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Alan Marks MD

By Alan Marks, MD

Increasingly, I see cancer care shifting from private or small, community-based practices to larger practices or more urban hospital centers. The statistics reflect this trend. The American Society of Clinical Oncology(ASCO) reported in 2014 that 1/5 of Americans reside in rural areas, but now only 1 in 33 oncologists practice in those areas. The Community Oncology Alliancereported in 2013 a 20 percent increase in clinic closings and mergers with hospitals. Oncology, it seems, is being consolidated – to the detriment of community oncologists.


Several different factors drive this shift. For one, the cost of inventory has become unmanageable. There’s also the ancillary/administrative services now required for oncology practices. My practice, for example, employs multiple financial counselors to aid patients in managing the sometimes crushing cost of cancer care, made worse in recent years by high co-insurance rates and the placement of cancer drugs onto specialty tiers. Many practices also need additional dedicated staff to handle the administrative tasks related to insurance processing of prior authorizations and co-pay assistance.

I understand the lure of larger, consolidated practices and hospital-based systems. Not every oncologist wants to also be a small businessman. Others try, but find that the burden is overwhelming.


On a larger scale, we must consider the effect of consolidation on patient care. Community practices, by design and tradition, value the physician-patient relationship. Physicians in more consolidated care settings can certainly hold the same level of commitment to their patients, but the management of these practice settings sometimes places particular emphasis on growth and financial considerations.


Take 340B, for example. By design, the 340B Drug Pricing Program should equip hospitals to provide medication and health care access for indigent patients. It requires pharmaceutical companies to provide deep drug discounts to 340B eligible institutions, hospitals with a certain percentage of un- or under-insured patients.

As more hospitals acquire community practices and satellite offices, they assume a double benefit: both the discounted drug prices and patients whose insurance may reimburse for the drug in full. The financial advantage encourages hospitals to consume still more practices.


The use of clinical pathways offers another example of budget-driven policy in consolidated care settings. Pathways encourage clinicians to guide patients through a predetermined set of therapies in a predetermined order. Pathways encourage efficiency and reduce expenses, often by dictating the use of lower-cost drugs as the first line of therapy.

To elicit cooperation from physicians, insurance companies may provide practitioners a financial incentive. Physicians in community practices can make decisions about whether or not to implement clinical pathways on an individual or small group basis, but physicians in larger, more consolidated care environments may find decisions about the use of clinical pathways being pushed down on them from leadership.


When efficiencies and cost considerations drive our health care system, we may risk losing our focus on individualized care. We risk losing oncologists who are local, a personal face in a connected community. We also risk losing the anchor of traditional medicine – the relationship between a physician and his or her patient.

Making matters worse, we are losing young physicians. In tandem with care consolidation, fewer residents are opting to pursue oncology. ASCO predicts that by 2025 oncology will have a deficit of 1,500 medical oncologists.

Cancer patients may still receive care, but will their physician know them? Will the care they direct reflect patients’ individual needs? Or will these patients, many fighting for their lives, find themselves driving too far, waiting too long to see a physician who has too little time – and, for the sake of efficiency, sets them on mandated step care pathways?

Alan Marks, MD, is president of the Florida Society of Clinical Oncology and chairman of AfPA’s Oncology Therapy Access Physicians Working Group.

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