The healthcare system in the United States has become increasingly unsustainable. We hear frequent reports in the media and within our hospitals about the inability to improve health outcomes despite spiraling healthcare costs. The financial burden of cancer care is monumental. In 2008, overall costs were estimated at $228 billion, which included $93 billion in direct medical expenditures, $18.8 billion in lost productivity, and $116.1 billion in indirect costs.

One example of this economic burden is seen in an analysis of patients with metastatic breast cancer. In this analysis, direct costs averaged $35,164 per year. New targeted-therapy drugs costs range from $20,000 to $50,000 per year per patient, and these costs continue to increase. Another example is seen in colorectal cancer therapy, which increased an incredible 340-fold between 1994 and 2004.

 The drugs we prescribe as oncologists account for 40% of all Medicare prescription costs. This is in contrast to only 4% of federal dollars that are directed toward cancer prevention.

 This article will discuss the impact that the Patient Protection and Affordable Care Act (PPACA) will have on our patients with cancer, on our hospital systems, and on us, the physicians.

Historically, Americans have low rates of adherence to recommended screenings for breast, cervical, and colorectal cancers. ”

Impact of Health Reform on a Patient With Cancer

When you combine the costs of tests, imaging, physician services, chemotherapy, surgery, and radiation therapy, the price tag on cancer treatment may range anywhere from $40,000 to more than $100,000 per patient. There are provisions within the PPACA that may offer modest advantages for our patients, including greater scrutiny when raising insurance premiums. Because of the increased requirements for employers to provide insurance coverage, individual states will form health insurance exchanges or cooperatives that offer low-cost options for workers as well as create competition in the marketplace. It is unclear how this will be federally regulated; many of these exchanges may operate differently because they will be created at the state level. Federally, the government will provide subsidies to low-income individuals so they can obtain insurance. With these changes, it has been estimated that 32 million additional individuals may be covered by 2019.

One of the biggest concerns of patients is whether PPACA will cover preexisting conditions. Under the current plan, children with preexisting conditions such as cancer are protected from being excluded from insurance and will also be covered until the age of 26 under a parent’s insurance plan. For those patients who fall into the category of non—Medicare-eligible retirees older than age 55, there will be access to subsidized high-risk pools and insurers will not be allowed to set annual or lifetime limits on coverage. These changes will likely have a significant impact on patients with cancer who may fall into the age range that is not yet eligible for Medicare benefits.

A major challenge for our patients is finding coverage for their skyrocketing prescription drug costs. This will become especially important in cancer treatment as we increasingly develop targeted agents, many of which are in oral form. Currently, there is a large gap in Medicare Part D coverage. Many patients find themselves in the “donut hole,” causing them to struggle financially because their coverage is lacking. As the PPACA reforms take effect, there will be a $250 subsidy for those affected by the donut hole. By 2020, however, it is projected that 75% of oral medications will be covered by Medicare—a significant improvement over today’s Medicare coverage.

Historically, Americans have low rates of adherence to recommended screenings for breast, cervical, and colorectal cancers. Recent Centers for Disease Control data reveal that 38% of Americans older than age 50 have not had their recommended colonoscopy and sigmoidoscopy screening, and 24% of women aged 40 to 50 years and 21% of women over age 50 have not had recommended mammogram screening in the last 2 years.

 Preventive, quality-focused, cost-effective care will be the major PPACA initiatives, with preventive services coverage being federally mandated. Medicare will cover 100% of actual charges and fees for preventive care, such as cancer-screening exams. Incentives to Medicare beneficiaries may increase compliance with screening recommendations; this might ultimately save thousands of lives while cutting healthcare costs.

The expanded healthcare access will affect those covered under Medicare, private insurance, and PPACA. Unfortunately, of the 32 million people with newfound coverage, up to 50% will be covered under Medicaid and may not benefit from the expanded coverage. It is unclear if those with Medicaid will face the same challenges they currently do. In addition, it is possible that hospitals and private practice will continue to suffer financially by caring for Medicaid patients.

Impact of Health Reform on Private Practice and Hospital Systems

PPACA will have both positive and negative impacts on hospital finances. Under the expanded care, up to 95% of the US population will be insured. On the positive side, this will dramatically decrease the number of completely uninsured people, reducing hospitals’ bad debt. Currently, approximately 15.3% of the population is uninsured and 35% is underinsured. For the most part, hospitals are burdened with uncompensated medical care costs that one 2001 report estimated to be $35 billion.

These financial benefits, however, will be offset by a $14 billion reduction in Medicaid’s disproportionate share hospital (DSH) payments, which will begin in 2014.

 DSH payments provide financial assistance to hospitals that serve a large number of low-income patients, such as the uninsured and those with Medicaid. Medicaid DSH payments are the largest source of federal funding for uncompensated hospital care. For the hospitals that depend on DSH, this will add additional burden to an already stressed system; this may ultimately result in hospital consolidations, additional hospital services bring cut, and hospital closures. Medicare will provide expanded coverage by making cuts using the following strategies: not paying for hospital-acquired conditions, which will save $1.4 billion over 10 years; not paying for excessive readmissions, saving $7.1 billion over 10 years; and additional Medicare/Medicaid efforts to reduce fraud, saving $2.9 billion over 10 years.

In order to raise the quality of care delivered and provide incentives to hospital systems that are able to cut costs, accountable care organizations (ACOs) are an integral aspect of provisions set to go into effect next year. According to the Centers for Medicare & Medicaid Services (CMS), an ACO is defined as “an organization of healthcare providers that agrees to be accountable for the quality, cost, and overall care of Medicare beneficiaries who are enrolled in the traditional fee-for-service program who are assigned to it [sic].”

 The pillars of ACO are care coordination, care effectiveness, population health management, safety, and efficiency.

 In this system, if an ACO is able to meet performance standards and achieve a specified level of savings for an “episode of care,” then the ACO would share in some of the cost savings. The expected effect of ACO implementation on cancer care remains unknown at this time.

Medical oncologists have felt significant financial pressures even prior to the passing of PPACA. The American Society of Clinical Oncology estimates that 80% of patients in this country receive their care in a community setting. Under this model, patients typically visit their physician in a private-practice office where they receive their infusional chemotherapy. Under this system, the private practice has purchased the drug and will bill the payer for both drug and administration. PPACA is expected to drastically alter this model by changing reimbursement for chemotherapy, supportive drugs, and professional services, and by attempting to move all practices toward ACOs.

Prior to 2005, the CMS reimbursed practices at 95% of average wholesale price for chemotherapy and associated drugs, and this rate was quite profitable for oncologists. With the Medicare Modernization Act of 2005, the oncologists’ profits plummeted after drug reimbursement became based on average sales price (ASP) rather than average wholesale price (AWP). (

Editor’s note: Before we went to press, the Senate introduced S. 733, a bill designed to correct this reimbursement issue.

) ASP provides approximately 49% less in value than AWP. These changes have already increased the number of referrals to hospital infusion centers and have created partnerships between hospitals and private groups in order to shift financial risk to larger hospital systems. In addition to decreased margins in delivering pharmaceuticals, reimbursements for professional services will also decrease. The combination of these financial threats poses a major risk to small private practice groups because they will likely struggle to meet ACO regulations.

In the future, the stresses on the healthcare system will magnify. By 2030, the US population will expand to 365 million people, with 72 million adults over the age of 65. As the baby boomer population ages, the incidence of cancer is predicted to increase more than 45% from 2010 to 2030. There were 1.6 million patients with cancer in 2010; this number will swell to 2.3 million in 2030.

 This increase will occur as the oncologist workforce continues to shrink. In preparation, it is essential that our disjointed system of care be restructured to be more efficient, nonduplicative, cost-effective, evidence-based, and safe. As these cancer care delivery models evolve, it will be essential that physicians take an active role in policy changes in order to protect their livelihood as well as continue to provide high-quality patient care.

Sheetal Kircher, MD, is a second-year fellow at Northwestern University Feinberg School of Medicine in Chicago, Illinois.

American Cancer Society. Economic Impact of Cancer Web site. http://www.cancer.org/cancer/cancerbasics/economic-impact-of-cancer. Accessed on March 13, 2011.

Schrag D. The price tag on progress—chemotherapy for colorectal cancer. 

Meropol NJ, Schulman KA. Cost of cancer care: issues and implications. 

American Hospital Association. Special Bulletin. Summary of major provisions in final house reform package. March 22, 2010. http://www.nmhs.net/documents/HCreformfinalsummary032010_000.pdf. Accessed March 20, 2011.

Behavior risk factor surveillance system survey data. Atlanta, GA: US Department of Health and Human Services, Centers for Disease Control and Prevention; 2007.

Whitman G. Hazards of the individual health care mandate. 

Medicare “Accountable Care Organizations” Shared Saving Program—New section 1899 of Title XVIII. https://www.aace.com/sites/default/files/CMSPremlimQA.pdf. Accessed March 20, 2011.

McClellan M, McKethan AN, Lewis JL, et al. A national strategy to put accountable care into practice. 

Smith BD, Smith GL, Hurria A, et al. Future of cancer incidence in the United States: burdens upon an aging, changing nation. 

Articles

The healthcare system in the United States has become increasingly unsustainable.

Healthcare Reform and the Future of Oncology

Sairah Ahmed, MD, is an associate professor in the Department of Lymphoma/Myeloma, of the Division of Cancer Medicine, and director of the CAR T Program at The University of Texas MD Anderson Cancer Center.

	For an incoming first-year hematology/oncology fellow, July 1st is when you are once again the new kid on the block. Whether you are starting a fellowship at your home institution or in a new city, July 1st marks the beginning of the final phase of training that we have worked so hard to arrive at. Although completing fellowship at your home institution may give you a leg up on finding the bathroom, it will not, unfortunately, lessen the learning curve inherent to the most challenging year of training. And although you may initially still perceive yourself as a third-year resident mastering the skills of hypertension and diabetes management, to your patients, you are now their oncologist.

	The field of hematology/oncology is unlike many other medical sub-specialties in that there is very little exposure to it during residency. During the earlier part of your first year, you will rattle-off chemotherapy side effects and tell patients and their families “what they can expect.” At that point, however, you may barely be able to pronounce the drug, let alone provide patients the knowledge they need to prepare for toxicities. I spent my first year of fellowship studying the “hallmark” articles and memorizing National Comprehensive Cancer Network (NCCN) guidelines. I imagined myself going home after work to sit and read about each of my clinic patients. As the demands of first-year fellowship became obvious, however, I realized that this was not how I was going to gain my knowledge. Between learning to write orders, performing bone marrow biopsies, and running the oncology services, there were many days when I was glad to have an opportunity to eat lunch, let alone absorb the latest 

	Most of the knowledge I attained during the first year of fellowship came from interacting with patients and learning how to take care of them. As you make your way through the first year, you’ll realize that you are no longer memorizing a list of side effects, but rather explaining to your patients the toxicities that you have actually witnessed. As the initial feelings of being overwhelmed wear off, you will slowly become comfortable with this “new language” of oncology.

	As I entered fellowship, I prepared myself for the academic challenge and even cleared my weekends in anticipation of spending most of my time at the hospital. I studied NCCN guidelines and tried to read everything that I thought would prepare me. It was the emotional toll of learning how to be an oncologist, however, that proved to be the most challenging. No matter how hard I searched, I could not find an algorithm that explained how to tell my 21-year-old patient and his family that his cancer had progressed and he was dying. This part of the job did not become easier for me emotionally during the first year. As I learned the natural history of diseases, however, I became more comfortable with these difficult conversations.

	What surprised me about these encounters was the fulfillment and great satisfaction I found in supporting my patients through their treatment journey, whether it meant receiving more chemotherapy or making the difficult decision to transition to hospice. I was fascinated by the fact that cancer is the ultimate equalizer—it disregards race, gender, and socioeconomic status, and gives patients the same hopes and fears. As the year progressed, I grew to appreciate that fact that although the victory of remission is obvious, the less obvious victories such as controlling pain or nausea truly impact our patients’ quality of life.

	The first year of fellowship was more challenging for me than any other time during my training. At this point in our lives, many of us have families and other obligations that may seem incompatible with being a first-year fellow. After finishing clinic most days, I would frantically run to to pick up my two-year-old daughter from daycare by 6:00 pm. While balancing family and fellowship is not easy, it is possible to juggle both with careful planning, support from your family, and prioritization. In my experience, a personal support system—from a spouse, family member, friend, or coworker&mdash;is crucial during the first year of fellowship. Caring for patients with cancer requires you to give yourself both academically and emotionally, and having a support system is very important as you learn how to handle the death and dying of your patients.

	Another key to surviving your first year of fellowship is relying on the second- and third-year fellows for help as you navigate the first few months. Although senior fellows may seem like they have everything figured out as they diligently work on research projects and quote data from hallmark articles, remember that they started out just like you. The worst mistake you can make is not asking for help when needed. The senior fellows and attendings would rather be asked the important questions than have serious mistakes made.

	As you settle into your first year, you will become comfortable performing bone marrow biopsies and will not be scared every time your pager goes off. You will inevitably become more comfortable with the never-ending thrombocytopenia consults and will start thinking about your future as an oncologist. Finding a meaningful mentor that understands your clinical and research goals will be important to establish early. Many times, these relationships happen naturally as you get to know the faculty and learn about their interests. On the other hand, you may find yourself intrigued with a certain research topic and need to seek out people in the department. Either way, a good mentor will help develop your interests and open up opportunities.

	It is now July 1st of my second year, and although I can fully recognize how much I have learned about the science of oncology and the art of treating patients, I still cannot pronounce all of the chemotherapeutics and need to look up the staging systems of some malignancies. After so many years of learning general medicine, you have finally arrived at your specialty of choice. As you battle your way up the learning curve, it may feel at times that you are simply trying to survive. Rest assured that you will approach July 1st a resident, but leave your first year of fellowship as an oncologist.

Sheetal Kircher, MD, completed her first year of fellowship at Northwestern Memorial Hospital in June 2010.

	During my first year of fellowship in a combined hematology and oncology program, I spent much of the year trying to balance my clinical obligations with my life outside of the hospital. My first year involved 11 months of inpatient ward training in malignant hematology, solid oncology, and stem cell transplant rotations, interspersed with inpatient consult in benign hematology and oncology. In addition to the rigorous inpatient schedule, I also spent three half-days in disease-specific outpatient clinics. While the learning curve was steep, the bigger challenge was balancing work demands with a husband and toddler at home. I anticipated that the second year of fellowship would be the time to catch my breath, and in many ways, this was true.

	Although I felt an incredible sense of relief after the clinical marathon of first-year fellowship, my second year has been busy in a different way, with a shift in focus toward pursuing clinical, translational, or basic science research. The daily schedule during my second year provided me with a mental and physical breather. Holding a pager six days per week during the first year created a mental “bond” to the hospital; even when I was physically away from the hospital, it was hard to truly “exhale” and reflect. During my second year, I finally felt that I could exhale. Upon reflection, it became clear that although the first year of fellowship was intense, I had gained an immeasurable amount of knowledge in a short time. I also gained a sense of confidence and pride knowing the myriad challenges I overcame. As a second-year fellow, I was able to counsel the incoming first-year fellows and reassure them that the first year would not only be survivable, but also an incredible chance to lay a strong foundation for their career. Perhaps one of the biggest distinctions between the first and second year is that the second year was a time to solidify my clinical knowledge, build my resume, and prepare for the process of applying for jobs, which will begin relatively early during the third year.

	Much of the second and third years of fellowship are designed to allow time for research pursuits, particularly for physicians who are interested in an academic career. For those who hope to pursue a career in academic medicine, most agree that a successful and productive second year of fellowship begins with identifying the right mentor. Ideally, mentorship should begin during the first year of fellowship, although expectations for research productivity should be modest. If nothing else, establishing a mentor or network of mentors during the first year and meeting on a regular basis can help create the framework for a productive relationship and enable you to “hit the ground running” at the beginning of your second year. This is especially true for those who begin fellowship with a particular disease focus or interest, or who develop one early on. An ideal mentor is someone whom you respect; who is experienced and academically successful; and who is approachable, available, and invested in your own success.

	Many mentors may have projects that are near completion or in various stages of development, and a fellow is the ideal candidate to complete them. Faculty are usually very receptive to fellows who are interested in helping complete projects. This can be an opportunity for fellows to gain skills that will be applicable in the future, even if their disease focus or interests change with time. Such a situation is a “win-win” for both parties—the mentor benefits from the outside help, while completed projects can help fellows “build” their resumes and provide them with an opportunity to present at conferences and meetings. Although projects that are initiated during fellowship often take years to complete and may continue beyond fellowship, they can provide fellows with valuable skills that can transcend their professional career.

	For fellows interested in pursing a career in academic oncology, the second year of fellowship is an important time to consider applying to programs such as the American Society of Clinical Oncology (ASCO)/American Association for Cancer Research or the American Society of Hematology (ASH) Clinical Research Training Institute workshops to gain further skills useful in clinical research. These workshops focus on teaching fellows and junior faculty the various methods of clinical trial design and technical writing, and tend to take place in July and August, with application deadlines as early as December. If you are interested in applying for these programs, it is helpful to know about them ahead of time in order to identify a project for the application process. Furthermore, the second year of fellowship is a time to consider applying for fellow training grants that are available through various organizations, such as the ASCO Young Investigator Award or the ASH Fellows training awards. This is also an ideal time to begin projects that could be used when you apply for these awards during the third year of fellowship.

	The second year provides plenty of time to broaden your knowledge and solidify everything learned during the first year. Most fellowship programs have numerous conferences and tumor boards that can be more consistently attended during the second and third years. During your first year of fellowship, it can be a challenge to attend all of the didactic opportunities that are available while simultaneously balancing your clinical responsibilities. The second year may also provide more time to read the primary data in order to support your clinical decisions. Most fellowship programs have physicians continue in one or more clinics during the second year of fellowship while scheduling less inpatient service. This is crucial for developing and strengthening the clinical skills necessary for going into practice after fellowship, especially for those who may be interested in clinical practice.

	Whether you are pursuing an academic or clinical position post-fellowship, being productive during your second year is important. The time to start applying for jobs comes sooner than imagined (or at least sooner than I had imagined). Most faculty advised me that for academic jobs, resumes are sent as early as July through October. Since the job search begins early in the third year of fellowship, the latter part of my second year was also dedicated to updating my resume, completing projects that could be included in my resume, and asking for letters of recommendation and references. I personally chose to start the process quite early because I knew that I would be on maternity leave when I would need to send resumes to various institutions. If you know very early which particular institutions or geographic locations you prefer, the annual ASCO meeting is a good venue to begin to make some contacts for the job search.

	While the first year of an oncology fellowship may be the most physically and emotionally demanding, the second year is crucial for training and preparing physicians for their career post-fellowship. For me, the second year of fellowship was a time to really get involved with clinical research to prepare me for an academic career and improve my skills as a clinician.

Josephine Feliciano, MD, completed her second year of fellowship at Northwestern University Feinberg School of Medicine in June 2010.

	Congratulations—you’re a third-year fellow and there’s finally a light at the end of a long, dark tunnel. Suddenly “the real world” is a tangible reality. After years of training, you are entirely capable of dealing with the science of medicine, from looking up NCCN guidelines to treating solid and hematologic malignancies, from writing review articles to talking to patients about goals of care. An acute leukemia at 3:00 am no longer strikes fear in your heart. But nothing in training has prepared us for the next steps&mdash;looking for a job, navigating contracts, and trying to decide where you will be happiest for the rest of your professional career. Scary thought, huh?

	One of the first decisions to be made is whether to pursue a career in academia or private practice. While some decided this long ago, the choice isn’t so black and white for the rest of us. So why choose private practice over academia? The obvious answer is monetary compensation, but ultimately, it’s about personality. Being part of a practice provides a great deal of control over where, when, and for whom you work. You are the master of your fate and captain of your soul—how many times has that happened before? After years of self-discipline, finally what you want matters; how much it matters may be up for debate!

	On the other hand, why choose academia over private practice? Teaching, clinical and translational research, and subspecializing in a specific malignancy are all included in the mix, but again, it’s personality. Those who choose academia like to be constantly challenged and crave the feeling of juggling several balls at the same time. They focus on multiple problems while trying to advance scientific knowledge, always hoping that one of those balls won’t go splat at the wrong moment!

	Below is my advice for navigating the details after the private practice vs academia decision is made.

 Once the geographic area is decided, start networking with friends, colleagues, and physicians in the area—both in other specialties and your own. Determine which practices you’re interested in, whether they’re hiring, and send out interest letters and your curriculum vitae (CV). An extremely important asset are your faculty; the connections they have within the community and across the country is an invaluable tool&mdash;USE THEM!

	By September, actively gather information about where to apply, and by November, send out CVs and set up interviews. Winter and spring will be an interview merry-go-round. Ask the questions you never asked in residency or fellowship interviews: What is the base salary? Are there bonuses? How does partnership work? How is vacation decided? What is the call schedule? What are the details of the non-competence clause? The list is endless and will reflect what is most important to you. Remember to trust your instincts and pay attention to the intangibles—all the things that make you love your work environment. Don’t underestimate the importance of these factors.

	Before accepting the final offer, make sure a lawyer reviews the contract. The devil is in the details, and your responsibilities should be clear prior to signing on the dotted line.

 Geographic location, a specific research interest, or treating a particular tumor type may drive your choice. Sometimes having more than one goal makes it harder to find a perfect fit. Again, talk to faculty, as they will have the inside track on open positions or cancer centers that are hiring. Former fellows and colleagues are great resources to tap as well. Use ASH and ASCO to network; it may lead to interviews later.

	In September, start sending out letters of intent with CVs attached. Don’t limit the search to institutions with open positions—include all institutions you’re interested in. Sometimes the job you want isn’t being offered yet, but it never hurts to ask. Gently having faculty mentors call or email can also help open the door to an interview.

	Academic interviews usually include a job talk, which may entail discussing the clinical research you’re involved in or detailing the time spent in a basic or translational lab. THE most important aspect of the talk is your grasp of the subject matter. From the mundane to the most technical, you want to impart to the audience how intimately involved in the project you were, not that the post-docs in your lab did most of the work and you can’t tell the difference between a Western blot and a microarray. If you’re discussing a clinical project, know how the information was collected and how to interpret the statistics, and be able to explain the hypothesis behind the study. No one expects entirely independent data; however, if you can’t intelligently discuss your project, it’s very hard to be taken seriously. Confidence and the ability to answer queries serenely will make you stand out from the rest of the crowd.

	The tricky part is making sure the job they offer is the one you want. Is there enough research time? How does the tenure track work? How many clinics during the week? How many service months? How is salary determined (RVUs vs grants)? And finally, if your heart is set on lung cancer but the open position is in lymphoma, are you willing to compromise? Once more, get a lawyer to review the contract, although most institutions have basic stipulations that are set in stone.

	Last but not least, if you’re slightly insane, follow me down the path to yet another fellowship. There are a few options if you haven’t tired of a training salary and want to attain PGY-8 status. I chose a stem cell transplant fellowship, but there are others in transfusion medicine or pharmacogenomics. The application process was circumspect compared to a job hunt or even prior training positions. There are a very finite number of institutions that offer these positions and interviews are the same flavor as before, just longer.

	In the words of George Burns, “I look to the future because that’s where I’m going to spend the rest of my life.” After the stress and confusion wear off, you’ll realize that the hardest part is over and now begins the start of your career!

	A few words of wisdom for incoming first-year fellows:

	• This is toughest year of training you’ll ever experience. You will learn an immense amount, but there will be days (lots and lots of days) that you want to give up. Don’t! It will get better and you will sleep again.

	• Ask questions. You’re in fellowship to learn; the aim is for you to be taught and trained well.

	• Remember internship and the mantra “Eat when you can, sleep when you can, and just get through today.” Relearn the mantra.

	• It’s hard to tell people they are dying and you can’t change that reality. Burnout is real and you have to avoid it. Use everything you can to keep centered— family, friends, co-fellows, sports, alcohol…ok, I was kidding about the alcohol! But expect the emotional roller coaster; we all get on the ride but aren’t ready for the sudden fall.

	Understand that difficult patients (and families) are often a manifestation of fear and loss of control. It’s seldom personal and they don’t really hate you. Avoid saying, “I understand what you’re going through” unless you’ve experienced the same. Try, “I can’t imagine what you’re going through,” and then just listen….a lot.

Sairah Ahmed, MD, completed her third year of fellowship at Northwestern University Feinberg School of Medicine, Robert H. Lurie Comprehensive Cancer Center, in June 2010. She is starting a stem cell transplant fellowship at MD Anderson Cancer Center in July 2011.

For an incoming first-year hematology/oncology fellow, July 1st is when you are once again the new kid on the block.

Sheetal Kircher, MD

Articles

Healthcare Reform and the Future of Oncology

A Year-by-Year Look at a Fellowship Program