‘Survival’ of Private Practice Medical Oncologists at Risk

CHICAGO—“Is the private practice oncologist at risk? I think we are,” said Bruce Feinberg, DO, at the first national conference on purchasing oncology services, sponsored by the American Cancer Society and the Kerr L. White Institute for Health Services Research, Decatur, Ga.

When Dr. Feinberg first went into private practice oncology 10 years ago, 80% of the cancer patients throughout the country were treated in their own communities by private practice oncologists, and 80% of the cost of cancer care was controlled by private practice oncologists. Today, private practice oncologists are getting fewer referrals for cancer care from primary care physicians, and they are receiving less in payment for the services they do provide.

In his talk, Dr. Feinberg asked the audience to consider the prognosis for private practice oncology. “Oncologists must take charge of their destiny. It’s not just a question of earnings, but of survival,” he said.

There is increased competition from HMO staff-model specialists, hospitals, home infusion companies, and national cancer companies for a shrinking reimbursement dollar pool, “and case management is challenging the autonomy of physicians and causing private practice medical oncologists to capitulate their role,” said Dr. Feinberg, CEO of Georgia Cancer Specialists, a community-based, centralized and integrated medical oncology practice in Decatur, Ga.

Dr. Feinberg nevertheless believes private practice medical oncologists can “take charge of their futures and maintain their clinical autonomy” by developing models for the delivery of cancer care that make them “directly responsible for the cost and quality and value of cancer care.”

Model for Survival of Private Practice Oncologists

He and his associates at Georgia Cancer Specialists created such a model in 1993 by first surveying both payers and patients and discovering the features they equated with the best in cancer care: high quality care, easy accessibility, and compassionate scope.

Georgia Cancer Specialists demonstrated the quality of their services by including in their practice board-certified oncologists and clinical oncology-certified nurses and by becoming accredited by the Joint Commission on Accreditation of Healthcare Organizations. They added radiation and gynecologic oncology services, plus palliative care, pain management, hospice, home health, nutrition, and support groups.

The group practice also expanded their network of oncologists on the theory that “if patients are closer to your offices, they are more likely to seek services in a timely fashion that will result in more rapid intervention, better outcomes, and less hospitalization,” Dr. Feinberg said.

Even with the best model of health care delivery, however, private practice medical oncologists still have to be price competitive, Dr. Feinberg acknowledged. Georgia Cancer Specialists therefore established procedures for itemizing the fixed and variable costs that the oncologists could control directly and by creating uniformity in health care delivery to minimize cost variability.

These methods helped the oncologists discover, for example, that their average length of hospital stay for neutropenic fever was the same as the Medicare national average in 1993. By shifting their treatment of this complication to the outpatient setting, they were able to cut the length of hospital stay for this condition by 3 days with a reduction in costs of $3,000 per patient, according to their 1994 analysis.

Georgia Cancer Specialists, as a small group practice, cannot afford to assume high risk, Dr. Feinberg said. Therefore, the oncologists also developed an elaborate model for projecting costs. The model predicts cancer incidence rates in the central Georgia area by age, gender, and race, and it breaks down specific types of cancer by stage. After applying a clinical pathway to such data, the oncologists can determine the total cost of care they might expect for treating a particular cancer population.

So, while private practice medical oncologists are under intense pressure in the emerging managed care market, they can protect their “clinical and financial autonomy and provide the best care possible for patients,” Dr. Feinberg said, if they are “more assertive and actively involved in the process and development of health care plans.”