The end of community oncology practice

[lilPhysician]

Oncology is about caring for some of the most vulnerable patients in our society but new medicare proposals are just irresponsible

Currently, many oncology practices are forced to close their doors because of ASP (Average Sales price) + 6%, a rule passed in 2003 that medicare will only pay a 6% margin on oncology drugs. Many smaller practices are actually spending more on buying the drugs than what they get in return, forcing them to close their doors.

Now, medicare wants to bankrupt cancer care. Cuts proposed are ASP + 0.5-2.5%

Taken from Article on Medscape:

Referring to part of the proposal that would modify drug reimbursement on the basis of zip codes in certain regions of the United States, Allen S. Lichter, MD, chief executive officer of the American Society of Clinical Oncology (ASCO), said that it is "inappropriate for CMS to manipulate choice of treatment for cancer patients using heavy-handed reimbursement techniques."

In a statement, he added that physicians "did not create the problem of drug pricing, and its solution should not be on their backs."

Soon after the CMS issued the proposal, Ted Okon, executive director of the Community Oncology Alliance (COA), tweeted that the pilot project "is the most contrived, absurd experiment on cancer care I have seen.

"We're talking about a cancer 'moonshot' and a fight against cancer," he told Medscape Medical News. "So I thought this country was at war with cancer, not cancer care."

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[lilPhysician]

Oncology is about caring for some of the most vulnerable patients in our society but new medicare proposals are just irresponsible

Currently, many oncology practices are forced to close their doors because of ASP (Average Sales price) + 6%, a rule passed in 2003 that medicare will only pay a 6% margin on oncology drugs. Many smaller practices are actually spending more on buying the drugs than what they get in return, forcing them to close their doors.

Now, medicare wants to bankrupt cancer care. Cuts proposed are ASP + 0.5-2.5%

Taken from Article on Medscape:

Referring to part of the proposal that would modify drug reimbursement on the basis of zip codes in certain regions of the United States, Allen S. Lichter, MD, chief executive officer of the American Society of Clinical Oncology (ASCO), said that it is "inappropriate for CMS to manipulate choice of treatment for cancer patients using heavy-handed reimbursement techniques."

In a statement, he added that physicians "did not create the problem of drug pricing, and its solution should not be on their backs."

Soon after the CMS issued the proposal, Ted Okon, executive director of the Community Oncology Alliance (COA), tweeted that the pilot project "is the most contrived, absurd experiment on cancer care I have seen.

"We're talking about a cancer 'moonshot' and a fight against cancer," he told Medscape Medical News. "So I thought this country was at war with cancer, not cancer care."

By the Way, these proposals are from March 2016

 

[lilPhysician]

Oncology is about caring for some of the most vulnerable patients in our society but new medicare proposals are just irresponsible

Currently, many oncology practices are forced to close their doors because of ASP (Average Sales price) + 6%, a rule passed in 2003 that medicare will only pay a 6% margin on oncology drugs. Many smaller practices are actually spending more on buying the drugs than what they get in return, forcing them to close their doors.

Now, medicare wants to bankrupt cancer care. Cuts proposed are ASP + 0.5-2.5%

Taken from Article on Medscape:

Referring to part of the proposal that would modify drug reimbursement on the basis of zip codes in certain regions of the United States, Allen S. Lichter, MD, chief executive officer of the American Society of Clinical Oncology (ASCO), said that it is "inappropriate for CMS to manipulate choice of treatment for cancer patients using heavy-handed reimbursement techniques."

In a statement, he added that physicians "did not create the problem of drug pricing, and its solution should not be on their backs."

Soon after the CMS issued the proposal, Ted Okon, executive director of the Community Oncology Alliance (COA), tweeted that the pilot project "is the most contrived, absurd experiment on cancer care I have seen.

"We're talking about a cancer 'moonshot' and a fight against cancer," he told Medscape Medical News. "So I thought this country was at war with cancer, not cancer care."

More from the article:
Under the proposed reimbursement model, Medicare Part B would pay the ASP an add-on of only 2.5% and a flat fee of $16.80 per drug per day, regardless of its price.


The second phase would implement value-based purchasing tools similar to those employed by commercial healthcare plans, pharmacy benefit managers, hospitals, and other entities that manage healthcare benefits and drug utilization.

 

[gutonc]

It's definitely the end of the classic PP buy and bill (and soak) model. But not community oncology care.

But that writing has been on the wall for years for those who were paying attention. Anybody who pays a significant partnership buy-in to a PP onc group now is an idiot.

 

[lilPhysician]

It's definitely the end of the classic PP buy and bill (and soak) model. But not community oncology care.

But that writing has been on the wall for years for those who were paying attention. Anybody who pays a significant partnership buy-in to a PP onc group now is an idiot.

So what's left for people going into oncology? If the new models penalize oncologists, IM residents will choose to go into GI and cardiology. Oncology will be relegated as an "other" specialty like ID/neph which are already having issues. What's sad is cancer incidence is bound to increase with the aging population so incentivizing oncology makes more sense.

 

[lilPhysician]

So what's left for people going into oncology? If the new models penalize oncologists, IM residents will choose to go into GI and cardiology. Oncology will be relegated as an "other" specialty like ID/neph which are already having issues. What's sad is cancer incidence is bound to increase with the aging population so incentivizing oncology makes more sense.

Oncology will turn into primary care for really sick, neutropenic patients in terms of the way it is structured in practice.

 

[bashwell]

So what's left for people going into oncology? If the new models penalize oncologists, IM residents will choose to go into GI and cardiology. Oncology will be relegated as an "other" specialty like ID/neph which are already having issues. What's sad is cancer incidence is bound to increase with the aging population so incentivizing oncology makes more sense.

1) What's left for oncology is the specialty itself. Cancer is still both fascinating and frightening, and so makes some enjoy its pursuit.

What's left for oncology is the patient population. Some people enjoy helping and working with the patients.

What's left for oncology is the fellow oncologists and other colleagues you see regularly at tumor boards, etc. Some people enjoy being in a specialty where they "fit" well with their colleagues and others.

2) It's not all about the money, but oncologists will still make more money than probably like 90% of the population. That's still a great living if you're doing what you enjoy, right?

Money matters aren't isolated to oncology either. It's happening in many other specialties too. No one is truly safe, not always. Not even cardiologists and gastroenterologists. Proceduralists may be safeR for a time, but what if bundled payments are introduced across the board for example?

3) Anyway, best to do what you enjoy, because the future you envision may or may not be there when you arrive. Hopefully your enjoyment will always be there.

 

[lilPhysician]

1) What's left for oncology is the specialty itself. Cancer is still both fascinating and frightening, and so makes some enjoy its pursuit.

What's left for oncology is the patient population. Some people enjoy helping and working with the patients.

What's left for oncology is the fellow oncologists and other colleagues you see regularly at tumor boards, etc. Some people enjoy being in a specialty where they "fit" well with their colleagues and others.

2) It's not all about the money, but oncologists will still make more money than probably like 90% of the population. That's still a great living if you're doing what you enjoy, right?

Money matters aren't isolated to oncology either. It's happening in many other specialties too. No one is truly safe, not always. Not even cardiologists and gastroenterologists. Proceduralists may be safeR for a time, but what if bundled payments are introduced across the board for example?

3) Anyway, best to do what you enjoy, because the future you envision may or may not be there when you arrive. Hopefully your enjoyment will always be there.

I agree with your overall point that we should do what we want to do. But your point that we should be happy making more than 90% of Americans make is totally missing the point.

The market dictates what someone is paid. It is a total abstraction. That's why putting in a stent pays you more than managing hypertension. Or for that matter, why a person can sell toilets for a living and make millions. At the end of the day, do you want a bureaucrat deciding what you make? Because if it were up to him, we should all be making less money.

1) we have to advocate for oncology as a field
Radiation oncologists treat cancer too. You know what they did when Washington threatened cuts? They got every congressman to sign a petition to not cut reimbursement. They stood up for themselves. And they make a crap ton of money. And there are far fewer of them than medical oncologists. For that matter, IR , derm, pathology, gastroenterology, urology, radiology, and surgeons all deal with cancer patients on a daily basis. Yet their reimbursement stays afloat while oncology is under attack year after year.

2) just because an oncologist makes less doesn't mean cancer costs will be fixed. More than the providers, it's pharmaceutical companies and the insurance industry that drives up cost. If oncologists could provide affordable chemo and get compensated fairly, everyone would win. But instead, pharma and big insurance walk away with billions while oncologists get hosed. Oh by the way, the same congressman that decided you should make less is getting lobby money from big pharma too.

3) we went to medical school for four years and train for at least another six to become practicing oncologists. Heck, why do fellowship for three years if you make slightly better or the same than a hospitalization? And deal with families, death, toxic medications, infections? Don't you think that deserves more respect?

4) we will lose the best and brightest people to other specialties. I want to help my patients but I want to help myself too. Having six figure debt and choosing to do a fellowship is a sacrifice. People will do interventional cards and GI to make money and laugh at oncology if we don't defend ourselves.

5) you can't have a moonshot to cure cancer if you hose the specialists that are supposed to train and treat patients with cancer. Unless you want to watch your patients die without hope and new therapies, we should support the providers who make innovation and care possible.

 

[bashwell]

I agree with your overall point that we should do what we want to do. But your point that we should be happy making more than 90% of Americans make is totally missing the point.

The market dictates what someone is paid. It is a total abstraction. That's why putting in a stent pays you more than managing hypertension. Or for that matter, why a person can sell toilets for a living and make millions. At the end of the day, do you want a bureaucrat deciding what you make? Because if it were up to him, we should all be making less money.

1) we have to advocate for oncology as a field
Radiation oncologists treat cancer too. You know what they did when Washington threatened cuts? They got every congressman to sign a petition to not cut reimbursement. They stood up for themselves. And they make a crap ton of money. And there are far fewer of them than medical oncologists. For that matter, IR , derm, pathology, gastroenterology, urology, radiology, and surgeons all deal with cancer patients on a daily basis. Yet their reimbursement stays afloat while oncology is under attack year after year.

2) just because an oncologist makes less doesn't mean cancer costs will be fixed. More than the providers, it's pharmaceutical companies and the insurance industry that drives up cost. If oncologists could provide affordable chemo and get compensated fairly, everyone would win. But instead, pharma and big insurance walk away with billions while oncologists get hosed. Oh by the way, the same congressman that decided you should make less is getting lobby money from big pharma too.

3) we went to medical school for four years and train for at least another six to become practicing oncologists. Heck, why do fellowship for three years if you make slightly better or the same than a hospitalization? And deal with families, death, toxic medications, infections? Don't you think that deserves more respect?

4) we will lose the best and brightest people to other specialties. I want to help my patients but I want to help myself too. Having six figure debt and choosing to do a fellowship is a sacrifice. People will do interventional cards and GI to make money and laugh at oncology if we don't defend ourselves.

5) you can't have a moonshot to cure cancer if you hose the specialists that are supposed to train and treat patients with cancer. Unless you want to watch your patients die without hope and new therapies, we should support the providers who make innovation and care possible.

I think you're tilting at windmills. Just because I didn't raise these issues in my response to you doesn't mean I don't think they're important or relevant. Just because I didn't raise these issues doesn't mean I wouldn't advocate or promote or otherwise support them. I do and I would.

However, you can't directly control a lot of the stuff you mentioned above. You're worrying over some things you can't do anything about, at least not right now as a med student (assuming your current profile is accurate). I'd suggest having some patience for now.

In any case that's why I suggested you should focus on what you enjoy rather than how much money you're going to make, because what you enjoy should hopefully be more stable than how much money you may or may not make in the future, which depends on a number of variables you may or may not able to control. Some you can, others you can't.

Again, this doesn't mean I don't think money is important or relevant, but you don't need to obsess about it. At best, money should be a secondary or peripheral issue in choosing a specialty.

Besides, oncologists are likely going to make good money in the future. Of course, no one has a crystal ball about the future. In theory it's possible every single doctor in America including oncologists could end up making far less money tomorrow than they make today. We don't know what will happen in the future. However, we can try to make the most informed decision possible based on the best data today and what we think will most likely potentialize. Based on which probabilities are more likely, which factors and variables are more constant, etc. What else can we do?

By the way, lots of specialists such as ID specialists don't make as much money as many hospitalists. But there are other advantages. Such as being a specialist. You don't have to put up with a lot of what PCPs have to put up with. You can be consulted by hospitalists and others. These sorts of things might be worth more than money to some people.

As for respect, that's not about which specialty you're in or not in. That's about other things like your knowledge and skill as a physician. As I'm sure you know, not all doctors are equally good. And some of the doctors I most respect are in specialties many people tend to snub their noses at.

Last thing for now is that some of what you're saying isn't isolated to oncology. Healthcare in general is changing, and that's affecting a lot of other specialties too.

In the end, just choose what you like, based on what you want to do with your life. Sure, nothing wrong with plugging your likely future salary into the equation, that's perfectly fine and good, but just realize there's a lot more than just money in selecting a specialty.

 

[TexasMed22]

Seems like this thread was (partially) incorrect. PP community oncology practice may be less common now than in 2016 due to health system consolidation, but oncologist salaries seem to be actually increasing, even adjusted for inflation, and even more so that most other specialties. Per medscape, oncology was at 329k in 2016, it is at 463k now, which is an increase in absolute terms, since inflation adjusted 329k should be 427k. Also, per MGMA, between 2010 and 2019 oncology had the single greatest salary growth of any specialty, at an average of 4% per year. Obviously these salary surveys aren't perfect (likely deflated), but I think they do a decent job of capturing trends.

 

[TexasMed22]

Here's the recently released 2023 AMGA data, Hem Onc continues to have the highest average increase in compensation of any specialty (4.2%).

 

[hehe5347]

Does anyone have recent MGMA data?

 

[HemOncCheng]

Does anyone have recent MGMA data?

it can not be shared here, already I heard that any contract attorney or reviewer can share the data with you if you are reviewing yours

 

[Ubba]

Here's the recently released 2023 AMGA data, Hem Onc continues to have the highest average increase in compensation of any specialty (4.2%).

View attachment 380324

350 was grotesque underpayment.

 

[Doc mu]

Here's the recently released 2023 AMGA data, Hem Onc continues to have the highest average increase in compensation of any specialty (4.2%).

View attachment 380324

What about endo, rheum...etc?

 

[TexasMed22]

What about endo, rheum...etc?

AMGA only gives data for specialties with >500 responses to the survey IIRC

 

[Doc mu]

AMGA only gives data for specialties with >500 responses to the survey IIRC

Very interesting post however, how would you explain this growth in salary for heme/onc is it just due to inceased demand?

 

[osprey099]

Very interesting post however, how would you explain this growth in salary for heme/onc is it just due to inceased demand?

More cancer patients and also exponentially more therapies that are very expensive. 10+ years ago, immunotherapy wasn't that common, and we certainly didn't have ADCs, plethora of targeted treatments, bispecifics, etc.

 

[HemOncCheng]

More cancer patients and also exponentially more therapies that are very expensive. 10+ years ago, immunotherapy wasn't that common, and we certainly didn't have ADCs, plethora of targeted treatments, bispecifics, etc.

It is a matter of how much insurance want to pay for and how long the reimbursement at this level can go. But patient care and disease treatment wise, it is way better, we are make progress.