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A Survey of Oncology Trends
CANCER CARE SHIFTS TO COSTLIER HOSPITAL OUTPATIENT SETTINGS
More breast cancer patients are now being treated in hospital outpatient settings and at a higher cost rather than in physicians’ offices, according to the Oncology: Nationwide and Region Cancer Care Report, 2011–2012 Edition.1 Prostate cancer patients and colorectal cancer patients were slightly more likely to be seen in physicians’ offices.
Average charges for treatment in the hospital outpatient setting were significantly higher than average for treatment in a physician’s office for breast cancer (
The 40-page report (2011–2012 Edition) explores current practices in oncology from various perspectives using patient claims data on breast, colorectal, and prostate cancer treatments; findings from a survey of 165 oncology practices; and survey results from 123 managed care plans.
Data were analyzed nationally and by geographic region. Five reports were published, each containing national and region-specific data. The five regions were Northeast, Central, Southeast, Southwest, and West. In the Oncology: Nationwide and Region Cancer Care Report, 2010 Edition, breast cancer patients were treated primarily in physicians’ offices, except in the Northeast, where hospital outpatient treatment was dominant. As the site of care varied, so did charges for similar treatments. Following are additional 2011–2012 Edition highlights from the national data.
MOST CANCER PATIENTS HAVE EARLY-STAGE DISEASE UPON DIAGNOSIS
Most patients with breast, prostate, or colorectal cancer who are treated with chemotherapy or biologic agents have a diagnosis of early-stage disease, according to an analysis of patient claims data from 2009, provided by SDI Health LLC.
About twice as many women with a breast cancer diagnosis were seen in hospital outpatient settings (1.3 million women) than in physicians’ offices (550,000 women).
Nationwide, 90% of breast cancer patients receiving hospital outpatient treatment were discovered to have the disease at an early stage, whereas 10% were found to have metastatic disease at diagnosis. For breast cancer patients seen in physicians’ offices, the ratio of early-to-metastatic disease was 74% to 26%. Increasing coverage limitations and reimbursement issues cited in oncology practices and managed care surveys may provide insight into site-of-care considerations.
Slightly more men with prostate cancer were seen in physicians’ offices (860,000) than in hospital outpatient settings (840,000). Nationwide, 96% of prostate cancer patients seen in outpatient settings and 63% of those seen in physicians’ offices had a diagnosis of early-stage disease.
Similar numbers of patients with colorectal cancer were seen in physicians’ offices (360,000) and in hospital outpatient settings (340,000). Nationwide, 87% of colorectal cancer patients seen in hospital outpatient settings had early-stage disease. Of colorectal cancer patients seen in physicians’ offices, 59% had early-stage disease.
MORE MEDICAID PATIENTS HAVE METASTATIC DISEASE UPON DIAGNOSIS
The type of insurance coverage varied by disease state, and the proportion of patients with early-stage disease varied with insurance coverage. Most breast cancer patients had commercial insurance (53% of physicians’ office patients; 50% of hospital outpatients), followed by Medicare. For patients with either prostate cancer (66% and 50%, respectively) or colorectal cancer (50% and 35%, respectively), the largest proportion had Medicare coverage, followed by commercial insurance.
Although far fewer breast cancer patients were covered under Medicaid (physician’s office, 4%; hospital outpatient setting, 6%), Medicaid patients had the highest proportion of metastatic cancer diagnoses. Among Medicaid recipients, the proportion of breast cancer patients with a metastatic cancer diagnosis was 38%, compared with 25% of commercially insured patients seen in physicians’ offices (
Higher rates of metastatic disease were also seen in both prostate cancer patients (63%) and colorectal cancer patients (55%) with Medicaid coverage who were treated in physicians’ offices. These findings suggest that Medicaid patients might not be seeking health care on a timely basis or might not have easy access to care.
“Medicaid patients are more likely to have difficulty accessing care because of low provider reimbursement rates, and/or patients may seek care on more of a reactive basis,” says Dawn Holcombe, MBA, President of DGH Consulting.
ONCOLOGISTS FEEL SQUEEZED BY PLANS’ REIMBURSEMENT RATES AND POLICIES
In the survey of oncology practices, oncologists’ responses revealed tensions in managing the business aspects of cancer care delivery. (For many questions, totals exceeded 100% because respondents were asked to check all responses that applied.)
Topping the list of oncologists’ concerns affecting practice–payer relations were payment rates for professional services (67%), followed by payment rates for drugs (65%).
When health plan representatives were asked to identify their top concerns, they also cited payment rates for professional services (72%), followed by payment rates for drugs and off-label use of drugs (tied at 68%).
Oncology practices reported a lack of success in negotiating effective contracts with payers. Only 32% considered the majority of their contracts to be profitable. For 42% of respondents, the response was “don’t know.” The most commonly reported drug-reimbursement rate (43%) was the average sales price plus 6%—the rate used by the largest payer in the U.S., Medicare.
Nearly half of practices (49%) reported that they saw more patients than a year ago, and 52% reported decreasing net profit. When the use of a specific drug resulted in a revenue loss to the practice, oncologists most often referred patients to the hospital (54%) (
Most cancer care was provided through physicians’ practices. Two-thirds of practices nationwide were staffed by five or fewer oncologists, although practice size varied by region. The Northeast region had the highest proportion of solo practitioners (26%).
Only 44% of practices nationwide reported using an electronic medical record (EMR) system (
Several areas of potential collaboration between oncology practices and health plans were identified by both groups, including survivorship management programs, advisory panels, and participation in the American Society of Clinical Oncology’s Quality Oncology Practice Initiative.
When asked about their interest in collaborating with others to participate in payer programs in the next 12 to 18 months, 45% of oncology practices responded that they were most interested in working with area hospitals and least interested in working with for-profit vendors; 55% of practices were not interested in working with for-profit vendors.
To obtain a copy of the current oncology report (2011–2012 Edition), please send an e-mail request to
Average charges for breast cancer regimens by setting and payer, nationwide. Orange = top five regimens; purple bars = all regimens. (Data from
Patients with breast cancer seen in physicians’ offices, by disease stage and payer (nationwide). (Data from
When use of a drug results in a loss of revenue (nationwide). (Data from
Use of electronic medical records (nationwide). (Data from