Cancer Care in America: A Shifting Landscape

ALEXANDRIA, Va.–The U.S. cancer care system faces tremendous turbulence while dealing with growing numbers of cancer patients and survivors, mounting pressures to control rising healthcare costs, and widespread oncology practice transformation, reports a new study by the American Society of Clinical Oncology (ASCO). The State of Cancer Care in America: 2015, today published in the Journal of Oncology Practice and presented at a Congressional briefing, chronicles the current realities of the cancer care system and examines trends in the oncology workforce and practice environment that are affecting patient care and access.   “This year’s report clarifies multiple stresses in our nation’s cancer care system, but there is reason to be hopeful,” said ASCO President Peter P. Yu, MD, FACP, FASCO. “With this knowledge and insight, we can identify ways to ensure that all patients with cancer receive high-quality care-and help oncology practices adapt, survive and succeed in today’s demanding healthcare environment.”   Building on findings released last year in ASCO’s inaugural report, The State of Cancer Care in America: 2015 paints a picture of significant progress in the fight against cancer coupled with profound changes occurring in the cancer care practice landscape that threaten patient access to these advances.   Report Highlights Key Progress Against Cancer   According to the ASCO report, there is a wider array of treatment options now available for many cancers. In 2014, the FDA added 10 new treatments to its list of more than 170 approved anti-cancer agents, and also approved four new medical devices and tests that may improve patient outcomes through early detection of cancer. In addition, more than 770 cancer therapies are in the research and development pipeline and therapies are demonstrating dramatic improvements in efficacy-signaling unprecedented opportunities for beneficial and clinically meaningful cancer outcomes.   As a result of these and other advances, cancer patients are living longer than ever before. Today, more than two-thirds (68.5 percent) of patients with cancer live beyond five years after their diagnosis, compared to 49 percent in 1975. This positive trend is contributing to an increasing number of cancer survivors: In 2014, more than 1.6 million cancers were diagnosed, bringing the total number of Americans alive today who have received a cancer diagnosis in their lifetime to 14.5 million. These cancer survivors will need follow-up care for late complications or side effects of treatment, and future cancer screening.   But Also Points to Growing Challenges to High-Quality Care Delivery   Growing cancer care demand. Due largely to an aging population, a dramatic 45 percent increase in cancer incidence is expected by 2030, leading to an overwhelming demand for cancer care and post-treatment services in the relatively near future. At the same time, obesity is also on the rise in this country and is expected to contribute to an additional 500,000 cancer cases over the same time period.   Disparities in access to cancer care persist. The benefits of cancer screening and treatment advances have not been experienced consistently across racial and ethnic groups, as evidenced by differences in incidence and mortality rates. African Americans, for example, are 2.5 percent more likely to develop cancer than whites and 19.6 percent more likely to die from cancer.   Oncology workforce size remains constant, but may soon be outpaced by growing demand. The nation’s ability to care for an increasing number of people with cancer depends on a workforce that is sufficient in size, diversity, and geographic reach. ASCO reports that, with approximately 11,700 oncologists currently providing direct patient care (up slightly from last year), the following worrisome trends may adversely impact patients’ ability to obtain specialty cancer care:   An aging oncology workforce. A steadily growing proportion of medical oncologists (nearly 20 percent) are 64 years of age or older, far outpacing the number of oncologists entering the field. With oncology medical training taking at least 10 years from medical school entry, this trend suggests a training pipeline unable to replace physicians who are retiring. Gaps in racial and ethnic workforce diversity. Approximately 13 percent of the U.S. population is African American, while only 2.3 percent of practicing oncologists and 4 percent of oncology fellows are African American. Similarly, Hispanics represent 17 percent of the U.S. population, but only 3 percent of practicing oncologists and 5.8 percent of oncology fellows are Hispanic. Poor coverage in rural America. For the more than 59 million Americans living in rural areas of the country, accessing high-quality cancer care requires overcoming significant hurdles and dramatically affects treatment options. ASCO reports that, overall, 10 percent of physicians practice in rural areas, but only 4.8 percent of new physicians are choosing to practice in non-urban areas. In oncology, where treatment is highly specialized and often requires numerous treatment sessions and frequent follow-up clinic visits, only 633 medical oncologists and hematologists (5.5 percent) practice in rural sites, and nearly three quarters of rural oncology practices (73.3 percent) have only one location. Professional burnout on the rise. The report includes data showing that fully one-third of oncology fellows experience professional burnout and do not anticipate working as many hours as senior colleagues. ASCO cautions that failure to address physician burnout and other quality of life issues could lead to serious workforce consequences, with oncologists reducing their patient volume or retiring at an earlier age. Oncology practice adaptation in full-swing, prompted in part by growing concerns over cost of cancer care and financial sustainability. Oncology practices continue to experience extreme volatility, with changes occurring in virtually every facet of the cancer care delivery system. Economic constraints, competition, growing administrative burden, and proliferation of cost-containment programs are documented among the many pressures that contribute to practice uncertainty about their continued existence.   Financial instability and changing payment models. In 2014, cost and payer pressures persisted as the most pressing oncology practice concern, especially among physician-owned and hospital-based practices. Escalating drug prices was also a major concern. Nearly three quarters (72 percent) of practices report continuing to work in a fee-for-service payment system; other payment models (including capitation and bundled payment) are being used to a lesser degree-but are on the rise. About 36 percent of oncology practices report either implementing, or considering implementing, a pathways program and 30 percent were considering medical home programs that emphasize care coordination. At the same time, Medicare recently announced plans to dramatically change 85 percent of its fee-for-service payment system to a value- or quality-based model by 2016 and 90 percent by 2018. Practice consolidation continues. One quarter of all community-based oncology practices report the likelihood of becoming affiliated with a hospital over the next year. Preauthorization a major concern. Oncology practices report the administrative burden imposed by insurance companies and time spent dealing with patient insurance issues are reducing the time available for patient care. “Patients need us to find better ways to pay for and incentivize high-quality, value-based care,” said Dr. Yu. “ASCO is currently developing and testing an alternative payment approach that reflects the current realities of oncology practices and ensures that patients receive the full range of services that are integral to their care.”   Moving Forward: ASCO Recommendations   The State of Cancer Care in America: 2015 sets forth a series of recommendations to quell the disruption occurring in the national cancer care system and ensure that all patients with cancer have access to high-quality care. ASCO calls on each stakeholder in the cancer care delivery system to implement changes, including the following recommendations directed to Congress:   Immediately repeal the Sustainable Growth Rate (SGR) formula and replace it with a sustainable structure that incentivizes the delivery of high quality cancer care. The perennial threat of the SGR serves to further destabilize the cancer care system by infusing financial uncertainty into an ever-changing reimbursement landscape and impeding practices’ ability to plan for the future.  As the 21st Century Cures initiative moves forward in the House-and the “Innovation for Healthier Americans” legislation in the Senate-ensureinteroperability of medical records and provide the resources to enable practices to track and report quality measures, while serving patients in an environment of widespread change in care delivery and payment systems. Prevent further erosion of the national research infrastructure and support continued breakthroughs in cancer therapies by increasing the budgets of the National Institutes of Health and the National Cancer Institute by at least $32 billion and $5.32 billion, respectively. For more information on ASCO recommendations and additional findings reported in The State of Cancer Care in America: 2015.