I have been in a small or solo suburban medical oncology practice since 2001. My practice is breast cancer dedicated. I have terrific staff and phenomenal patients. I love it.
But right now, I am seriously considering closing my practice.
Why? Over the past several years, the increasing cost of chemotherapy drugs has risen and the reimbursement for chemotherapy has fallen to the point where my practice is at the tipping point.
In addition to the high drug costs, giving chemotherapy is complex and expensive. In my practice, it requires two highly trained nurses, a nurse practitioner, and a really top-notch biller.
Because chemotherapy drug prices are tied directly to how much chemotherapy is purchased, small practices like mine—whether urban, suburban, or rural—pay more for the same chemotherapy drugs than larger practices do. But we still have the same safety and staffing requirements.
In 2013, I purchased $3.4 million in chemotherapy, about average for oncologists, but in my case that high cost is due to a handful of very expensive drugs for breast cancer.
I have worked hard to increase my practice efficiency, including a complete transition to an electronic health record, but quality oncology care is time intensive, so it isn't possible to dramatically increase the number of new patients that I see. I won't compromise on quality.
For the past two years, my practice has lost a significant amount of revenue. Oncologists like me purchase chemotherapy on credit and then scramble to get reimbursed. I have assumed a significant amount of debt (too much to note publicly) and had a significant reduction in my own income, down to the same amount I took home 10 years ago.
Since it went into effect in April 2013, the sequester has resulted in a loss of $12,000 in Medicare revenue for my practice—that amounts to one payroll or one month's rent.
I experienced a significant staff shortage last year because of overlapping staff maternity leaves, and ended up sending my patients to my local hospital for three months. They received good care but were very distressed to receive much higher bills for their out-of-pocket expenses than for the exact same chemotherapy administered in my office.
What are my options? Purchase, merge, sell, or close?
I negotiated with an academic medical center for a year and a half for purchase, merger, or sale of my practice. Last month, they withdrew from the negotiations, explaining that the economic climate for outpatient oncology is too precarious in Maryland.
I am considering attempting merger with other oncology groups, locally and regionally. It is a daunting task. I am also seriously considering closing my practice. Both of those decisions would have a very significant impact on my staff and patients. I really want to preserve the small, nurturing, and high-quality practice environment that I have cultivated.
I sincerely hope that the changes outlined in ASCO's State of Cancer Care in America report will be enacted. Small practices like mine would benefit directly from:
- lifting the sequester;
- introduction of new payment models that don't rely on buying and billing for expensive chemotherapy drugs, and
- an eventual transition to payment for quality and not quantity or location of care, be it urban, suburban or rural.
These changes would go a long way towards alleviating the workforce issues I have described—that is, early retirement, burnout, increasing scarcity of oncologists in rural areas, and the steep decline in the number of small practices.
Hopefully, these changes will occur rapidly enough that I won't have to close my practice doors in the near future.
Adapted from remarks delivered at a Capitol Hill briefing in March where the American Society of Clinical Oncology released its comprehensive report on the state of cancer care in the U.S., “Delivering High-Quality Cancer Care: Charting a New Course for a System in Crisis” (OT 4/10/14 issue)