Operating margins for community oncology practices are decreasing, although the trend seems to be slowing, according an analysis of the results from the 2012 National Practice Benchmark (NPB). There are also indications that the narrowing difference between operating cost and total medical revenue has also eased, buying some time for practices to adjust their business models and perhaps survive.

Matthew Farber, MA, director of Provider Economics and Public Policy at the Association of Community Cancer Centers in Rockville, Maryland, thinks that overall, the report does a good job of looking at work output and physician efficiencies, and extrapolating these and other measures out to the viability of the practice.

“While it has been a hectic last couple of years with consolidation, there has been stabilization in this area as practices have adapted to new payment methodologies, types of oral drugs, and some have done things like establishing dispensing pharmacies in their offices,” he noted. “This has really helped the business model and allowed them to continue ahead.”

Roughly 1400 medical oncologists, practice administrators, and other key staff from more than 900 practices were invited to participate in the NPB. The invitations were emailed and the survey was completed entirely online. Only one survey per practice was included in the data analysis. The instrument reflects data from calendar year 2011 or the most recently completed 12-month period.

A total of 114 responses were returned, with 11 discarded because they were duplicates. Just over half (52%) were practice administrators or office managers, 16% were chief financial officers/ directors of finance, and 8% were physicians. The rest were made up of miscellaneous titles. There were responses from 42 states.

“In 2011, we completed the first trend analysis of 6 years of data from the NPB report and, on the basis of that analysis, made four predictions about what we would see when we completed the 2012 report on 2011 data,” the authors of the NPB analysis wrote. “These were (1) the squeeze on operating margins would persist; (2) no new efficiency gains would be evident; (3) service delivery measures would remain at 2010 levels; and (4) labor costs would rise faster than revenue.”

		Figure. Number of Patient Visits per FTE HemOnc

		Adapted from J Oncol Pract. 2012;8(5):292-297.

The prediction from a year ago that the decrease in the difference between costs and revenues would continue in 2011 was not found. However, most of the “ease of the squeeze,” as termed by the authors, was from stability in income and a very slight decrease in operating costs from one year to the next.

When efficiency is reported as patient visits per full-time equivalent (FTE) hematologist/ oncologist (HemOnc), the researchers saw little to no change in the number of visits per doctor (

) and predict no significant differences in 2013’s review of 2012 outcomes. However, when work achieved by doctors is seen using work relative value units (wRVU) per FTE HemOnc, there are suggestions that further productivity gains are possible.

The report also sees some glimmers of hope in the area of labor, cost, and revenue. Last year, the authors predicted that the amount of positive difference between practice cost and revenue per staff FTE would shrink in 2011 and they would cross when the 2012 information was obtained. However, this year a much more favorable future is predicted, and the authors do not see the difference shrinking as much as predicted by the 2010 data.

Business structure change is still seen as an important variable. The authors noted that “cautious optimism” appears to be the mood of those responding to the survey. Although the number of respondents who said they were currently involved in a structure change increased 5% year over year, a high number of respondents remain confident that their business structure will be viable and unchanged for at least 3 to 5 years. Overall, the authors predicted a continued slow and steady change in business structure instead of a wholesale shift nationally.

“Readers of the 2012 survey may reasonably have a sense of optimism as they reflect on the amazing resiliency and adaptability that allow this system to positively respond to stress,” the authors wrote. “Time and again, spanning back to our first survey in 2005, we have quantified the results of oncology practices getting the job done when the rules change.”

The difficult part going forward is to know what happens if payers start to require more use of specialty pharmacies or do not allow in-office dispensing of drugs. This may take away from operating revenue and change the bottom line picture yet again.

“Another interesting question is, ‘Will offices be able to handle an increase in the number of Medicaid patients, and will it drive them further to the negative side?’” Farber pointed out. “Overall, I think most practices will remain viable, as this report suggests, even with these changes.”

	Barr TR, Towle EL. Oncology practice trends from the national practice benchmark. 

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The narrowing difference between operating cost and total medical revenue has eased, buying some time for practices to adjust their business models and perhaps survive.

Practice Benchmark Report Offers Hope for Survival of Independent Oncology Practices

The high cost of cancer treatments means that commercial payers will be increasing their management in the category. As this occurs, oncology practices, especially smaller community-based operations, may find it harder to stay viable. How well individual practices handle payers’ increased cost management will be a major concern going forward.

The Zitter Group, a specialized business intelligence firm headquartered in Millburn, New Jersey, conducts a semiannual survey of oncologists, practice managers, and insurance companies. Their Summer 2012 

 showed some areas of agreement between the players. It also reveals some disconnect in perception.

All agree that the intensity of management will be ramping up over the next 2 years. Oncologists, however, expect this increase to be much greater than what payers are projecting. Just over two out of every three cancer physicians (68%) expect more aggressive management of costs by payers, while only 39% of insurance companies think they will have highly aggressive policies in place within the next 2 years.

“Much of this is related to different viewpoints of those being managed and those doing the managing,” said Lee Goldberg, director of Syndicated Research at The Zitter Group. “As payers have been increasing the intensity of their management through application of financial controls and prior authorizations, oncologists perceive that things are going from easy to difficult. This may cause them to overestimate how bad things are.”

On the other side, he noted that payers think their actions are starting from a very low baseline of aggressiveness. Because of this outlook, those footing the bill think there is a much longer way to go.

Practicing oncologists see the current payer management intensity as being greater than those who are doing the management. Only 13% of insurance company respondents consider their oncology management policies to be highly aggressive. In contrast, 25% of oncologists feel oncology management is aggressive.

“Although probably less than in years past, oncologists may still be surprised at how much more difficult the private insurance companies can make it for them,” Goldberg noted. “I think there is still a tendency to underestimate how aggressive the payers can be.”

There is also a divide, albeit smaller, between payers and practices concerning the estimated percentage of current cancer treatment costs that could be eliminated without having a negative impact on outcomes. Zitter’s Summer 2012 Index showed that on average, payers think that 20% of current costs could be removed (

). Results from the Winter 2011 edition of the Index found that oncologists and practice managers estimated that lower rates of 18% and 16%, respectfully, could be taken out of the system without quality repercussions.

		Figure. Payer estimates of costs that could be eliminated from cancer treatment without negatively impacting health outcomes.

Goldberg thinks some of the sense among payers that waste is higher in the system is related to their desire to restrain costs. Another factor might be related to perspective. Payers have a broader experience with the cost of care than any individual practice.

“What is more interesting from my standpoint is the disconnect we see between what payers do to hold down costs and what practice managers see as the major drivers of costs,” Goldberg said. “Insurers are using reimbursement controls and utilization management techniques such as prior authorizations. Managers contend that prior authorization is the single biggest contributor to excess costs in oncology care.”

He sees a slow and stepwise restructuring of the relationship between those who pay for the services and those who provide them. This is reflected not only in reductions in buy-and-bill reimbursement, but also in other forms of reimbursement such as episode-of-care or bundled payments currently being seen in trials. Practices can look forward to an expansion of these efforts going forward.

“I can’t yet say these alternative reimbursement structures are a good thing or a bad thing,” said Goldberg. “The carrot is that the doctors are going to share in the savings. The stick being that those who come in over costs are going to lose money. I think that is essentially what the future will look like.”

How this will impact practices, especially the smaller community-based ones, is still open for discussion. Much of the ability of these practices to remain viable is most likely going to be related to regional economics.

The smaller practices that have a position of leverage because they are the only one in the area will do better. If the practice is one of two and the insurers need them in their network to keep their policyholders happy, there is obviously more negotiating leverage.

“Size of the practice will also affect what they have available to help themselves survive,” said Owen J. Dahl, MBA, FACHE, LSSMBB, an independent oncology practice consultant with the Medical Group Management Association. “Those with only one or two physicians practicing in smaller communities can’t get pricing breaks that bigger practices are offered. What I am seeing in most of those cases is the doctors just throwing up their hands and turning to community hospitals to buy the practice, or working out a deal to send all their infusion patients to the hospital.”

One possible way to address some of the cost issues is the evolution of the group purchasing organization (GPO). GPOs are developing what Dahl said are some interesting technology and tools to help with reporting, compliance, and other issues.

“If perchance a small or mid-size practice gets involved with a GPO, there might be a large enough network to influence payers through the organization,” said Dahl. “They may be able to offer tools to some practices, allowing them to show good adherence to guidelines and outcome measures. This may help survival of the community-based model in the long run.”

Community practice viability may hinge on understanding and adapting to more aggressive payer involvement

What Does Increased Payer Cost Management Mean for Oncology Practices?

Recovery Audit Contractors (RACs) are individuals dispatched by the Centers for Medicare & Medicaid Services (CMS) to look for overpayments to physicians. Since they are paid a contingency fee for locating discrepancies, they are quickly becoming viewed as bounty hunters by many practices.

“RACs are tasked by CMS to go out and find overpayments and underpayments for Medicare services,” said Abby Pendleton, Esq, from The Health Law Partners, PC, in Southfield, Michigan. “The reality is that they are really out there looking for overpayments. Their percentage of any recovery runs between 9% and 12%.”

		Figure. RAC Jurisdictions in the United States

The Recovery Audit Program was initiated under the Medicare Modernization Act of 2003. Following a 3-year RAC test program, the Tax Relief and Healthcare Act of 2006 mandated the implementation of a nationwide RAC program. There are currently four assigned RAC agencies, each representing roughly 25% of the country (

RACs review claims on a post-payment basis. They are supposed to use the same Medicare policies as carriers, fiscal intermediaries, and similar Medicare programs and follow the CMS manuals.

Unlike other types of auditing, these contractors can only look at specific issues approved by CMS prior to the review. Although many of these will probably be the same from contractor to contractor, others may be suggested by the RAC subject to CMS approval.

Currently, the look-back period is 3 years. CMS also limits the number of medical records that can be demanded, based on the number of physicians in a given practice.

If they find a concern, they can use statistics to extrapolate how much money should be returned to Medicare. This is not always based on chart audits.

“Contractors are not required to show everything you have done wrong,” said Jeffery Ward, MD, Clinical Practice Committee Chair for the American Society of Clinical Oncology. “For example, if they audit a sample of ten charts out of 1000 a practice submitted for a specific code and they think two of them are wrong, they will ask for repayment for 200 patients.”

This means that all practices should take audits very seriously.

“I don’t think there is any question that a RAC audit has the potential to destroy a practice financially,” noted Ward. “These audits can very easily turn into big dollar losses and decimate a practice.”

The next question becomes, what can a practice do to avoid being audited? Apparently there is very little.

“We are often asked what can someone do to avoid audits,” said Jessica Gustafson, Esq, also with The Health Law Partners. “I believe that it isn’t a matter of if, but rather when, an audit takes place.”

For RAC audits, and most others, the best defense is good charting. Since every RAC gets specific marching orders from CMS, it is also suggested that the practice contact their contractor to see what they can review and concentrate on those issues.

“Physicians in particular have to pay special attention to enhancing their documentation knowing that at some time it will be reviewed by someone,” said Pendleton. “Include information on medical necessity so when an auditor comes in it is very apparent to someone who doesn’t know the patient why something was done.”

Ward notes that having a good rationale for a treatment or intervention may not always be enough. He points to a controversy oncologists are having when RACs deny payment for using pegfilgrastim (Neulasta).

“When the medication was approved 10 years ago, the label said it should not be given any time 2 weeks before chemotherapy or until 24 hours after chemotherapy,” said Ward. “In the interim, we have developed dose-dense regimens giving chemotherapy at 2-week intervals. The literature shows Neulasta can safely be given on the day of chemotherapy, and many use it in that manner when next-day therapy is a hardship for the patient.”

However, RACs are denying claims and asking for paybacks because this is outside of the parameters of the label.

“The money is not being demanded because the medication was inappropriate to give or it did not benefit the patient,” Ward stressed. “Physicians did not follow the strict label that may have been approved years ago, so the RACs are denying claims simply because they can.

Medications can be very fertile ground for RACs. Many medicines are approved for one indication, but as oncologists gain more experience with them, more uses become clinically acceptable and even part of standards of care. However, RACs might see things differently than a clinician regarding the offlabel use of drugs.

If you are audited and claims are denied, all the experts agree that there is little to lose, and quite a bit to gain, by appealing. Pendleton noted that documentation from the CMS suggests that over 60% of all appeals are found in the provider’s favor. These figures are probably conservative since CMS publishes figures on a fiscal-year basis and it can take over a year to exhaust appeals.

“Our experience indicates the success rate could run to 90% or more,” Pendleton said. “If you are confident the service you provided was appropriate, you should appeal because you have a reasonable likelihood of winning.”

If a practice is audited and payments are denied, there is a very stringent protocol and timeline for appeal. Should one be missed, the appeal dies. Because of this, it is suggested that practices designate a person responsible for assembling records for the initial audit and keeping track of all deadlines for appeals.

“The reality of the situation is that the physician community is under a lot of pressure from auditors, and it’s not just RACs,” said Gustafson. “In addition to other players under Medicare, we are seeing significant increases in audits by private payers. Practices need to acknowledge this and establish protocols for addressing these issues from initial documentation through to the last appeal.”

Since recovery audit contractors are paid a contingency fee for locating discrepancies, they are quickly becoming viewed as bounty hunters by many practices.

Putting Practices on the RAC: Recovery Audit Contractors Scrutinize Oncology Practices

Accountable Care Organizations (ACOs) are groups of doctors, hospitals, and other providers tied together to provide care to a cohort of Medicare patients, according to the the Centers for Medicare and Medicaid Services (CMS). ACOs are an important part of the Patient Protection and Affordable Care Act and have also been gaining ground among private payers. Oncologists should be aware that the need to refer patients between ACO members can raise legal issues for practices.

“Many legal concepts play into ACO formation, restricting physician participation in them,” said Barton C. Walker, JD, a healthcare attorney with McGuire Woods, LLP, in Charlotte, North Carolina. “Laws such as the Stark Law and Anti-Kickback Statute say if you are a doctor and have financial interests in an entity that provides certain kinds of health services, you can’t make a referral to that entity unless you fit into one of the handful of exceptions or safe harbors.”

The structure of ACOs can make this a legal puzzle.

“In ACOs, doctors across specialties agree to be responsible for a certain number of patients,” said Martin Merritt, JD, a healthcare lawyer with Martin Merritt, PLLC, in Dallas, Texas. “This requires people to refer back and forth across the participants. A literal reading of the Stark Law says this is a violation since an ACO is a relationship.”

Merritt noted that there are added concerns because not every Medicare patient a physician sees will be a part of their ACO. “Everybody knows an internist can refer a patient to an oncologist in the ACO when there is a problem with cancer,” said Merritt. “What happens when a person not involved in the ACO needs to be referred between the same two physicians?”

The Stark Law is a strict liability statute, so good intentions do not protect you and the adverse outcomes can be severe. A violation subjects physicians to substantial monetary penalties and exclusion from participation in Medicare and other federal programs. In addition, each individual billing is considered a separate violation. A practice that files thousands of Medicare claims every month can be bankrupted by the combination of the government reversing payment and added percase civil penalties.

To address these issues, the CMS and its Office of the Inspector General (OIG) issued guidelines on the subject in October 2011. According to the regulations, financial relationships between ACO participants are waived under the Stark Law if “reasonably related to the purposes of the [Medicare] Shared Savings Program.”

The agencies define “reasonably related” using six characteristics:

		Promoting accountability for the quality, cost, and overall care for a Medicare population

		Managing and coordinating care for Medicare fee-for-service beneficiaries through an ACO

		Encouraging investment in infrastructure and redesigned care processes for high-quality and efficient service delivery for patients, such as appropriate reduction in Medicare costs and expenditures

		Evaluating health needs of the ACO’s assigned population

		Communicating clinical knowledge and evidence-based medicine to beneficiaries

		Developing standards for beneficiary access and communication

“It is interesting to note that commercial ACOs were not expressly included,” said Walker. “You have to be more careful when dealing with organizations tied to private payers. There are other long-standing exceptions to the Stark Law that these commercial ACOs will have to try to fit into.”

The other concern when looking into ACOs is the Anti-Kickback Statute. This law prohibits the offer or receipt of compensation in exchange for referrals or services under Medicare or Medicaid.

Unlike the Stark Law, the Anti-Kickback Statute is an intent-based statute and calls for criminal penalties. Conviction for a single violation may result in a fine of $25,000 and 5 years in jail, and results in mandatory exclusion from federal healthcare programs.

The government may also assess civil monetary penalties, which could result in treble damages plus $50,000 for each violation of the Anti-Kickback Statute. As in Stark, every bill submitted is a separate offense.

The OIG and CMS have made an exemption for ACOs when they distribute shared savings among participating practices and hospitals in the year it is earned. They also state, however, that payments made to a physician either directly or indirectly cannot induce the doctor to limit medically needed services.

Although there are concerns that physicians should be aware of, the need for the physician practice to reinvent the wheel when they look at joining ACOs is minimal. Few practices will lead the ACOs.

“Most ACOs we have seen are being driven by hospitals or payers,” said Walker. “They almost always will have in-house counsel or an outside advisor helping them structure the ACO.”

The majority of physicians will come into ACOs that have already been set up and vetted from a legal standpoint. Most times, an individual practice will only need their own attorney to double-check and make sure the originator has structured the agreements properly.

“Most practices’ ACO concerns are more mundane than the big picture legal or structural concepts,” said Walker. “They need to ensure that the paperwork is consistent with what was agreed to in areas such as how long the practice is committed to the group, how can they exit if needed, how extra money is divided, what are their responsibilities if the ACO is not successful financially, if there is any up-front or continuing capital commitment, and similar concerns.”

Both experts agree that any physician considering joining an ACO should consult with an attorney who is well versed in the intricacies of the Stark Law and Anti-Kickback Statute.

“Make sure you pick a lawyer with a specialty in healthcare and these specific laws,” said Merritt. “This is not a problem that you can trust to a business law generalist. You need to proceed very carefully with the help of a very knowledgeable healthcare lawyer in your state.”

Oncologists should be aware that the need to refer patients between ACO members can raise legal issues for practices and should consider two key laws before participating.

Legal Considerations With Accountable Care Organizations

		Figure. Changing Trends in Location of Cancer Care

. Published August 15, 2012. Accessed September 10, 2012.)

	According to a study by the consulting firm Inside Oncology, the majority of patients with cancer will be treated outside of private community practices by 2016 (

). The same report noted that 5 years ago, the split was generally seen as 80% community versus 20% hospital-based care. Today they estimate that ratio has changed to 50/50.

	In this changing landscape, community practices must decide whether to remain independent or become part of a larger practice model. “Current trends certainly have not favored the smaller office model,” said David Eagle, MD, president of the Community Oncology Alliance. “If you think the trends are going to continue, you have to look at all of your options, including bigger practices.”

	Despite the need to be forward-looking, however, planning ahead has become increasingly difficult for community practices as the healthcare “crystal ball” continues to get murkier.

	“Most oncologists I have talked to have given up on long-term planning within their practice,” said Eagle. “Planning anything beyond a 5-year time horizon is not seen as viable in the current environment. We have had too many predictions of what is ‘inevitable’ in medicine that later failed to materialize.”

	Regardless of this uncertainty, however, oncologist must choose a practice path. In making this decision, they will have to weigh several key factors.

	It is impossible to separate the medical and financial components of oncology practice. Money has to come in to pay the physician for his or her time, support the many services to patients that are required, hire a staff, pay for the new electronic health records and quality of care documentation needed to give excellent care, and get paid for giving that excellent care.

	“Larger groups and hospital-based practices usually have access to greater resources,” said Kenneth Hertz, FACMPE, principal with Medical Group Management Association Health Care Consulting Group. “It is imperative that you have business resources available to analyze, run, manage, improve and correct, the medical side of the equation.”

	Additionally, larger practice models may result in a paycheck and resources for patient care that might not be as readily available in a small private office. Most of the day-to-day business operations are shouldered by the hospital or larger group, freeing up more time for seeing patients, keeping up with the changes in treatment, and other professional undertakings.

	Regional factors must also be considered is choosing a practice model. For example, Therese Mulvey, MD, physician chief at Southcoast Centers for Cancer in New Bedford, Massachusetts, noted that in her state, laws have long banned physician-owned ancillary services, such as imaging suites. This means that physicians practicing in the state have not been able to subsidize the under-reimbursed costs of oncology treatment using income from these other services. Conversely, those in other states may have added problems if they need to replace this source of cash flow as Medicare and private insurers move toward bundled payments or episodic care.

	The advent of these newer payment methods also may mean that more of the financial risks are transferred to the physician and practice. This incentivizes community oncologists to join larger practice models, because the more people you have to spread the risk over, the easier it becomes to manage.

	“The margin for error has become so small that you not only have to be at the top of your game, but you have to stay there,” noted Hertz. “Being a good doctor is important, but that is pretty much the minimum. It gets you into the game, but that is all.”

	One of the major unknowns is how the Patient Protection and Affordable Care Act is going to impact practices. The sudden influx of new, paying patients may keep smaller practices afloat.

	“We still don’t have a good handle on what is going to happen in 2014 when a large population of patients suddenly gains insurance,” said Vivian Ho, PhD, the James A. Baker III Institute Chair in Health Economics at Rice University in Houston, Texas. “More people getting insurance and needing care means there is more money flowing into a system that may have to cope with physician shortages.”

	Ho said the impact will vary between states. “The benefit to oncologists from increasing the number of insured depends largely on the number of uninsured in a given state,” she said. “In Texas, where 25% of the population is uninsured, I think there will be a benefit. Now, whether that is going to be the same in places like Connecticut, where there are already generous plans in place, is an open question.”

	And yet, despite all of these complex considerations, Mulvey is hopeful that an oncologist’s choice of practice model will still boil down to one noble criterion. “Most of us who have changed our practice situations did so after a lot of thought,” said Mulvey. “It is not just about the money. It is simply how do I best maintain the ability to care for my patients?”

	Guy D, Rodgers S. Most cancer patients will be treated in integrated delivery networks (IDN) and cancer institutions by 2016, predicts new report. 

. Published August 15, 2012. Accessed September 10, 2012.

Community oncologists must weigh multiple factors when deciding to consolidate or remain independent.

Which Practice Model Is Best for You?

	Over the last few years there has been a marked decrease in the number of independent oncology practices. The 

, a recently released study by the Community Oncology Alliance (COA), shows that 241 clinics have closed over a 4.5-year time period ending in 2011.

	“The key driver of consolidation in oncology is financial strain,” said David Eagle, MD, president of COA. “While there are some concerns about business and professional changes, the key driver is almost purely financial. All of the others are secondary to payment issues.”

	The reimbursement changes began with the Medicare Modernization Act of 2003 (MMA). Congress moved payments from a profit margin above the average wholesale price to an average sales price. They hoped this would better match payments with the services provided by oncologists.

	“The problem is that Congress overdid it,” said Eagle. “The money they took away from chemotherapy and supportive drugs was more than they put toward infusion services. In addition, Medicare has been cutting payments for infusion services every year since MMA was implemented.”

	Payments for infusion services have declined by a total of 35% since 2004—a figure that rises to nearly 50% after factoring in medical inflation. An analysis of oncology practice expenses by COA and Avalere Health showed Medicare payments covered only 57% of the cost of providing these services.

	“Over time, private payers have also begun migrating to the same system,” said Eagle. “That is one of the reasons that a law enacted in 2003 is just hitting its apex.”

 suggests the trend away from community practices may be accelerating. There was a 20% increase in the number of physician-owned community oncology practices impacted in the 12 months since the release of the previous report. Additionally, there was a 21% year-over-year increase in clinics closed.

	Passage of the Patient Protection and Affordable Care Act (ACA) may stimulate another round of consolidation in oncology practices. This time, however, other specialties may be impacted, as well.

	“When the ACA passed, it launched another increase in efforts to buy out physician practices,” said Vivian Ho, PhD, James A. Baker III Institute Chair in Health Economics at Rice University in Houston, Texas. “Some hospitals believe strongly that we are moving toward more accountable care, either the Medicare or other models. They are preparing by acquiring physician practices to bring as much care in-house as they can.”

	Another driver of oncology practice consolidation is that Medicare seems to be moving toward a payment model geared toward rewarding large organizations. Some of the programs require a minimum of 5000 patients for entry.

	Both the federal programs and private insurers are looking to shift risks from them to the practicing physician. Thus, they are moving toward more bundling of treatment payments, episodic care, large accountable care organizations, and the like.

	“There are many names for the changes being made, but the bottom line is a realignment of people and providers,” said Kenneth Hertz, FACMPE, a principal with the MGMA Health Care Consulting Group. “These changes in who has the risk exposure tend to drive people to work together so they can reduce costs, provide better compensation to the providers, spread the risk over more people, and obtain more and easier access to financial resources.”

	Governmental payers have already moved toward bundled payment for some cardiovascular disease codes to cover not only the hospitalization, but all services up to 30 days after discharge. The National Cancer Institute estimates that the total US cost for cancer care is $125 billion dollars, and that figure is projected to go as high as $158 billion (in 2010 dollars) by 2020. Because of this “target-rich environment,” Medicare is looking at putting a target on the backs of oncologists next.

	One frequently overlooked change in the oncology landscape is how radically the definition of what constitutes good cancer care has evolved over the last two decades.

	“Medical oncology, and to a degree radiation oncology, is very different than it was when I went into practice 20 years ago,” said Therese Mulvey, MD, physician chief, South Coast Center for Cancer Care, New Bedford, Massachusetts. “At that time you basically saw a patient with cancer, you determined the correct treatment plan, administered that therapy, and then followed the patient for a period of time. Patients, and the entire healthcare industry, are now expecting that we will be able to provide far more services to the individual patient.”

	Counseling and social work services, nutritional support, integrative medicine, patient navigation, outreach and support groups, and genetic screening are now part of what most consider standard care. Smaller practices have problems providing all of the needed resources in this environment.

	“Some of the migration to hospital employment or to larger practice entities has to do with being able to provide all the services that we now believe to be part of high quality care,” said Mulvey. “The expectations are completely different, yet reimbursement has only gone down during that time. This quality of care standard is hard for smaller practices to deliver unless there is some link to the resources of a larger organization.”

	She stressed that although much of the talk on this subject focuses on how reimbursement changes are causing problems throughout oncology, a lot of the impact on the financial stability of practices is driven by patients’ wants and needs. “It has crossed the line where oncologists are no longer being asked to do the same with less, we are now being asked to do significantly more with less,” she said. “It is combining increasing responsibilities with lower reimbursements that really drove oncologists to look for partners. Those who could help them achieve high-quality patient care in a way that did not bankrupt everybody.”

			Community Oncology Alliance practice impact report. Community Oncology Alliance. 

. Published April 4, 2012. Accessed August 31, 2012.

			Providing high quality care in community oncology practices: an assessment of infusion services and their associated costs. Avalere Health, LLC. 

			The cost of cancer. National Cancer Institute. 

. Published January 12, 2011. Updated February 18, 2011. Accessed August 30, 2012.

Driven by changes in reimbursement and standards of care, independent community oncology practices continue to dwindle.

Kurt Ullman