The State of Cancer Care in America: 2014

The First-Ever Comprehensive Examination of Threats Facing the U.S. Cancer Care Delivery System

Dr. Blase Polite, Chair-Elect of the American Society of Clinical Oncology’s Government Relations Committee and Assistant Professor of Medicine, University of Chicago

(Alexandria, VA, Tuesday, March 11, 2014) – This is a time of extraordinary change and opportunity in cancer care. A dynamic and integrally related combination of scientific and technological advances, healthcare policy changes and demographic shifts is reshaping virtually every aspect of oncology. This transformation has profound implications for millions of people with cancer and their families in the United States and around the world.

In The State of Cancer Care in America: 2014, ASCO examines the many factors that affect our nation’s ability to reach these goals, from current and projected demand for services and oncologist workforce supply to the full range of economic, regulatory and administrative pressures that oncology practices face. This report also examines how a growing emphasis on quality measurement and demonstration of value, together with the rapid expansion of health information technology, stands to improve the care that patients receive.

ASCO presents this overview of the current state of cancer care in the United States with an eye to the future. The report includes recommendations intended for policymakers, cancer care professionals, researchers, and others with a stake in improving our nation’s cancer care system.

Key Findings and Recommendations

1. THE ONCOLOGY WORKFORCE

ASCO regularly monitors the size, distribution and diversity of the U.S. oncology workforce to identify trends that could affect patient access. The Society’s latest analysis identified several key challenges:

• Potential workforce shortages. ASCO estimates that, by 2025, demand for oncology services will grow by 42 percent or more, while the supply of oncologists will grow by only 28 percent.
  In this scenario, there could be a shortage of more than 1,487 oncologists in 2025. Shortfalls will be driven by tremendous growth in the number of Americans over the age of 65, along with the aging of the oncology workforce and large numbers of anticipated retirements. Furthermore, ASCO’s research indicates that these shortfalls may be further exacerbated by high levels of burnout, potentially leading to reduced clinical load or early retirement.
• Geographical concentration and rural gaps. The vast majority of oncology care providers are concentrated in certain regions of the country and in urban areas generally. Only three percent of oncologists are based in rural areas, where twenty percent of Americans live.
• Need for greater workforce diversity. As we work to reduce racial and ethnic disparities in cancer care, it is important to increase the number of oncologists from underrepresented racial and ethnic groups. Today, there are lower percentages of African- and Latino-American physicians in oncology than in many other medical specialties.

To ensure continued availability of oncology services for patients nationwide, ASCO recommends the following:

• Identify creative strategies for leveraging the oncology workforce—for example, collaboration with primary care professionals on overall coordination of patients’ cancer care, allowing oncologists to focus on patients receiving active treatment of the disease.
• Leverage technology and innovative practice models, such as telemedicine and visiting consultants to improve patient access and better connect other providers to cancer specialists.
• Monitor and address physician burnout. Professional organizations should explore ways that burnout can be prevented and/or addressed and encourage confidential reporting of burnout to gain a more accurate understanding of this challenge.
• Monitor and address the size and diversity of the oncology workforce. ASCO will continue to enhance its research, while advocating for targeted interventions to ensure that the workforce of oncologists will be appropriate in size and diversity to address future demands.

2. THE STATE OF ONCOLOGY PRACTICE

This report highlights findings from ASCO’s second annual census of U.S. oncology practices, conducted in 2013, along with related data from other sources. Key findings include:

• Practice size increasing. The median size of practices increased substantially between those reporting in 2012 and 2013, from nine physicians per practice to 15. Whether this is true growth or an artifact of sampling is not certain, however, these results are consistent with other qualitative information about practice consolidation and mergers over the past year.
• Financial instability for oncology practices. Practices cited financial pressures as the greatest threat to their ability to continue providing high-quality care. As a result of cost pressures, significant numbers say they are cutting back on support staff or clinical research, or are sending patients tohospitals to receive chemotherapy. According to the 2013 Medscape Physician Compensation Report, oncology was one of only two specialties to experience an overall decline in annual income between 2011 and 2012. Endocrinologists were down three percent, and oncologists were down four percent.
• Greatest threats faced by small community-based practices. The 2013 ASCO census suggests that smaller community practices handle a disproportionate share of patient care, particularly in the southern and western United States, yet are under far greater economic pressure than larger practices. Nearly two-thirds of small practices (63 percent) reported that they were likely to merge, sell or close operations in the next year.
• Practices are gradually adapting to a changing healthcare system and new technologies. A majority have adopted electronic health records, and a sizable minority are considering new payment models. Small practices, however, may lack the resources to adapt.

To sustain oncology practices’ ability to meet patient needs in every community, ASCO recommends the following:

• Payers should align payment systems with the goal of delivering high-value, patient-centered care, and provide funding and support to help struggling practices make the transition to value-driven payment models.
• Test a range of promising cancer care delivery models that address the unique challenges of treating the disease. Specifically, policymakers should launch demonstration projects through the Innovation Center within the Centers for Medicare & Medicaid Services or other appropriate avenues.
• Reduce instability in federal payment systems. This includes repealing the flawed Sustainable Growth Rate (SGR) formula and reversing Medicare cuts caused by sequestration, along with other financial pressures that are disproportionately harming small community practices.

3. QUALITY IN CANCER CARE

Although the U.S. cancer care system is arguably the world’s best, the quality of care remains inconsistent, contributing to disparities in outcomes and unnecessary costs. Many organizations are working to measure and improve the quality, consistency and value of cancer care. This report examines the following key developments:

• Physician-led quality initiatives show potential to improve care. A number of different quality improvement efforts are being implemented in oncology with physician leadership and participation. For example:

— Data from ASCO’s Quality Oncology Practice Initiative (QOPI®), in which more than 850 oncology practices have participated, offer compelling evidence of improvement on several measures, related to both cancer-specific treatment and broader measures such as high-quality end-of-life care.

— Both Medicare and private insurers are working with physicians to pilot test new payment or care delivery approaches that reward high quality care. These range from clinical pathways to patient-centered medical homes, which promote aggressive disease management, care coordination and strong patient/physician communication.

• “Big data” arrives in cancer care. The adoption of health information technology is already transforming many aspects of cancer care, but more dramatic change is on the horizon. Within years, big data initiatives such as ASCO’s CancerLinQ™ and the collaboration between IBM’s Watson and Memorial Sloan-Kettering Cancer Center will unlock and analyze data from large numbers of patients—and feed conclusions back to doctors in the form of personalized guidance for each patient. Such guidance will be vital in an area of increasingly complex treatments tailored to the genetics of each patient’s tumor

To maximize the benefits of these efforts for patients and to achieve consistent, high-quality care, ASCO recommends the following:

• Build on existing investments made by the oncology community in quality monitoring and information technology. In particular, Congress and the Administration can work with the oncology community to pursue a national oncology quality measurement system that is efficient, meaningful and relevant to oncology professionals and their patients.
• Advance “learning health systems” such as ASCO’s CancerLinQ, which have the potential to dramatically improve oncology care, but will require engagement by payers and policymakers to have the greatest impact.
• Remove disparities in access to cancer care, in part by requiring health insurers to set benchmarks that include benefits and services essential to the care of all patients with cancer.
• Establish a common understanding of how to define and measure value in oncology care, so that physicians, payers and others have a common method for assessing the relative value of cancer treatment options and making treatment and coverage decisions.