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Healthy — and not so healthy — competition
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ASCO published its annual report on the state of cancer care in America earlier this spring.
As in previous years, the report highlights significant achievements — the introduction of new drugs and biologic therapies for cancer and the positive impact of the national cancer moonshot initiative — as well as ongoing challenges, including continuing disparities in access to cancer care and the lack of impact on outcomes for some cancers.
Changes in cancer incidence and an increasing number of cancer survivors continue to raise questions about our ability to deliver the necessary care for our patients, and navigating the volume-to-value transition is a major theme of the report. The impact of big data and the necessity for interoperability of electronic health records also are key themes.
Competitive pressure
The report included results of the ASCO Trends Survey, which explores high priorities for practicing oncologists in academic, hospital-based and physician-owned, community-based settings. Perhaps not surprisingly, major areas of concern for all groups included increasing practice and facility expenses, drug pricing, additional workload from the use of electronic health records, and increasing pressure from payers.
I was interested to see competitive pressure listed as a significant challenge, especially for physician-owned practices but also among hospital and health system–owned practices. It appears to be a lower priority issue for academic centers.
The increasing regulatory and administrative burden of the Affordable Care Act has resulted in consolidation in health care. Many community-based, private practices have been absorbed by various financial and administrative models into larger systems. As consolidation continues and provider networks narrow, the impact on the competitive environment is unpredictable but, in many areas, is likely to decline.
The impact of a competitive market on the quality of cancer care delivery and on the experience of our patients is unclear and what follows are purely personal impressions — unsupported by evidence-based literature — based on my own personal experience of having worked in several health care markets in the United States and having observed different competitive environments.
I should also add that recent events at my own cancer center, extensively covered in the media and ongoing as I write this editorial in late April, have also made me think harder about the effects competition for patients and for revenue have had on our ability to deliver the best possible services.
Cancer services generate substantial revenue for most practices and health systems, based on technical procedures, ancillary services and the substantial margins that can be generated from anticancer drugs. These high margins drive competition.
Even in our value-based future with declining margins, ultimate financial success will be based on the number of patients seen, so cost and quality initiatives are still likely to be paired with innovation, research and volume-growth strategies. Although margins are likely to decline, the increasing cancer incidence means that the demand for services will rise dramatically and the competitive landscape will remain very aggressive.
Impact on patients
From the perspective of our patients, competition in health care — like other enterprises — should be regarded as positive.
I have had the good fortune to work in two cities — Cleveland and Salt Lake City — in which two major health systems exist and compete for patients. In both cases, the hospital-based system and the university-based system compete aggressively for patients, but are able to collaborate in areas that benefit the community, including research, prevention and education efforts.
As a result, patients have more choice — as long as payers maintain their networks — each system has to work harder to attract patients, the quality of care rises, and the emphasis on value means each institution must control its costs to maintain a competitive advantage.
Further, excellent community-based oncologists work alongside the larger systems, providing even more patient choice and expanding the landscape of high-value, evidence-based care available. The local communities are beneficiaries of innovations in cancer care delivery and in basic and translational research from all local providers.
I also have worked in an environment in which one cancer care system has dominated and where other institutions have been unsuccessful in developing viable cancer services.
There is no suggestion that the oncologists of all disciplines in that environment are not excellent, but there has been a lack of coordinated transdisciplinary cancer care and significant out-migration of the local population for cancer services. Although I am not aware of evidence that outcomes differ in that environment compared with others, the fact remains that patients in this major metropolitan area have very limited options for their care unless they have the means to travel, and even though quality of care may be excellent, access to that care is inconsistent.
As health care transformation progresses, we transition from volume- to value-based cancer care and our patient numbers expand, we should embrace competition in our communities as a positive influence for our patients and hope that consolidation ultimately does not limit patients’ access to the provider of their choice.
Reference:
ASCO. J Oncol Pract. 2017;doi:10.1200/JOP.2016.020743.
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John Sweetenham, MD, FRCP, FACP, is HemOnc Today’s Chief Medical Editor for Hematology. He also is senior director of clinical affairs and executive medical director of Huntsman Cancer Institute at University of Utah. He can be reached at john.sweetenham@hci.utah.edu.
Disclosure: Sweetenham reports no relevant financial disclosures.