At the recent Community Oncology Alliance Conference, one session explored the question “Why does the site of cancer care matter?” Community oncology clinics are closing or being acquired by hospitals at a swift pace and they are looking hard at the reasons why that’s the case, what makes sense financially and how it impacts the patient. It was argued that the site of care matters a lot and should be kept in the community setting – for the healthcare system in general and also for patients on an individual level. The panel included a patient advocate, a hospital-based physician and a community-based physician and all seemed to agree on these three important reasons:
- The difference in cost of care and reimbursement. Most of this hour long session focused on cost. Citing a report developed by Milliman, it was noted that changing the site of care from low-cost physician offices to higher-cost hospital outpatient settings is one of the key cost drivers in cancer care. Reimbursement is much higher when the care is delivered in a hospital outpatient setting, rather than a physician’s office. A panelist relayed one of his patient’s experiences getting his yearly bone marrow biopsy. It was several hundred dollars in the clinic setting and the next year, in a hospital setting, the same biopsy was $7,000. There was also a lot of discussion about the loosely regulated 340B Program which has expanded in recent years. It allows hospitals to be designated “safety nets” and receive deep discounts on drugs, seemingly regardless of whether or not they are helping needy patients. These factors significantly increase costs to patients and payers and make it difficult for community clinics to stay open, especially when you add on sequestration and the new pressures of value-based care.
- The well being of the patient – access to care and affordability. The patient advocate shared her story and much of it was echoed by the other panelists. When she was told that her doctor was becoming part of a hospital system and her appointments would be at a facility 30 miles away she panicked. She was worried about the practical matter of how she would get to her appointments and how much extra time she would be spending in transit. She also worried about losing the close relationship with her clinic staff and how much more it was going to cost in a hospital outpatient setting where copays and out of pocket expenses are much higher. And what about cancers that are physically very painful or patients who are experiencing lots of complications – is asking them to travel long distances to receive care ok?
- The greater good of society. One panelist read from the Physician Charter which he holds very dear. The third of its Fundamental Principles is the Principle of social justice. It states “The medical profession must promote justice in the health care system, including the fair distribution of health care resources. Physicians should work actively to eliminate discrimination in health care, whether based on race, gender, socioeconomic status, ethnicity, religion, or any other social category.” Patients should be cared for in the place where they will receive the best care at a fair price. They deserve the ability to get care in their community at a price they can afford.
Until our healthcare system addresses the causes of consolidation that community oncologists face – declining payments, administrative burdens and, regulatory requirements and other pressures, fewer referrals, higher payments for hospitals and 340B drug discounts – clinics are at risk and patients will lose this important access to affordable care that is close to home.