A new survey from the Association of Community Cancer Centers (ACCC) shows that practicing oncologists in today's challenging health care environment are grappling with key issues ranging from the high cost of drugs, to marketplace competition and consolidation, to electronic health record (EHR) interoperability, to escalating pre-authorization demands, to value-based reimbursement, to staffing shortages.
The survey of 2017 data, "Trending Now in Cancer Care," is the eighth annual one done by ACCC, and it included 293 respondents from 209 organizations. The survey was done in partnership with Advisory Board, a best-practices firm based in Washington, D.C., that uses a combination of research, technology, and consulting to improve the performance of more than 4,500 health care organizations. The majority of those taking the survey (52%) were non-teaching community hospitals, while 21 percent were teaching hospitals.
Results of the survey help shape ACCC's agenda for its annual meeting and cancer center business summit, to be held March 14-16 in Washington, D.C. Survey findings fuel the ACCC's "commitment to helping our members thrive-not merely survive-in a tumultuous and ever-changing health care environment," said ACCC President Mark S. Soberman, MD, MBA, FACS, Medical Director of the Oncology Service Line and Chief Physician Executive of Monocacy Health Partners, Frederick Regional Health System in Maryland.
Cancer Center Challenges
The majority of survey respondents, 68 percent, named the cost of drugs and/or new cancer treatments as the biggest threat to cancer program growth. Some 47 percent named physician alignment around services and program goals as a top threat, while 46 percent named changes in health care coverage. Specifically, respondents cited cuts to fee-for-service reimbursement and shifting reimbursement from fee-for-service to value-based care as threats to their cancer center's growth. Despite both public and private payers moving from fee-for-service to value-based reimbursement, one in three cancer programs are still not participating in value-based contracts, according to survey data.
The strong trend of marketplace consolidation for cancer centers continues, the survey shows. Some 21 percent of respondents reported that they merged with or acquired a health system or hospital; 18 percent affiliated with a cancer program; 16 percent merged with or acquired an independent physician practice; and 16 percent entered into a professional services agreement or co-management agreement. The survey shows the top reasons driving marketplace partnerships include maintaining and/or growing market share (50%) and increasing alignment with hospitals and/or physicians (25%).
Overall, most respondents said they are content with mergers and consolidation, with 49 percent reporting themselves satisfied and 21 percent reporting themselves very satisfied. Only 7 percent of respondents said they were dissatisfied, while just 3 percent said they were very dissatisfied.
Health Information in Oncology
As previously reported in Oncology Times, information technology (IT) issues and glitches continue to plague cancer programs. As highlighted at the recent annual conference of the nonprofit ECRI Institute in Washington, D.C., EHR use can lead to more physician time spent on the computer, often after hours at home; difficulty employing the software, leading to navigational overload; lack of coordination among professionals writing notes in the EHR; and a time delay in workflow when there is a patient information mismatch.
On the ACCC survey, the vast majority of respondents, 80 percent, said their EHR systems have increased the workload of physicians and staff. Survey respondents reported the following three biggest IT challenges: EHR interoperability (37%); automating data abstraction (22%); and insufficient support from the IT team (17%). Lack of interoperability was cited by 31 percent of survey respondents, while 51 percent said their EHR platforms do have interoperability capability. Half of survey respondents reported that EHR adoption has "slightly decreased" the time providers are able to spend with patients, while 16 percent reported that clinician time with patients "significantly decreased" after EHR adoption.
Part of the problem with EHR systems, as revealed on the ACCC survey, is that many cancer professionals are required to use multiple EHR platforms, which can cause confusion. The survey shows that one in four respondents use four or more EHR platforms, while one in three use two EHRs. Live polling of attendees at the 2017 ACCC annual conference asked those at the meeting how long their cancer program had been using their main EHR. While 47 percent said more than 5 years, 27 percent said less than 1 year, indicating that some professionals may still be developing familiarity with their center's main EHR platform.
In addition to IT issues with EHRs, survey respondents were also surveyed on pre-authorization demands. Asked whether the percentage of services for cancer patients requiring pre-authorization has increased in the past 12 months, 51 percent of respondents replied yes, stating that the demand has significantly increased. Some 31 percent also replied yes, stating that this pre-authorization demand has slightly increased.
Immunotherapy Trends
In 2016 and 2017, immunotherapy was named as the top clinical cancer advance by ASCO. The organization recently named CAR T-cell immunotherapy as its major advance for 2018. The overwhelming majority of survey respondents, 96 percent, reported that they prescribe immunotherapy agents for their patients. However, while they prescribe these agents, providers are split on their comfort level with management of patient side effects from these immunotherapies. Some 33 percent of respondents said they were "very comfortable," while 32 percent said they were "very uncomfortable" with this type of patient management.
ACCC Executive Director Christian Downs, JD, MHA, told Oncology Times that many community oncologists are not only concerned about immunotherapy side effects, but also about how to treat them if and when they occur. He cited the increased time commitment of treating the patient twice-first with an immunotherapy and then in several months for side effects. To help community oncologists using these new therapies, the ACCC has issued a report, "Immuno-Oncology: Transforming the Delivery of Cancer Care in the Community."
As for molecular testing of cancer patients, only 27 percent of survey respondents said their oncologists participate in a molecular tumor board. Fully 82 percent said the biggest barrier to molecular testing is insurance coverage. Among survey respondents who offer molecular testing, 47 percent said they send biopsy samples to outside laboratories. Only one in four, 26 percent, have in-house molecular testing laboratories.
Tackling Costs, Patient Care
When asked about opportunities for cost savings in their practices, 63 percent of survey respondents cited clinical standardization; 62 percent cited drugs; 28 percent cited supplies; and 24 percent cited capital expenses, such as radiation and imaging equipment. Respondents see clinical standardization as a way to help reduce variation in care and reduce duplicative patient services. Nearly 30 percent said they intend to improve clinical standardization by adopting clinical pathways for medical oncology; one in three cancer programs have developed their own clinical pathways for medical oncology (32%) and radiation oncology (30%).
But cost savings are not easy in daily practice. The survey noted the rising demand for non-reimbursed services such as financial and nutritional counseling and patient navigation. Fully three out of four cancer programs surveyed have a dedicated financial advocate on staff. Asked to name their top funding sources for these non-reimbursed services, 63 percent of respondents ranked funding them from the operating budget first; 39 percent ranked charging for these services second; and 32 percent ranked paying for them from the organization's charitable foundation third.
Along with a changing health care environment and reimbursement issues, cancer centers face major staffing problems due to labor shortages, according to the ACCC survey. Nearly half, 47 percent, reported vacancies for medical oncologists. Currently, 81 percent of respondents said they use nurse practitioners; 41 percent use physician assistants; and 21 percent use clinical nurse specialists. (Only 12% of respondents said they do not use advanced practitioners.) But 60 percent of respondents reported they had full-time equivalent vacancies for oncology nurses, while 35 percent said they had open positions for advanced practitioners.
Survey respondents were asked about their strategies to address health care disparities and/or access to cancer care. Some 84 percent said they partner with community organizations in outreach efforts to underserved populations; 84 percent said they use translators or translation software to ensure that all patients can participate in decision-making, regardless of the language they speak; and 80 percent use nurse navigators to help guide underserved patients through the complex process of cancer diagnosis and treatment. In addition, 73 percent of respondents said they offer educational services to their patients to improve health literacy, while 61 percent partner with organizations that provide transportation to patients for medical appointments.
Community cancer centers invest in cancer prevention and early detection as well as treatment. According to the ACCC survey, the majority of cancer programs offer cancer screening, with 94 percent offering breast cancer screening; 83 percent lung cancer screening; and 63 percent colorectal cancer screening.
Peggy Eastman is a contributing writer.
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