Community oncologists man the front line of cancer care, treating upward of 85% of our nation’s patients. Over the past 2 decades, regulatory and economic changes have left many practices in a state of flux and uncertainty, some struggling to keep their doors open. To shed light on the community practice experience, K.M. Steve Lo, MD, shared a day in his life, and offered observations about today’s challenging environment.
The Practice
Our practice is essentially the sole oncology provider for the city of Stamford, Connecticut (population ~120,000), and some of the surrounding suburbs; the patient population covers a dynamic spectrum from poor inner city patients to the super-wealthy of Greenwich and New Canaan. In our waiting room, you might see a CEO of a major corporation sitting next to a patient on welfare, sharing the common experience of cancer. As a doctor, I find it’s rewarding to care for people from all walks of life.
Changing Times
This is my 20th year in private practice, and over the past 3 to 4 years I’ve seen rather dramatic changes that have affected our oncology services, in both positive and negative ways. On the positive side, I’m enjoying patient care more now than ever, and the main reason is that my cancer patients are living longer. When I first came into oncology, we had a limited number of drugs, most of which were highly toxic and not very effective. Consequently, most of our patients with metastatic disease died within the first year. In contrast, over the past decade we’ve had an explosion of exciting new drugs that have clearly improved survival rates. Today, it’s not surprising for patients with advanced disease to live beyond 5 years with good quality of life.
For instance, I have a patient with metastatic lung cancer who is now 10 years out. Her husband was killed on 9/11, and she was thrilled because just this summer she attended her son’s wedding, something she never dreamed she would live to see. She gave me such a big hug of gratitude, which was an extraordinary high because in human terms it validated the care I deliver every day.
On the negative side, over the past few years practice costs have skyrocketed. Staff salaries, benefits, and medical insurance have risen dramatically along with malpractice insurance, not to mention the day-to-day costs of running the office. Moreover, diminishing reimbursement for cancer drugs squeezes our margins so tight that it’s very challenging. We’re lucky in that our practice has seven doctors, so we’ve been able to defray and absorb the fiscal pain. But a lot of smaller and single-doctor practices operate on the verge of bankruptcy.
Another negative is the sheer expense of the chemotherapeutics, which can cost $10,000 per month for a single drug, adding to upwards of $70,000 worth of therapy for a single patient. In some cases, the insurance company refuses to reimburse us, even after prior approval, citing any number of reasons, such as a prior existing condition of which we had no knowledge. We end up absorbing the loss. Occasionally a drug manufacturer will increase the price of an agent more than its Medicare reimbursement rate. It takes Medicare months to readjust the rate, so we end up losing money each time we administer that treatment—money we can’t recoup.
The EMR Conundrum
The national transition to a fully digitized health-care system is imminent, but our own transition to electronic medical records (EMRs), which began about 3 years ago, proved to be painful. EMRs are very expensive, not just the software and implementation process, but also the hidden costs for which we weren’t prepared. For example, our EMR did not interact well with our other systems, so we needed to hire technicians to develop interfaces that were interoperable. Each interface ran $20,000 to $40,000, and the process became like an unending house renovation nightmare.
In short, electronic medical records have had a huge negative impact on our practice, in terms of costs as well as a decrease in efficiency. People picture the EMR’s functionality as similar to a smart phone or an iPad, but one should really think of the current EMR as more like the first version of Windows, or maybe DOS. Naturally, these machines will, like all electronics, eventually improve vastly in functionality and decrease markedly in cost. But currently, our EMR is an expensive, clunky, inefficient machine.
Laborious data-entry time aside, my biggest gripe with the EMR is that it takes away from the important face-to-face interaction I have with my patients. I find myself spending more time inputting information than I do having eye contact with my patient. The machine, with its constant need for data entry, distracts me during important discussions with very vulnerable patients.
Hospital Collaboration
By nature, community oncologists revere their autonomy. And the most drastic change to our practice—due largely to growing economic challenges and burdensome administrative issues—was integrating with the Bennett Cancer Center at Stamford Hospital. We’re still independent, but we’ve partnered very closely with the hospital so we can continue to provide comprehensive oncology services.
The benefit for us is that the hospital is much more effective in managing a large office staff and in dealing with the high operating and drug costs. Our physicians can now concentrate more on patient care than on business. The hospital has also picked up a lot of the administrative burdens involved in our clinical trials section. It was a tough decision, but in the end, given the changing environment, partnering with the hospital was a good strategic move for our practice.
The Day Begins…
I usually arrive at my office at about 7:00 AM. I pick up faxes and paperwork from the night before, and then I cross my fingers and power up our office electronic medical records system. If everything is glitch-free, I power up the hospital’s EMR—which is separate from our office EMR—and check out all the pertinent data, admissions, lab work, and so on. I typically have about two to four inpatients, so after I’ve gone over their charts electronically, I run over to the hospital and do my rounds.
I wait until I get back to my office to enter the hospital notes into the EMR, which typically takes longer than the time I spent with the patients. Again, using the EMR is a finicky, labor-intensive process that has added extra layers of administrative time to my day.
I usually finish the notes about 8:00 or 8:30, and then begin seeing my office patients. I schedule about 30 minutes for follow-ups and about an hour for a new patient consult. I try to save my consults for the end of the day, because in the more complicated cases, an hour simply isn’t enough time. I usually see between six and eight patients in the morning.
Unfortunately, time that used to be reserved for important schmoozing, either with colleagues or patients, is now consumed by inputting notes and documentation. If we do not document a patient’s visit properly, we may be reimbursed for only a fraction of what we have done. We also have to meet a host of different criteria, such as meaningful use for the EMR, which is incredibly complex and time-consuming. Then there are the ABCs of QOPI, which I support in spirit, but the implementation process for certification adds a lot of extra work, without really improving care.
A Working Lunch that Blends into Night…
I try to reserve an hour for lunch in the afternoon, usually to deal with any emergencies, patching up loose ends, running over to the hospital, or returning phone calls that have been triaged as semiurgent to urgent. We also have working lunches that might encompass tumor boards or a specialist’s lecture updating us on new things being done in the community, such as in pain management or palliative care. In between the multitude of issues that come up, I’ll run back to the office and grab a bite at my desk, all the while checking e-mail, voice mail, lab results, and preparing for my afternoon patients.
At 1:00 PM, I begin seeing patients until 5:00 or 5:30 in the evening. If I have some walk-ins, hospital consults, or emergency admissions, I might not see my last patient until 7:00 PM. After that I work on some more notes, return calls, and head for home, making more return calls in the car. I get home between 7:00 and 8:00 PM, have a quick dinner and catch up with the family, and then I go up to my home office and spend another hour or so working. Since I can now access my office and hospital EMRs from home, I spend that time checking labs, responding to e-mails, and reviewing treatment plans.
Over the past few years, the problems associated with EMR and the requirements of Quality Oncology Practice Initiative (QOPI), meaningful use, and insurance reimbursement have created a tsunami of demands on the private-practice oncologist. They have taken time away from my patients and my family. That said, the rewards in caring for patients with cancer still outweigh the growing challenges faced in community oncology practice. ■
Disclosure: Dr. Lo reported no potential conflicts of interest.
