ASH Panel: How Many Hemotologists/Oncologists Are Enough?

NASHVILLE--The independence of hematologists/oncologists, includingthe specialty's right to determine the size of its residency programs,is being threatened by the changes occurring in health care, DanielRosenblum, MD, said at a forum on health-care reform at the annualmeeting of the American Society of Hematology (ASH).

The estimated 2,500 to 3,500 hematologists in the United Statestoday are unevenly distributed throughout the population, he said.The number of hematologists/oncologists per million populationranges from about 5 in Chicago to 42 in Washington DC, for example.

"It is hard to say that these numbers are based on the needfor hematologists by incidence of disease," said Dr. Rosenblum,of Suburban Hospital, Bethesda, Md, and chairman of the ASH committeeon practice.

He noted that the number of hematologists required per millionpopulation has been estimated at 5, and eliminating the numberof practicing hematologists in excess of that number could saveperhaps a half billion dollars a year. With that statement, Dr.Rosenblum initiated a discussion on the "wisdom, apart fromthe economic motivation," of limiting the proliferation ofspecialists, including hematologists, as has been proposed.

John Adamson, MD, of the New York Blood Center, and president-electof ASH, said that the society has not critically evaluated theneed for future subspecialists in hematology/oncology "toalign ourselves with the community's real needs."

He noted that two subspecialties--cardiology and gastroenterology--havevoluntarily begun to reduce the number of trainees in their fields,but he expressed concerns about how such reductions in hematologywould be achieved. "Who will set the target for the numberof hematologists who should be in the community practicing?"he asked.

Mark Chassin, MD, former commissioner of the New York State Departmentof Health, addressed the possibility of downsizing by selectivelyreducing the use of unnecessary health service.

In his presentation, John Eisenberg, MD, chief of medicine, GeorgetownUniversity Medical Center, noted that the field of hematologymay require more specialists than might be justified simply bythe incidence of hematologic diseases, since hematologists areinvolved in expanding fields like bone marrow transplant and otheremerging technologies.

"So maybe we're about right in terms of the number of hematologiststhat we currently have," Dr. Eisenberg said. And even ifthe numbers are off by a factor of 30% to 50%, as some suggest,the field would still be far less overpopulated than truly overgrownspecialties such as gastroenterology and cardiology.

He argued that to downsize the number of people in residency trainingcould be a mistake for several reasons: The hematologists comingout of training programs generally do not spend all their clinicaltime in the specialty; some hematologists are academics doingresearch, with little clinical involvement; and some hematologistsmay also practice primary care. "However, if these individualsplan to enter community-based referral practices, we do risk havingtoo many hematologists," he said.

A Cost-Containment Dilemma

A member of the audience questioned the panel about an increasinglycommon dilemma: managed care plans that balk at paying for bonemarrow transplants (BMT) and other expensive procedures in high-riskpatients (those with only a 20% to 30% chance of survival) orrefuse to pay the extra costs that such patients may incur. Capitatedplans, for example, pay a flat rate per number of members enrolledand would reject the idea of using different payment rates fordifferent levels of risk.

Dr. Eisenberg commented that the dilemma arises when physiciansand hospitals are paid by the episode of care (as has long beenthe case with surgeons) and thus assume the financial risk. Hesaid that health-care providers must develop better predictorsof the costs of treatment of various types of patients and negotiatewith managed care plans based on those costs. Managed care plansthat reject proposals to adjust payments for high-cost patientsare simply making explicit their cutoff point beyond which theydo not consider BMT to be cost effective.

Development of national guidelines on the use of BMT would bea better solution, Dr. Eisenberg said. Such guidelines would allowphysicians to say to certain high-risk patients that their prognosisis not sufficiently positive to justify the transplant. "Atsome point we have to bite the bullet and draw the line,"he concluded.

Another tactic is to publicize the managed care plan's policyon transplantation. "When you make these policies publicor when the newspapers pick it up and then the clients of thatHMO find out what the cutoff point is, the market will speak,"Dr. Eisenberg said.

Plan patrons will either insist that high-risk patients be coveredor will balk at paying extra to accommodate such patients. Eitherway, "it takes the decision out of the hands of the individualphysician," he said.