My work with ASCO's Quality Oncology Practice Initiative for the past eight years had unexpected positive side effects. The friendships and professional relationships made with community oncologists, particularly those who represented the 23 founding practices that built and tested QOPI, have been personally rewarding in many ways.
The most surprising result of these relationships has been the progressive growth of my insight and understanding of a world I never worked in—the private practice of oncology. While there is no substitute for practice itself for gaining a full understanding of the rewards and challenges, working with these oncologists has taught me a lot. The more I learned the more interested I became in the issues facing community oncology practices.
Surprisingly, oncologists in academia face many of the same issues. In fact, all physicians, practices, and hospitals are trying to deal with a maelstrom of conditions with unpredictable effects, such as declining reimbursement, accountable care organizations (ACOs), the Affordable Care Act (ACA), the changing attitudes of newer physicians, and the still shaky financial environment here at home and abroad. These factors have already led providers to make voluntary professional changes that seem to be accelerating.
The most dramatic of these changes is the river of physicians giving up independent practice to become employed by hospitals, large non-profit organizations such as the Permanente Medical Groups, the Geisinger Clinic, and others. Also, experienced community oncologists are being recruited to manage academic medical clinics using their in-the-trenches experience.
The formation of ACOs, essentially collaborative provider groups that are reimbursed as a unit, is part of the ACA. This has led to a scramble by hospitals and health systems to employ physicians so that costs of the entire episode of care may be controlled with the expectation that profit margins would increase. The need to control medical costs is a major rationale for the ACA, of course.
Some hospitals and health systems have gone even further on this track. They are reorganizing their administrative structures to include doctors in leadership roles, a canny move since controlling costs will require physician trust and collaboration. As reported by John Iglehart in the April 2011 issue of Health Affairs, the huge for-profit health system HCA is reorganizing to form ACOs and to increase their employed physician roster substantially above the current 2,000.
Carilion Clinic Forming ACO with Aetna
Perhaps the most intriguing example offered by Iglehart is the announcement in March 2011 by Carilion Clinic, the largest health care provider in southwest Virginia, that it was joining forces with the insurer Aetna to form an ACO and offer cobranded commercial health plans for businesses and individuals.
In 2006 Carilion seemingly anticipated the shifts in health care by changing from a hospital organization to become a physician-led clinic “bent on offering more patient-centered, coordinated care at lower cost. As a consequence,” Iglehart noted, “Carilion, which already employed a number of primary care doctors, added approximately 200 specialists in fields such as cardiology and radiology, and now it has an employed-physician base of roughly 600.”
But other factors are also playing a role in these seismic changes.
Reimbursement declines since passage of the 2003 Medicare Modernization Act, which increased pharmaceutical benefits for seniors using funds previously paid to doctors for medications and their administration, have taken a heavy toll of smaller primary care and specialty practices. This led to many oncologists in particular joining larger practices and other multispecialty oncology groups, both for-profit—e.g., US Oncology—and non-profit—e.g., the Permanente Medical Groups.
Many physicians are tired of trying to maintain an independent business with the reimbursement woes, increasing regulation, and liability costs, and the inability to afford the purchase and maintenance of an electronic health record system. So they are “seeking shelter from the storms of private practice in the arms of larger and better financed hospitals.”
Iglehart also reports that in the past year about half of all cardiologists in private practice have become employed, mostly by hospitals. Jack Lewin, CEO of the American College of Cardiology, says the trend is driven almost entirely by “Medicare's drastic cuts in payments for services in outpatient offices, [the] same services for which Medicare pays two to three times as much in hospital outpatient settings.”
Tradeoff for Increased Family Time
Another factor propelling this seismic shift is that younger physicians and many women physicians are willing to forego greater income in exchange for the increased family time possible as an employed physician. Many also see owning and running a practice as stressful and unattractive, especially in the current climate of financial and professional uncertainty.
A survey by the Medical Group Management Association shows that in 2002, physicians owned 70% of practices and hospitals owned 25%. In 2009 physicians owned 40% of practices and hospitals owned 55%. That trend has not leveled off as yet.
‘The $64 Question’…
The $64 question (that amount shows how old I am): Is this trend good for oncology patients and/or oncologists? Well, possibly. There are substantial hurdles to making these changes lead to higher-quality care at lower cost.
- First, doctors and hospitals have a long history of tense and unproductive relationships when that outcome depends on strong collaboration and mutual sacrifice. Older physicians who have developed a certain way of practicing and a lifestyle built on the old model may ultimately find such arrangements constraining. Such complex, long-term relationships require strong leadership by physicians and hospital administrators that can be threatened by the turnover of key leaders.
- However, we know that it is possible for this integrated model to succeed from many long-standing examples such as the Mayo Clinic and Kaiser Permanente. Also, some hospitals have changed their management structures to include physicians at the highest levels of administration, including seats on the board of directors.
- Second, arguments over money can sow distrust and anger, leading to festering wound in the relationships. Earning trust would require a high degree of transparency and joint planning and agreement on the terms of such rewards. Hospitals would be able to reward physician employees for productivity while they could not do so for volunteer physicians because of Stark regulations. Also, under the reform bill and ACOs, Medicare is breaking with past restrictions by encouraging physician alliances, banding doctors together to cut costs and share in savings with insurers.
- Finally, if implemented, will ACOs do what is intended—i.e., improve the quality of care and lower costs? My most optimistic answer is probably. Certainly, it will not work uniformly well and will fail at some sites.
- The tests so far have shown that it takes years to demonstrate savings, if they occur at all. Ironically, I think it may be easier to lower or stabilize costs than to demonstrate a substantial improvement in quality.
- The latter can happen, of course, but measuring quality is an evolving science and, except for a few areas of narrowly focused processes—e.g., reducing catheter-caused infections—acceptable, apples-to-apples outcome standards for complex diseases like cancer are not in place. Fortunately, work in this area is proceeding apace.
- So I believe it is more likely than not that patients will be better off in the long run and costs will be stabilized (that is as certain as I can be at this stage).
- Will oncologists be better off? With at least some success, in the long haul I believe the answer is Yes for a couple of reasons. If the patients are better off, we as physicians are “better off” because we have been successful in our core mission. Second, all agree that the current system is not sustainable and, if not addressed quickly, draconian cuts in services that hurt patients will be forced on us. So participating in an attempt to head that off and helping to shape it to protect patients has become a part of our mission. Who better to do that than those of us serving patients?
More Eloquence from Gawande
In his wonderful commencement address at Harvard Medical School (New Yorker, 26 May 2011) Atul Gawande eloquently made this case. He likened the cowboy, the iconic loner, to the fiercely independent physician we have known up to now. He then compared cowboys, a collection of loners, to pit crews at the auto racetrack, who are the epitome of intense collaboration, efficiency, and teamwork.
He said, in effect, that we are in a new era of medical complexity, sub-specialization, and growing problems of patient access and cost. He believes we must be more like pit crews in today's world to achieve the greatest good for the most people. He ends by saying he recently spoke to a real cowboy who described the nature of his work in 2011; it has evolved to become much like the pit crews, with careful planning and electronic communication to move and handle cattle. I would like to think that if cowboys can do it with cattle and pit crews can do it with cars, we could do it for our patients.