 survey was a series of questions on delivery and payment models. Twenty-four percent of respondents (126 practices) reported they were considering novel delivery/payment models with payers. Within this group, the majority (56%) estimated that between 10% and 40% of their patients would be included in such a model. Twenty-seven percent reported fewer than 10% of their patients would be involved, and 16% of practices reported that more than 40% of their patients could be involved. Sixty-three percent of practices are looking at payment models that reward care coordination services, whereas 37% are looking at payment models that reward pathway adherence. For those practices that are considering the medical home model, 15% would be paid only for care coordination, 57% would be rewarded for decreased use, and 28% would adopt a payment model based on a gain sharing arrangement. Fewer than 10% of survey respondents answered the question regarding pathway use. We therefore did not attempt to
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No. of Practices
70
100
1–2 physicians 3–6 physicians ≥ 7 physicians
Percent
A
Hanley et al
1,800
2013
1,400 1,200 1,000 800 600 400 200 0
25th percentile
50th percentile (median)
Mean
75th percentile
Figure 6. New patients in previous 12 months.
analyze these responses further but note that the option of an open text field (“other”) for respondents to describe the type of pathway the practice is using confirmed the wide variety of pathways available. In addition to the three listed on the survey as examples (Cardinal/P4, Innovent, Via), responses included more than a dozen different pathway programs currently in use.
Patients Practices were asked to report the number of new patients seen in the previous 12 months (Fig 6). Responding practices (n ⫽ 263) reported an average of 1,620 new patients, with a median of 700 new patients. Although the data seem to indicate growth in new patient volume, compared with 2012 data, the difference may be largely related to increased practice size among the 2013 respondents. To examine this further, we looked at the number of new patients for practices describing themselves as private community practices. In practices with one to two physicians, the average number of new patients seen in the last year was 387; for practices with three to six oncologists, the average was 1,227; for practices with seven or more physicians, the average was 2,700 (Appendix Fig A4, online only). Additionally, when looking ahead, practices reported they were very likely to increase patient volume (23%) or somewhat likely to increase patient volume (32%); only 15% of practices were somewhat or very likely to decrease patient volume (Appendix Fig A5, online only).
were considering the purchase of another practice and slightly more likely to report consideration of a merger with another practice. The percent of respondents reporting that they were somewhat or very likely to close or sell the practice remained stable across the two surveys (close the practice: 2012, 6%; 2013; 7%; sell the practice: both years, 9%; Appendix Figs A7-A9, online only). We also examined the likelihood of practice changes in the private community practice setting by practice size. Small practices (one to two oncologists) and practices of seven or more physicians reported consideration of mergers in nearly equal numbers (20 v 19 practices). Small practices were more likely to report consideration of selling (20 sites) or closing (16 sites) compared with larger practices. Not surprisingly, none of the small practices reported they were considering purchase of another practice. Conversely, practices with seven or more oncologists were the most likely to report that they were considering the purchase of another practice. One practice of this size reported they were considering practice closure. Bigger swings between 2012 and 2013 occurred with practices reporting the likelihood of affiliating with other entities. In 2012, 10% of practices said they were considering affiliation with another practice, 15% with a community hospital, and 11% with an academic medical center. Those numbers increased in 2013 to 16%, 26%, and 17%, respectively (Fig 7). Despite turbulence across the practice community, many respondents indicated a strong potential for hiring clinical and nonclinical staff. This is particularly true for oncologists; 44% of practices reported they were somewhat or very likely to hire oncology physicians in the next 12 months; in 2012, 32% of practices were considering such hires. For each of the other staff categories, the percent of practices reporting they were somewhat or very likely to hire in a specific category follow: nononcology physicians, 15%; nurse practitioners, 35%; physician assistants, 21%; certified oncology nurses, 32%; licensed practical nurses, 12%; other clinical staff, 22%; and administrative staff, 19%. Each of these represents an increase across all staff categories compared with 2012 (Appendix Fig A10, online only). Although fewer sites reported consideration of layoffs, there was an increase in the number of respondents in 2013 reporting the likelihood of layoffs across almost all staff categories surveyed, except for nurse practitioners (3% of sites in both years; Fig 8). In 2012, 3% of sites reported considering laying off
Practice Pressures We asked practices to report what they felt was the greatest pressure they currently faced. Practices were offered eight options, including “other.” The choices reported most frequently were cost pressures (24.2%), payer pressures (21.2%), and competitive pressures (18.4%). The least frequently reported pressures were drug shortages (0.9%), “other” (5.1%), and local economic pressures (7.2%). Of note, drug shortage was chosen by 5% of respondents in 2012 (Appendix Fig A6, online only).
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Academic medical center
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Looking Ahead: The Next 12 Months
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2013 2012
16
Another practice
5
10
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20
25
30
Practices (%) Figure 7. Percentage of practices “somewhat or very likely” to affiliate with listed entities in 2012 and 2013.
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No. of New Patients
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2012
2013 ASCO Census
Very/somewhat unlikely Neither likely nor unlikely Very/somewhat likely
2013 2012
Begin administering chemotherapy onsite Begin sending patients elsewhere
Administrative staff
0 Other clinical staff
5
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Practices (%)
LPN/LVNs Certified oncology nurses Physician assistants Nurse practitioners Nononcology physicians Oncology physicians 0
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Practices (%) Figure 8. Likelihood of practice to lay off staff. LPN, licensed practical nurse; LVN, licensed vocational nurse.
oncologists, and the percentage of 2013 respondents was slightly higher at 5%. Larger differences between 2012 and 2013 respondents were seen in percentages of sites reporting that they were very or somewhat likely to lay off administrative staff or other clinical staff (a catchall category excluding licensed practical nurses, oncology certified nurses, physician assistants, nurse practitioners, or physicians; Appendix Fig A11, online only). In 2012, 5% of practices reported that they were somewhat or very likely to lay off other clinical staff, and 8% reported that they were somewhat or very likely to lay off administrative staff. In 2013, the percentages of respondents were 13% (other clinical staff) and 18% (administrative staff). These results are consistent with a pair of informal surveys conducted by ASCO earlier in 2013, which also showed a growing likelihood of staff layoffs secondary to budget sequestration.1 Another interesting phenomenon developing is the increase in the percentage of practices (2013: 26%; 2012: 13%) that plan to begin sending patients elsewhere or offsite for the administration of chemotherapy (Fig 9).
Discussion We believe this data set represents the largest and most diverse accumulation of data on trends in oncology practice in the United States. Although the number of responding sites decreased in 2013, those respondents account for a greater portion of practicing oncologists in the United States. Analysis conducted by Kirkwood et al2 concluded that the Physician Compare database (providers who filed claims with Medicare in the previous 12 months) yields the most reliable data on the number of practicing oncologists (n ⫽ 11,343).2 We used Physician Compare to determine the number of US practices that contained one or more oncologists in 2013. The query resulted in 2,571 practices. Because the database does not indicate whether oncology was the primary focus of the practice, Copyright © 2014 by American Society of Clinical Oncology
this figure likely overestimates sites that are primarily oncology. If our survey reached all 2,571 sites, the responses from 530 practices translates to a 20.6% response rate. The nonresponding 2,041 sites represent 3,332 oncologists, which suggests nonparticipating sites are likely skewed to small practices with one to two oncologists. The chief limitations of the data are the uncertainty of the overall number of practices that are primarily oncology and the inability, at this time, to directly compare data from sites that responded in both 2012 and 2013. We plan to incorporate the ability to directly compare data in future research and will also further refine our understanding of the number of oncology practices. Although direct comparisons are not currently possible, this study is consistent with other findings that suggest that oncology practices are getting larger and that practices are affiliating with hospitals through a variety of contractual mechanisms.3 Trends we observed include an increase of average practice size (⬎ seven physicians) and an increase in the percentage of practices reporting multiple specialties. Both of these trends could reflect increased representation of academic practices, an increasing consolidation of existing practices, or both. Given that more practices report affiliation with hospitals, it is not surprising to see an increase in the number of patients receiving chemotherapy in hospital clinics. This may, however, explain only part of the shift, given that several practices have reporting shifting patients to outpatient hospital settings in response to sequestration or other pressures.1 Respondents that reported being somewhat or very likely to send patients elsewhere for chemotherapy doubled in 2013 (26%). This increase may be caused by more practices affiliating with hospitals and/or the effects of the sequester, which effectively lowered reimbursement rates in the private practice setting to average sales price plus 4.3% and sent many drugs underwater for practices. Whether because of consolidation or other pressures, shift in site of care represents potential access issues if patients must travel longer distances to receive care, as well as possible increases in the cost of care.4-6 Largely similar percentages for payer mix between 2012 and 2013 are not surprising, because they reflect a relatively longstanding pattern of insurance coverage in the population of patients with cancer. However, with the introduction of health insurance exchanges and a larger population eligible for Medicaid through the Patient Protection and Affordable Care Act (ACA), the mix of payers may shift in ways that we cannot completely anticipate. Yang et al7 project that ACA coverage expansions (whether through Medicaid or insurance bought through the exchanges) will result in demand for an additional 500,000 oncology visits. It is unclear whether practices will be
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Figure 9. Percentage of practices “somewhat or very likely” to change chemotherapy administration policies.
Hanley et al
other stakeholders to advocate for changes and provide practical assistance to practices to ensure ongoing access to care. Acknowledgment We thank our colleagues and other members of the American Society of Clinical Oncology (ASCO) Clinical Practice Committee as well as Monica Tan, Suanna Bruinooge, and Deborah Y. Kamin, PhD, RN, from ASCO for their assistance and support. Authors’ Disclosures of Potential Conflicts of Interest Although all authors completed the disclosure declaration, the following author(s) and/or an author’s immediate family member(s) indicated a financial or other interest that is relevant to the subject matter under consideration in this article. Certain relationships marked with a “U” are those for which no compensation was received; those relationships marked with a “C” were compensated. For a detailed description of the disclosure categories, or for more information about ASCO’s conflict of interest policy, please refer to the Author Disclosure Declaration and the Disclosures of Potential Conflicts of Interest section in Information for Contributors. Employment or Leadership Position: Amy Hanley, American Society of Clinical Oncology (C); Karen Hagerty, American Society of Clinical Oncology (C); Elaine L. Towle, Altos Solutions (C); Anupama Kurup Acheson, American Society of Clinical Oncology (U) Consultant or Advisory Role: None Stock Ownership: None Honoraria: None Research Funding: None Expert Testimony: None Patents, Royalties, and Licenses: None Other Remuneration: None Author Contributions Conception and design: Amy Hanley, Karen Hagerty, Michael N. Neuss, Therese M. Mulvey, Anupama Kurup Acheson Collection and assembly of data: Amy Hanley, Karen Hagerty, Elaine L. Towle Data analysis and interpretation: Amy Hanley, Karen Hagerty, Elaine L. Towle Manuscript writing: All authors Final approval of manuscript: All authors Corresponding author: Amy Hanley, 2318 Mill Rd, Suite 800, Alexandria, VA 22314; e-mail: [email protected].
DOI: 10.1200/JOP.2013.001357
References 1. American Society of Clinical Oncology: ASCO sequestration impact survey: One month out sequestration affects care of Medicare patients. www.asco.org/advocacy/ asco-sequestration-impact-survey-one-month-out-sequestration-affecting-caremedicare-cancer 2. Kirkwood MK, Bruinooge SS, Goldstein MA, et al: Enhancing the American Society of Clinical Oncology workforce information system with geographic distribution of oncologists and comparison of data sources for the number of practicing oncologists. J Oncol Pract 10:32-38, 2014 3. Welch WP, Cuellar AE, Stearns SC, et al: Proportion of physicians in large group practices continued to grow in 2009-11. Health Aff (Millwood) 32:16591666, 2013 4. Moran Company: Results of analyses for chemotherapy administration utilization and chemotherapy drug utilization, 2005-2011, for Medicare fee-for-service benefi-
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ciaries. https://media.gractions.com/E5820F8C11F80915AE699A1BD4FA0948 B6285786/01655fe9-7f3d-4d9a-80d0-d2f9581673a1.pdf 5. Moran Company: Cost differences in cancer care across settings. https:// media.gractions.com/E5820F8C11F80915AE699A1BD4FA0948B6285786/ adebd67d-dcb6-46e0-afc3-7f410de24657.pdf 6. Pyenson BS, Fitch KV: Site of service cost differences for medicare patients receiving chemotherapy. http://us.milliman.com/uploadedFiles/insight/health-published/site-ofservice-cost-differences.pdf 7. Yang W, Williams JH, Hogan PF, et al: Projected supply of and demand for oncologists and radiation oncologists through 2025: An aging, better insured population will result in shortage. J Oncol Pract 10:39-45, 2014 8. Shanafelt T, Dyrbye L: Oncologist burnout: Causes, consequences, and responses. J Clin Oncol 30:1235-1241, 2012
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able to absorb this additional demand, given staffing, financial, and other challenges they face. Looking across both sets of results—likelihood of layoffs and hiring—an interesting picture emerges. Although the reported likelihood of staff layoffs increased, so did the likelihood of staff hiring—and at levels higher than those of layoffs. Given that these questions were asked separately, some of this discrepancy could result from practices answering the questions inconsistently. The apparent disconnect in responses could also be a result of the extreme uncertainty in payment reform and implications of the ACA. At the same time as coverage expands under the ACA, hundreds of thousands of baby boomers will become eligible for Medicare, and there will be effects on practice economics. The expected increase in cancer incidence as a result of the aging of the population, in conjunction with more insured patients secondary to the ACA, may force practices to make more infrastructure changes to handle increased patient numbers. Cost, payer, and competitive pressures were reported as top pressures facing practices, and these pressures are not surprising, given the changes in Medicare payment resulting from sequestration and unresolved problems with the Medicare physician payment formula. In addition, Medicare and private payers are demanding greater outcomes reporting in the move to base payment on performance. The demand for documentation translates to increased demands on physicians and advanced practice providers and results in more limited time with patients. This naturally raises concerns about provider burnout. A 2012 ASCO survey found that nearly 45% of oncologists reported experiencing burnout, and nearly 27% were moderately or highly likely to reduce clinical hours.8 Overall, the 2013 data demonstrate important findings related to practice size; plans to merge, sell, or affiliate; and consideration of alternate payment models. Although significant changes in policy are on the horizon, the nature of the changes remains largely unclear. The data collection and increasing ability to monitor trends on a yearly basis will enable ASCO and
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Appendix
≥ 7 physicians 2012 2013
1-2 physicians
0
50
100
150
200
250
No. of Practices
No. of Nurse Practitioners FTEs
Figure A1. Practice size reporting, 2012 to 2013.
7 6
2012 2013 (all) 2013 (omits acad. ctrs)
5 4 3 2 1 0
25th percentile
50th percentile (median)
Mean
75th percentile
No. of Physician Assistant FTEs
Figure A2. Full-time equivalent (FTE) nurse practitioners per practice. acad ctrs, academic centers.
4.5 4.0 3.5
2012 2013 (all) 2013 (omits acad. ctrs)
3.0 2.5 2.0 1.5 1.0 0.5 0
25th percentile
50th percentile (median)
Mean
75th percentile
Figure A3. Full-time equivalent (FTE) physician assistants per practice.
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3-6 physicians
Hanley et al
1-2 physicians (avg. 1.4) 3-6 physicians (avg. 4.5) ≥ 7 physicians (avg. 15)
2,500
2,700
2,000 1,500 1,227
1,000 387
500 0
Practice Size
Figure A4. New patients by practice size, among the private practices.
Very likely to increase patient volume Somewhat likely to increase patient volume Unlikely to change patient volume Somewhat likely to decrease patient volume Very likely to decrease patient volume 0
5
10
15
20
25
30
35
Practices (%) Figure A5. Likelihood of practice to change volume of patients it treats in the next 12 months.
2013 2012
Other Staffing issues (recruitment and… Payer pressures Local economic pressures Drug shortages Drug pricing Cost pressures Competitive pressures 0
5
10
15
20
25
30
Practices (%) Figure A6. Greatest pressure currently faced.
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No. of New Patients
3,000
2013 ASCO Census
Very/somewhat likely Neither likely nor unlikely Very/somewhat unlikely
Close the practice Sell the practice Merge with another practice
0
20
40
60
80
100
Practices (%) Figure A7. Likelihood of practice closure, sale, merger, or acquisition.
Close the practice
2013 2012
7 6
Sell the practice
9 9
Merge with another practice
15 12
Purchase another practice
11 5
0
5
10
15
20
Practices (%) Figure A8. Percentage of practices responding “somewhat or very likely” to undergo practice changes.
No. of Practices
25
1–2 physicians 3–6 physicians ≥ 7 physicians
20 15 10 5 0 Purchase
Merge
Sell
Close
Figure A9. Private community practices somewhat or very likely to undergo practice changes, by practice size.
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Purchase another practice
Hanley et al
Administrative staff Other clinical staff LPN/LVNs Certified oncology nurses
Nurse practitioners Nononcology physicians 2013 2012
Oncology physicians 0
5
10
15
20
Practices (%) Figure A10. Likelihood of practice to hire staff. LPN, licensed practical nurse; LVN, licensed vocational nurse. Very/somewhat unlikely Neither likely nor unlikely Very/somewhat likely
Administrative staff Other clinical staff LPN/LVNs Certified oncology nurses Physician assistants Nurse practitioners Nononcology physicians Oncology physicians 0
20
40
60
80
Practices (%) Figure A11. Percent of practices “somewhat or very likely” to lay off staff, comparing 2012 with 2013. LPN, licensed practical nurse; LVN, licensed vocational nurse.
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Physician assistants
Original Contribution
Results of the 2013 American Society of Clinical Oncology National Oncology Census By Amy Hanley, Karen Hagerty, MD, Elaine L. Towle, CMPE, Michael N. Neuss, MD, Therese M. Mulvey, MD, and Anupama Kurup Acheson, MD
Results: The Census collected 530 useable responses in
Abstract Purpose: The American Society of Clinical Oncology (ASCO) National Oncology Census (Census) provides a mechanism for ASCO to systematically gather and analyze information about current practice structures and potential changes at a time when practices are working to adapt to increasing administrative and financial pressures. The Census is conducted annually and reports on new and trending data.
Methods: The 2013 Census was launched on May 30, 2013, as a national survey of oncology practices. The survey required practices to answer 11 questions and provided additional optional questions.
Introduction The American Society of Clinical Oncology (ASCO) National Oncology Census (Census) originated as a mechanism to systematically gather and analyze information about current oncology practice structures and potential changes at a time of growing administrative and financial pressures. Specific information regarding oncology practice structure is necessary to understand how practices are adapting as they aspire to provide high-quality cancer care to the patients they serve. Absent this basic information about oncology practices, policy solutions and other interventions may be inadequate to respond to the anticipated shortage of oncologists or may inadvertently address the wrong issues. ASCO’s goals for the Census are to collect demographic data on as many US oncology practices as possible, including information on services offered, practice size, staffing characteristics, organizational structure, and affiliations; to learn how oncology practices are adapting to administrative and financial pressures with relation to these demographic characteristics; and to develop the capacity to monitor these characteristics on an ongoing basis. All this is being done to allow ASCO to tailor its advocacy, educational products, and practice support efforts appropriately to best meet the needs of its members and the larger oncology practice community as they care for patients in a shifting health care delivery landscape.
2013 compared with 632 respondents in 2012. Practices reporting in 2013, however, represented a total of 8,011 physicians compared with only 5,018 in 2012.
Conclusion: The pace of policy change in oncology practice is changing the landscape of how practices are organized. A greater number of practices with more than seven physicians responded in 2013, which could indicate overall growth in the size of oncology practice. Practices reported increased affiliations with hospitals through a variety of contractual mechanisms. In subsequent census efforts, ASCO will have the capability to match 2013 respondents to future respondents, allowing for increased precision in comparison of longitudinal data.
of optional questions were also included. ASCO emailed the survey to all US members and, through a variety of communications channels, encouraged participation by the entire oncology community. Nonrespondents were emailed and called to solicit involvement. The census was closed on August 30, 2013. ASCO received 685 responses to the census. Responses were excluded if physicians were not involved in direct patient care (n ⫽ 5), outside the United States (n ⫽ 23), and locum tenens or retirees (n ⫽ 12). Multiple responses from the same practice were included when it was clear that the responses represented separate sites of service. One hundred fifteen responses were identified as duplicates and removed from analysis. Additionally, practices that responded “greater than 100 physicians” or “greater than 30 physicians” were rounded to 100 or 30 respectively. Final analysis included 530 respondents. Rural-Urban Commuting Area Codes were used to place responders into “metropolitan” or “nonmetropolitan” categories. Additionally, five-digit zip codes were used to map responders. We report the census regions as West, Midwest, South, and Northeast. Data were compared with that of 2012 to identify any shifts. Because of differences in data collection methodology, direct comparisons of data from 2012 and 2013 respondent practices is not possible at this time.
Methods
Results Practice Demographics
The ASCO 2013 Census was launched on May 30, 2013. The brief survey required practices to answer 11 questions. A series
For the 2013 survey, we received 530 useable responses compared with 632 responses in 2012. Although the number of
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American Society of Clinical Oncology, Alexandria, VA; Oncology Metrics, a division of Altos Solutions, Los Altos, CA; Vanderbilt Ingram Cancer Center, Nashville, TN; Southcoast Hospital Group, Fall River, MA; Providence Oncology and Hematology Care Clinic, Portland, OR
Hanley et al
No. of Practices
250
2012 2013
200 150 100 50
West
South
Midwest
Northeast
Figure 1. Practices responding, by census region, in 2012 and 2013.
practices reporting decreased, the number of physicians included in the data reports increased. The reporting practices included a larger number of physicians, both in total (2013: n ⫽ 8,011; 2012: n ⫽ 5,018) and by average practice size (2013: 15 physicians per practice; 2012: nine physicians per practice). Reporting practices were grouped into the following groups: those with one to two physicians, those with three to six physicians, and those with seven or more physicians. Overall, more practices with seven or more physicians responded in 2013 (Appendix Fig A1, online only). Therefore, we analyzed practice size as a percentage of responses from each year to demonstrate where shifts in the size of practices may be occurring. There was an increase in the percentage of practices reporting seven or more physicians from 29% in 2012 to 42% in 2013. There were corresponding decreases in the percent of practices reporting between three and six (from 37% to 30%) or between one and two physicians (from 34% to 28%). Figure 1 shows the distribution of practice responses across the four census regions for both 2012 and 2013.1 The number of practices responding from each region decreased this year, except for the West, where the number slightly increased. We analyzed a more detailed breakdown of responding practice size by census region (Fig 2). With the exception of the Northeast, practices with seven or more physicians represented the largest number of practices reporting for each region. Even in the Northeast, practices with seven or more physicians were re-
West
South ≥ 7 physicians 3-6 physicians 1-2 physicians
Northeast
Midwest 0
20
40
60
Staffing
80
No. of Practices Figure 2. 2013 practice size and distribution by census region.
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Practices reported a mean of 9.8 full-time equivalent certified oncology nurses per practice, an increase from 6.7 in 2012. We again analyzed the responses with and without including academic cen-
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0
ported with just one less occurrence than the leading reporting group, those with three to six physicians. These results contrast quite strongly with the 2012 respondents; groups of seven or more physicians did not lead reporting in any of the census regions. In 2012, practices of three to six physicians led the reporting in all regions except the Northeast, where physician groups of one to two had a slight edge. Compared with 2012, this year’s survey responses represented more academic centers; these responses may have biased the overall study results. There was a doubling in the percentage of respondents to this year’s survey describing the practice as an academic practice (2012: 9.5%; 2013: 20.2%). In 2012, of the 599 practices providing information on this variable, 57 selfreported as an academic practice; in 2013, 107 practices of the 530 reporting used this descriptor. We therefore analyzed the responses regarding practice size with and without academic centers. Omitting academic centers from the analysis causes no change in the 25th percentile, and the 50th percentile (median) remained relatively stable at five physicians per practice versus four when omitting the academic centers. However, there was a significant shift in both the mean and the 75th percentile, suggesting that heavier reporting from academic centers for this year’s data does bias the overall number in favor of larger practice sizes. Of the 8,011 physicians represented in the survey, 4,635 were in academic practice and 1,782 reported they were in private community practice. Of those in private community practice, the average practice size was approximately seven physicians. Ninety private community practices reported having one to two oncologists in their practice; 91 practices consisted of three to six physicians. Seventy-two practices reported seven or more oncologists in the practice. We analyzed practice size by census region, focusing on only the practices that self-reported as private community practice. Groups of one to two oncologists dominated in the South; this was the only region where these small practices led the way in practice structure (Fig 3A). In the other three census regions, within private community practices, groups with three to six oncologists were most prevalent (notably, in the Midwest Region groups of seven or more oncologists were equally common; Fig 3B). Respondents were asked to indicate medical specialties represented in their practice (eg, gynecology oncology, surgical oncology). Compared with 2012, there was an increase in the percent of practices reporting multiple specialties. This could reflect increased survey participation by academic practices, an increasing consolidation of existing practices, or both. Practices similarly reported their operating structure. There was a slight decrease in the percentage of practices describing themselves as private community practice. Likewise, there was a small decrease in those reporting as private integrated group practices.
2013 ASCO Census
80
90 80
60
70 50 40 30
Uninsured/self-pay Private/commercial Medicaid Medicare
60 50 40 30
20
20 10
10
0
0 Other
B
Midwest Northeast
South
40
Midwest Northeast South West
35
No. of Practices
West
30 25
2013
Figure 5. Payer mix (mean), comparing 2012 with 2013.
centers are omitted from the analysis. Compared with 2012 data, it does seem to indicate that practices are increasing the number of nurse practitioners and physicians assistants.
20 15
Payer Mix
10
Despite the change in demographics between respondents in the 2012 and 2013 surveys, payer mix remained largely the same. Although there were increases in the percentage of uninsured/selfpay (3% to 6%) and Medicaid (7% to 10%) payers, they were not statistically significant (Fig 5). Approximately half of practices (52%) indicated that they were unlikely to experience changes in the number of Medicare patients they treat. Almost a fifth (18%) indicated they were very or somewhat likely to decrease the proportion of Medicare patients, whereas 25% were very or somewhat likely to increase the number of Medicare patients. Respondents indicate similar percentages for each of the other payer types. For Medicaid, 47% of practices anticipate no change, 18% anticipate a decrease, and 28% anticipate an increase. For privately insured, 57% of practices anticipate no change, 17% anticipate a decrease, and 22% anticipate an increase. For uninsured, 48% of practices anticipate no change, 28% anticipate a decrease, and 17% anticipate an increase.
5 0 1-2 physicians
3-6 physicians
≥ 7 physicians
Figure 3. (A) Practice size by census region. (B) Census distribution by practice size.
ters (Fig 4). The results of this analysis showed little change: a 25th percentile and median that tracked fairly closely together, with differences in the mean and 75th percentile that suggest skewing of the data by larger academic centers. However, the difference in full-time equivalent certified oncology nurses per practice was less striking than the difference in the number of physicians. We also compared the numbers from 2012 and 2013 for nurse practitioners and physician assistants (Appendix Figs A2 and A3, online only). The comparison responses for number of practitioners by type across 2 years of the census shows a change in the 25th and 50th percentiles, but there are larger differences for both professions in the mean and 75th percentiles when larger academic 12
No. of Certified Oncology Nurse FTEs
2012
10
2012 2013 (all) 2013 (omits acad. ctrs)
8 6 4 2 0
25th percentile
50th percentile (median)
Mean
75th percentile
Figure 4. Full-time equivalent (FTE) certified oncology nurses per practice. acad ctrs, academic centers.
Copyright © 2014 by American Society of Clinical Oncology
Delivery and Payment Models New to the 2013 survey was a series of questions on delivery and payment models. Twenty-four percent of respondents (126 practices) reported they were considering novel delivery/payment models with payers. Within this group, the majority (56%) estimated that between 10% and 40% of their patients would be included in such a model. Twenty-seven percent reported fewer than 10% of their patients would be involved, and 16% of practices reported that more than 40% of their patients could be involved. Sixty-three percent of practices are looking at payment models that reward care coordination services, whereas 37% are looking at payment models that reward pathway adherence. For those practices that are considering the medical home model, 15% would be paid only for care coordination, 57% would be rewarded for decreased use, and 28% would adopt a payment model based on a gain sharing arrangement. Fewer than 10% of survey respondents answered the question regarding pathway use. We therefore did not attempt to
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No. of Practices
70
100
1–2 physicians 3–6 physicians ≥ 7 physicians
Percent
A
Hanley et al
1,800
2013
1,400 1,200 1,000 800 600 400 200 0
25th percentile
50th percentile (median)
Mean
75th percentile
Figure 6. New patients in previous 12 months.
analyze these responses further but note that the option of an open text field (“other”) for respondents to describe the type of pathway the practice is using confirmed the wide variety of pathways available. In addition to the three listed on the survey as examples (Cardinal/P4, Innovent, Via), responses included more than a dozen different pathway programs currently in use.
Patients Practices were asked to report the number of new patients seen in the previous 12 months (Fig 6). Responding practices (n ⫽ 263) reported an average of 1,620 new patients, with a median of 700 new patients. Although the data seem to indicate growth in new patient volume, compared with 2012 data, the difference may be largely related to increased practice size among the 2013 respondents. To examine this further, we looked at the number of new patients for practices describing themselves as private community practices. In practices with one to two physicians, the average number of new patients seen in the last year was 387; for practices with three to six oncologists, the average was 1,227; for practices with seven or more physicians, the average was 2,700 (Appendix Fig A4, online only). Additionally, when looking ahead, practices reported they were very likely to increase patient volume (23%) or somewhat likely to increase patient volume (32%); only 15% of practices were somewhat or very likely to decrease patient volume (Appendix Fig A5, online only).
were considering the purchase of another practice and slightly more likely to report consideration of a merger with another practice. The percent of respondents reporting that they were somewhat or very likely to close or sell the practice remained stable across the two surveys (close the practice: 2012, 6%; 2013; 7%; sell the practice: both years, 9%; Appendix Figs A7-A9, online only). We also examined the likelihood of practice changes in the private community practice setting by practice size. Small practices (one to two oncologists) and practices of seven or more physicians reported consideration of mergers in nearly equal numbers (20 v 19 practices). Small practices were more likely to report consideration of selling (20 sites) or closing (16 sites) compared with larger practices. Not surprisingly, none of the small practices reported they were considering purchase of another practice. Conversely, practices with seven or more oncologists were the most likely to report that they were considering the purchase of another practice. One practice of this size reported they were considering practice closure. Bigger swings between 2012 and 2013 occurred with practices reporting the likelihood of affiliating with other entities. In 2012, 10% of practices said they were considering affiliation with another practice, 15% with a community hospital, and 11% with an academic medical center. Those numbers increased in 2013 to 16%, 26%, and 17%, respectively (Fig 7). Despite turbulence across the practice community, many respondents indicated a strong potential for hiring clinical and nonclinical staff. This is particularly true for oncologists; 44% of practices reported they were somewhat or very likely to hire oncology physicians in the next 12 months; in 2012, 32% of practices were considering such hires. For each of the other staff categories, the percent of practices reporting they were somewhat or very likely to hire in a specific category follow: nononcology physicians, 15%; nurse practitioners, 35%; physician assistants, 21%; certified oncology nurses, 32%; licensed practical nurses, 12%; other clinical staff, 22%; and administrative staff, 19%. Each of these represents an increase across all staff categories compared with 2012 (Appendix Fig A10, online only). Although fewer sites reported consideration of layoffs, there was an increase in the number of respondents in 2013 reporting the likelihood of layoffs across almost all staff categories surveyed, except for nurse practitioners (3% of sites in both years; Fig 8). In 2012, 3% of sites reported considering laying off
Practice Pressures We asked practices to report what they felt was the greatest pressure they currently faced. Practices were offered eight options, including “other.” The choices reported most frequently were cost pressures (24.2%), payer pressures (21.2%), and competitive pressures (18.4%). The least frequently reported pressures were drug shortages (0.9%), “other” (5.1%), and local economic pressures (7.2%). Of note, drug shortage was chosen by 5% of respondents in 2012 (Appendix Fig A6, online only).
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Academic medical center
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Looking Ahead: The Next 12 Months
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2013 2012
16
Another practice
5
10
15
20
25
30
Practices (%) Figure 7. Percentage of practices “somewhat or very likely” to affiliate with listed entities in 2012 and 2013.
V O L . 10, I S S U E 2
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No. of New Patients
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2012
2013 ASCO Census
Very/somewhat unlikely Neither likely nor unlikely Very/somewhat likely
2013 2012
Begin administering chemotherapy onsite Begin sending patients elsewhere
Administrative staff
0 Other clinical staff
5
10
15
20
25
30
Practices (%)
LPN/LVNs Certified oncology nurses Physician assistants Nurse practitioners Nononcology physicians Oncology physicians 0
20
40
60
80
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Practices (%) Figure 8. Likelihood of practice to lay off staff. LPN, licensed practical nurse; LVN, licensed vocational nurse.
oncologists, and the percentage of 2013 respondents was slightly higher at 5%. Larger differences between 2012 and 2013 respondents were seen in percentages of sites reporting that they were very or somewhat likely to lay off administrative staff or other clinical staff (a catchall category excluding licensed practical nurses, oncology certified nurses, physician assistants, nurse practitioners, or physicians; Appendix Fig A11, online only). In 2012, 5% of practices reported that they were somewhat or very likely to lay off other clinical staff, and 8% reported that they were somewhat or very likely to lay off administrative staff. In 2013, the percentages of respondents were 13% (other clinical staff) and 18% (administrative staff). These results are consistent with a pair of informal surveys conducted by ASCO earlier in 2013, which also showed a growing likelihood of staff layoffs secondary to budget sequestration.1 Another interesting phenomenon developing is the increase in the percentage of practices (2013: 26%; 2012: 13%) that plan to begin sending patients elsewhere or offsite for the administration of chemotherapy (Fig 9).
Discussion We believe this data set represents the largest and most diverse accumulation of data on trends in oncology practice in the United States. Although the number of responding sites decreased in 2013, those respondents account for a greater portion of practicing oncologists in the United States. Analysis conducted by Kirkwood et al2 concluded that the Physician Compare database (providers who filed claims with Medicare in the previous 12 months) yields the most reliable data on the number of practicing oncologists (n ⫽ 11,343).2 We used Physician Compare to determine the number of US practices that contained one or more oncologists in 2013. The query resulted in 2,571 practices. Because the database does not indicate whether oncology was the primary focus of the practice, Copyright © 2014 by American Society of Clinical Oncology
this figure likely overestimates sites that are primarily oncology. If our survey reached all 2,571 sites, the responses from 530 practices translates to a 20.6% response rate. The nonresponding 2,041 sites represent 3,332 oncologists, which suggests nonparticipating sites are likely skewed to small practices with one to two oncologists. The chief limitations of the data are the uncertainty of the overall number of practices that are primarily oncology and the inability, at this time, to directly compare data from sites that responded in both 2012 and 2013. We plan to incorporate the ability to directly compare data in future research and will also further refine our understanding of the number of oncology practices. Although direct comparisons are not currently possible, this study is consistent with other findings that suggest that oncology practices are getting larger and that practices are affiliating with hospitals through a variety of contractual mechanisms.3 Trends we observed include an increase of average practice size (⬎ seven physicians) and an increase in the percentage of practices reporting multiple specialties. Both of these trends could reflect increased representation of academic practices, an increasing consolidation of existing practices, or both. Given that more practices report affiliation with hospitals, it is not surprising to see an increase in the number of patients receiving chemotherapy in hospital clinics. This may, however, explain only part of the shift, given that several practices have reporting shifting patients to outpatient hospital settings in response to sequestration or other pressures.1 Respondents that reported being somewhat or very likely to send patients elsewhere for chemotherapy doubled in 2013 (26%). This increase may be caused by more practices affiliating with hospitals and/or the effects of the sequester, which effectively lowered reimbursement rates in the private practice setting to average sales price plus 4.3% and sent many drugs underwater for practices. Whether because of consolidation or other pressures, shift in site of care represents potential access issues if patients must travel longer distances to receive care, as well as possible increases in the cost of care.4-6 Largely similar percentages for payer mix between 2012 and 2013 are not surprising, because they reflect a relatively longstanding pattern of insurance coverage in the population of patients with cancer. However, with the introduction of health insurance exchanges and a larger population eligible for Medicaid through the Patient Protection and Affordable Care Act (ACA), the mix of payers may shift in ways that we cannot completely anticipate. Yang et al7 project that ACA coverage expansions (whether through Medicaid or insurance bought through the exchanges) will result in demand for an additional 500,000 oncology visits. It is unclear whether practices will be
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Figure 9. Percentage of practices “somewhat or very likely” to change chemotherapy administration policies.
Hanley et al
other stakeholders to advocate for changes and provide practical assistance to practices to ensure ongoing access to care. Acknowledgment We thank our colleagues and other members of the American Society of Clinical Oncology (ASCO) Clinical Practice Committee as well as Monica Tan, Suanna Bruinooge, and Deborah Y. Kamin, PhD, RN, from ASCO for their assistance and support. Authors’ Disclosures of Potential Conflicts of Interest Although all authors completed the disclosure declaration, the following author(s) and/or an author’s immediate family member(s) indicated a financial or other interest that is relevant to the subject matter under consideration in this article. Certain relationships marked with a “U” are those for which no compensation was received; those relationships marked with a “C” were compensated. For a detailed description of the disclosure categories, or for more information about ASCO’s conflict of interest policy, please refer to the Author Disclosure Declaration and the Disclosures of Potential Conflicts of Interest section in Information for Contributors. Employment or Leadership Position: Amy Hanley, American Society of Clinical Oncology (C); Karen Hagerty, American Society of Clinical Oncology (C); Elaine L. Towle, Altos Solutions (C); Anupama Kurup Acheson, American Society of Clinical Oncology (U) Consultant or Advisory Role: None Stock Ownership: None Honoraria: None Research Funding: None Expert Testimony: None Patents, Royalties, and Licenses: None Other Remuneration: None Author Contributions Conception and design: Amy Hanley, Karen Hagerty, Michael N. Neuss, Therese M. Mulvey, Anupama Kurup Acheson Collection and assembly of data: Amy Hanley, Karen Hagerty, Elaine L. Towle Data analysis and interpretation: Amy Hanley, Karen Hagerty, Elaine L. Towle Manuscript writing: All authors Final approval of manuscript: All authors Corresponding author: Amy Hanley, 2318 Mill Rd, Suite 800, Alexandria, VA 22314; e-mail: [email protected].
DOI: 10.1200/JOP.2013.001357
References 1. American Society of Clinical Oncology: ASCO sequestration impact survey: One month out sequestration affects care of Medicare patients. www.asco.org/advocacy/ asco-sequestration-impact-survey-one-month-out-sequestration-affecting-caremedicare-cancer 2. Kirkwood MK, Bruinooge SS, Goldstein MA, et al: Enhancing the American Society of Clinical Oncology workforce information system with geographic distribution of oncologists and comparison of data sources for the number of practicing oncologists. J Oncol Pract 10:32-38, 2014 3. Welch WP, Cuellar AE, Stearns SC, et al: Proportion of physicians in large group practices continued to grow in 2009-11. Health Aff (Millwood) 32:16591666, 2013 4. Moran Company: Results of analyses for chemotherapy administration utilization and chemotherapy drug utilization, 2005-2011, for Medicare fee-for-service benefi-
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ciaries. https://media.gractions.com/E5820F8C11F80915AE699A1BD4FA0948 B6285786/01655fe9-7f3d-4d9a-80d0-d2f9581673a1.pdf 5. Moran Company: Cost differences in cancer care across settings. https:// media.gractions.com/E5820F8C11F80915AE699A1BD4FA0948B6285786/ adebd67d-dcb6-46e0-afc3-7f410de24657.pdf 6. Pyenson BS, Fitch KV: Site of service cost differences for medicare patients receiving chemotherapy. http://us.milliman.com/uploadedFiles/insight/health-published/site-ofservice-cost-differences.pdf 7. Yang W, Williams JH, Hogan PF, et al: Projected supply of and demand for oncologists and radiation oncologists through 2025: An aging, better insured population will result in shortage. J Oncol Pract 10:39-45, 2014 8. Shanafelt T, Dyrbye L: Oncologist burnout: Causes, consequences, and responses. J Clin Oncol 30:1235-1241, 2012
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able to absorb this additional demand, given staffing, financial, and other challenges they face. Looking across both sets of results—likelihood of layoffs and hiring—an interesting picture emerges. Although the reported likelihood of staff layoffs increased, so did the likelihood of staff hiring—and at levels higher than those of layoffs. Given that these questions were asked separately, some of this discrepancy could result from practices answering the questions inconsistently. The apparent disconnect in responses could also be a result of the extreme uncertainty in payment reform and implications of the ACA. At the same time as coverage expands under the ACA, hundreds of thousands of baby boomers will become eligible for Medicare, and there will be effects on practice economics. The expected increase in cancer incidence as a result of the aging of the population, in conjunction with more insured patients secondary to the ACA, may force practices to make more infrastructure changes to handle increased patient numbers. Cost, payer, and competitive pressures were reported as top pressures facing practices, and these pressures are not surprising, given the changes in Medicare payment resulting from sequestration and unresolved problems with the Medicare physician payment formula. In addition, Medicare and private payers are demanding greater outcomes reporting in the move to base payment on performance. The demand for documentation translates to increased demands on physicians and advanced practice providers and results in more limited time with patients. This naturally raises concerns about provider burnout. A 2012 ASCO survey found that nearly 45% of oncologists reported experiencing burnout, and nearly 27% were moderately or highly likely to reduce clinical hours.8 Overall, the 2013 data demonstrate important findings related to practice size; plans to merge, sell, or affiliate; and consideration of alternate payment models. Although significant changes in policy are on the horizon, the nature of the changes remains largely unclear. The data collection and increasing ability to monitor trends on a yearly basis will enable ASCO and
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Appendix
≥ 7 physicians 2012 2013
1-2 physicians
0
50
100
150
200
250
No. of Practices
No. of Nurse Practitioners FTEs
Figure A1. Practice size reporting, 2012 to 2013.
7 6
2012 2013 (all) 2013 (omits acad. ctrs)
5 4 3 2 1 0
25th percentile
50th percentile (median)
Mean
75th percentile
No. of Physician Assistant FTEs
Figure A2. Full-time equivalent (FTE) nurse practitioners per practice. acad ctrs, academic centers.
4.5 4.0 3.5
2012 2013 (all) 2013 (omits acad. ctrs)
3.0 2.5 2.0 1.5 1.0 0.5 0
25th percentile
50th percentile (median)
Mean
75th percentile
Figure A3. Full-time equivalent (FTE) physician assistants per practice.
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3-6 physicians
Hanley et al
1-2 physicians (avg. 1.4) 3-6 physicians (avg. 4.5) ≥ 7 physicians (avg. 15)
2,500
2,700
2,000 1,500 1,227
1,000 387
500 0
Practice Size
Figure A4. New patients by practice size, among the private practices.
Very likely to increase patient volume Somewhat likely to increase patient volume Unlikely to change patient volume Somewhat likely to decrease patient volume Very likely to decrease patient volume 0
5
10
15
20
25
30
35
Practices (%) Figure A5. Likelihood of practice to change volume of patients it treats in the next 12 months.
2013 2012
Other Staffing issues (recruitment and… Payer pressures Local economic pressures Drug shortages Drug pricing Cost pressures Competitive pressures 0
5
10
15
20
25
30
Practices (%) Figure A6. Greatest pressure currently faced.
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No. of New Patients
3,000
2013 ASCO Census
Very/somewhat likely Neither likely nor unlikely Very/somewhat unlikely
Close the practice Sell the practice Merge with another practice
0
20
40
60
80
100
Practices (%) Figure A7. Likelihood of practice closure, sale, merger, or acquisition.
Close the practice
2013 2012
7 6
Sell the practice
9 9
Merge with another practice
15 12
Purchase another practice
11 5
0
5
10
15
20
Practices (%) Figure A8. Percentage of practices responding “somewhat or very likely” to undergo practice changes.
No. of Practices
25
1–2 physicians 3–6 physicians ≥ 7 physicians
20 15 10 5 0 Purchase
Merge
Sell
Close
Figure A9. Private community practices somewhat or very likely to undergo practice changes, by practice size.
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Purchase another practice
Hanley et al
Administrative staff Other clinical staff LPN/LVNs Certified oncology nurses
Nurse practitioners Nononcology physicians 2013 2012
Oncology physicians 0
5
10
15
20
Practices (%) Figure A10. Likelihood of practice to hire staff. LPN, licensed practical nurse; LVN, licensed vocational nurse. Very/somewhat unlikely Neither likely nor unlikely Very/somewhat likely
Administrative staff Other clinical staff LPN/LVNs Certified oncology nurses Physician assistants Nurse practitioners Nononcology physicians Oncology physicians 0
20
40
60
80
Practices (%) Figure A11. Percent of practices “somewhat or very likely” to lay off staff, comparing 2012 with 2013. LPN, licensed practical nurse; LVN, licensed vocational nurse.
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Copyright © 2014 by American Society of Clinical Oncology
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Physician assistants
