Three Research Projects Release Preliminary Data on Oncology Workforce Environment

Introduction
Anticipating a sea change in oncology practice over the next decade and beyond, the American Society of Clinical Oncology (ASCO) initiated a far-reaching research initiative in 2012 to collect and analyze oncology-related demographic and practice data to help guide the society’s response to the business and political landscape in which oncologists care for people with cancer.

The preliminary results of this research, published in the Journal of Oncology Practice on January 18, 2013, provide a foundational understanding of the current dynamics in today’s oncology practice, while underscoring a critical need to dig deeper into the impact that economic, social, and political pressures will have on the future practice of oncology.

“The oncology community has a responsibility to prepare for the future, which starts with gaining clarity about the present,” said ASCO President Sandra M. Swain, MD, FACP. “Recognizing the dearth of information about current oncology practice, ASCO has made a major commitment to expanding our understanding of the multiple factors that will impact the future care of patients with cancer.”

In 2011-2012, ASCO sponsored three major research projects that comprise this initiative:

• ASCO Workforce Information System
  
  

• ASCO National Census of Oncology Practices, and
  
  

• ASCO Study of Geographic Access to Oncology Care.

The preliminary findings of these studies are summarized below.

THE BIG PICTURE:   ASCO Workforce Information System

The ASCO Workforce Information System (WIS) provides a mechanism for ongoing data collection and reporting on the current status of the oncologist workforce—specifically, for assembling the latest available data on oncologist supply and cancer incidence and prevalence.

“Through careful study and analyses,” said ASCO President Swain, “ASCO can more accurately understand the current workforce make-up, put these in the context of historical data, anticipate workforce and clinical practice trends, and prepare current and future oncologists for an environment in which cancer care can be enhanced compared to traditional cancer delivery models.”

ASCO plans to publish WIS findings annually, reporting on new data and tracking trends over time. Unless otherwise noted, the following findings are for the year 2011 and apply to oncology practice in the United States.

Key Findings

An anticipated increase in cancer cases, the aging workforce, and constraints in the training pipeline could significantly impact the future capacity of the oncology workforce. With the elderly population predicted to rise significantly, the demand for oncology services is anticipated to substantially outpace capacity by 2020.

Cancer Incidence and Prevalence. In 2012, there were an estimated 1.6 million new cancer cases in the United States, an increase of 2.6 percent from the previous year. As of 2009, a total of 12.5 million people were living with a history of cancer (either as patients or survivors), an increase of 5 percent from the previous year, with 67.4 percent of patients surviving cancer 5 years after diagnosis in 2005.

Oncologist Supply and Demographics. Since 2004, the number of oncologists has been steadily increasing, approximately 3 percent each year. Compared to the overall physician workforce, the oncologist workforce is growing at an increased pace (2.8 percent from 2010 to 2011, compared to an overall physician increase of 1 percent).

Other key findings:

• There are a total of 13,084 practicing oncologists (specifically, those who designate hematology, hematology/oncology, or medical oncology as their primary specialty).

• Of the 13,084 practicing oncologists, 10,644 (81.4 percent) specified “direct patient care” as their primary professional activity.

• Of these direct patient care oncologists, the majority (58.3 percent) designate “group practice” as their employment setting.

• Females represent 28.4 percent (3,716) of the oncologist workforce, compared to 31.2 percent in the overall physician workforce. This proportion is rising consistently each year for all physicians and in each of the three main oncology subspecialties.

• The median age for oncologists rose from 51 in 2010 to 52 in 2011 (higher than the overall physician workforce).

• The number of oncologists ages 64 and older has been growing more rapidly than the overall number of oncologists—a factor that will impact retirement rates, part-time work arrangements, and productivity.

• In 2008, the number of oncologists 64 years of age and older surpassed the number of oncologists under age 40.

Oncologist Training. From 2004 to 2010, the number of residency slots (that feed into hematology, hematology/oncology, and medical oncology fellowship programs) remained relatively flat, increasing by only 0.6 percent between 2009 and 2010. The percentage of first-year internal medicine fellows in the oncology subspecialties combined has remained relatively stable since 2005, at approximately 14.5 percent of all subspecialty fellows in internal medicine.

Other key findings:
The proportion of International Medical Graduates (IMGs)—many of whom are on visas to study in the United States and may not permanently enter the U.S. oncology workforce—is increasing in oncology and is consistently higher than in the overall physician population.

• In 2011, the oncologist workforce was comprised of 32.8 percent IMGs, while the overall physician workforce was 24 percent IMGs.

• IMGs are also more prevalent in training programs than in the current workforce.

• Of oncology fellows in 2010, 44.7 percent were female, a percentage much higher than in the current supply.

• Under-represented minorities are even more under-represented in oncology than in fellowship and residency programs in general.

• The proportions of oncologist fellows who self-identify as Black or African American (3.1 percent in 2010) or Hispanic or Latino (7.5 percent) are consistently lower than in the parent internal medicine programs and in many of the other internal medicine subspecialty fellowships (e.g., the proportion for the infectious diseases subspecialty is 6.9 percent Black or African American and 12.1 percent Hispanic or Latino).

THE PRACTICE PICTURE:  ASCO National Census of Oncology Practices

In 2012, ASCO launched a landmark nationwide initiative to collect key data from U.S. oncology practices to address a lack of current and reliable information on how oncology practices are adapting to increasing administrative, financial, and political pressures, and to gather information about the existing and trending ownership structure of oncology practices.

“It’s important to understand how practices are responding to environmental stressors as they continue to provide cancer care to their patients,” said ASCO President Swain. “Absent this information, policy and practice solutions will inadequately respond to the needs of the community or may inadvertently address the wrong issues.

In addition to using census practice data and trend analysis to guide future policy efforts, ASCO will integrate findings into the development of practice benchmarks to help individual practices make informed business and practice decisions. ASCO will collect, analyze, and report on the census each year, with plans to significantly expand U.S. practice participation in 2013.

In the first phase of the census project, more than 600 U.S. oncology practices participated across the full range of settings. The preliminary findings are summarized below.

Key Findings

Amid a backdrop of high costs, drug shortages, competitive forces, payer restrictions, and other pressures, the ASCO Census strives to better understand how oncology practices are faring in the current economic, legislative, and regulatory environment. The census, specifically, looks at current oncology care specialties and services, practice settings, staffing and mergers, technology use, payer mix, and patient volume. Preliminary census findings reflect a mixed picture of how practices are adapting to the myriad stressors facing the oncology community.

Medical specialties. Seventy-one (71) percent of respondents reported a hematology/oncology specialty; 23.4 percent a medical oncology specialty, and 20.0 percent, radiation oncology.

Oncology services. Respondents indicated the range of oncology services provided by their practices: 43.8 percent reported providing chemotherapy services, 28.2 percent provide social work services, 26.7 percent are involved in clinical trials, 25.8 percent provide lab services, and 22.9 percent offer nutritional counseling.

Practice structure. Fifty-five (55) percent of respondents are working in private community practices, 12.4 percent in non-academic institutions, 11.3 percent in academic practices, and 9.8 percent are working in private integrated practices that are part of large health systems.

Practice affiliations. Fifty-seven (57) percent of practices report an affiliation with a community hospital, 28 percent with an academic medical center, and 28 percent with another type of medical center.

Practice staffing. Smaller practices reported a greater likelihood of laying off oncology physicians and oncology-certified nurses in the next 12 months, while larger practices reported a greater likelihood of hiring more of these providers. Practices in the North Central and West regions reported a greater likelihood of hiring oncologists in the next 12 months.

Mergers and Closings. Practices in metropolitan locations were more likely than those in non-metropolitan areas to have experienced mergers with other practices. Larger practices reported greater likelihood of purchasing other practices in the next 12 months, with smaller practices reporting greater likelihood of closing their practices in the next 12 months.

EHR/EMR Systems. Seventy-six (76) percent of U.S. practices reported using an electronic health/media records (EHR/EMR) system. More than 60 percent of these practices are using an advanced EHR/EMR system,[1] with about 16 percent using a basic EHR/EMR system, 15 percent planning to implement an EHR/EMR system within the next six months, and 8 percent reporting no EHR/EMR and no plans to implement such a system.

Insurance Coverage. Respondents were asked about their patients’ insurance: 47.4 percent of patients have Medicare coverage, 38.6 percent have private, commercial insurance, 9.2 percent of patients have Medicaid, and 4.8 percent have no health care insurance.

New patients served. Practices reported treating an average of 1,268 new patients each year.

Practice pressures. Census participants were asked to identify the greatest pressure affecting their practices; the top concerns (in rank order) include (1) payer pressures, (2) cost pressures, (3) competitive pressures, and (4) drug shortages.

Clinical trials participation. Seventy (70) percent of practices reported increasing participation in clinical trials, 21 percent reduced participation, and 9 percent eliminated participation in clinical trials.

ASCO plans to reopen the National Census of Oncology Practices in spring 2013, and encourages all practices to participate to ensure the data is representative of the oncology community. (Subscribe to http://ascoaction.asco.org/  for more information.)

THE TREATMENT PICTURE:  ASCO Study of Geographic Access to Oncology Care

Recognizing that understanding patient behaviors in seeking out treatment—and fully assessing potential barriers to healthcare access—is critical to ensuring that the oncology workforce is doing all it can to provide high-quality, high-value cancer care, ASCO also sponsored research to better understand why some individuals with cancer do not receive a first line of treatment.

ASCO contracted with the University of Iowa, with funding from the Susan G. Komen for the Cure, to analyze data from the Iowa Cancer Registry, providing a means to review all newly diagnosed cancer cases within a well-defined geographic area—the entire state of Iowa—and determine if geographic physician distribution and patient access to treatment sites contribute to disparities in cancer care. Iowa was chosen because of the combination of its robust physician database and cancer registry. As part of the project, the University of Iowa is helping ASCO understand how to analyze similar treatment trends and geographic distribution of oncologists on a national scale.

“Surprisingly little is known about why certain individuals with cancer do not enter treatment,” said ASCO President Swain. “This research offers an initial glimpse into how geographic distribution and availability of different types of providers correlate with whether patients pursue chemotherapy services. The data give us reason to explore further the trends that we are seeing–particularly in diseases for which treatment options are available.”

Key Findings

Based on a total of 113,885 invasive cancer diagnoses in 106,603 individual Iowa residents diagnosed between 2004 and 2010, the ASCO study shows that non-treatment appears to be related to patient characteristics and have at least some correlation to facilities available to people in their local areas influencing both patient and provider choice regarding available treatment options.

• Non-treatment was more common in certain cancers, advanced stages, older patients, those receiving initial treatment at non-accredited cancer programs, and patients who never consulted an oncologist, radiation therapist, or surgeon.

• The vast majority (83.3 percent) of invasive cancer cases in Iowa received treatment consisting of surgery, radiation, chemotherapy, hormone therapy, immunotherapy, stem cell transplant, endocrine therapy, or some combination of these treatments.

• A much smaller proportion of cases (12.3 percent) did not receive a first course of treatment.

•  The non-treatment rate in Iowa is 48 percent higher than the rate reported in the National Cancer Data Base (NCBS)[2] from cancer treatment centers accredited by the Commission on Cancer, suggesting that non-treatment is less common in patients seen in COC-accredited cancer programs and that non-treatment for cancer is more common than the NCDB data indicate.

•  Non-treatment was significantly more likely in cases with advanced age and cancer stage along with certain cancer sites (i.e., small cell and non-small cell lung/bronchus, and low grade non-Hodgkin lymphoma).

• Around 20 percent of lung/bronchus cancer and low-grade non-Hodgkin lymphoma cases and over 15 percent of prostate cancer and high-grade non-Hodgkin lymphoma cases received no treatment for their disease.

Reasons cases did not receive a first course of treatment:

• 9 percent—treatment was recommended, but refused.

• 1.4 percent—treatment was recommended, but the patient died prior to treatment.

• 89.6 percent—no treatment was planned, it was contraindicated, or no reason was provided for not treating.

• Surgery was the treatment modality most commonly contraindicated or not completed (for unknown reasons).

• Surgery and chemotherapy were the recommended treatment modalities most commonly refused.

• Distance to treatment facilities appears not to be a factor in non-treatment; however, the type of physician and facility where a patient received initial treatment is related to non-treatment rates.

ASCO plans to expand its research efforts on the state of cancer care, and summarize these efforts in an annual report summarizing these efforts beginning in 2013.

The original articles (cited below) detailing the three ASCO workforce studies were published in the January 18, 2013, issue of the Journal of Oncology Practice. For more information, click here.

Citations:

1. Kirkwood, M. Kelsey, et al. (2013). Tracking the Workforce: The ASCO Workforce Information System. Journal of Oncology Practice, 9, (1).

2. Forte, Gaetano J., et al. (2013). ASCO National Census of Oncology Practice—Preliminary Report. Journal of Oncology Practice, 9, (1).

3. Ward, Marcia M., et al. (2013). Who Does Not Receive Treatment for Cancer? Journal of Oncology Practice, 9, (1).