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The complex nature of cancer and symptom management is no secret to oncologists and their support staff members. Cancer patients need extensive support services, which are not often required in other physician practices. Precise measures of these services and the associated cost is lacking.
The American Society of Clinical Oncology (ASCO) and the Administrators in Oncology/Hematology Assembly (AOHA) of the Medical Group Management Association recognize that despite the importance of chemotherapy support services, there has been little information or research to assess the nature of these services and the extent to which they are provided. In an effort to categorize and measure the type of services in support of patients receiving chemotherapy, ASCO and AOHA conducted a two-phase research study of medical oncology practice activities in this important area.
In the first phase of the ASCO and AOHA research effort conducted in 2004, a typology of chemotherapy support services provided in conjunction with chemotherapy visits was identified. The initial study involved site visits to 14 oncology practices (12 geographically diverse community oncology practices and two faculty-based oncology practices). Six categories of support services (each containing a list of services and tasks) were identified in this first study phase:
ASCO then engaged the Lewin Group to determine the extent to which oncology practices provide support services in conjunction with chemotherapy. It was hoped that with this information, both policymakers and stakeholders within the oncology community would gain an increased understanding of both the actual services provided and, ultimately, their associated costs.
During this second phase of the study, which is the focus of this article, the Lewin Group was commissioned to quantify the extent to which oncology practices devote time to each type of support service and identify the staff members involved in providing them. Lewin conducted a nationwide survey of medical oncology practices in which surveys were mailed to more 1,800 medical oncology practices. Due to a low rate of response to the initial mailing, the survey was shortened and additional practices (beyond the original 1,800 practices that were initially contacted) were invited to participate.
Of the 123 practices that responded, 114 practices representing 721 medical oncologists and hematologists offered and provided at least one type of chemotherapy support service. Responding practices were distributed evenly across the four US Census Bureau regions: the Northeast, Midwest, West, and South. More than 75% of the responding practices identified themselves as a “private oncology practice/clinic.” Most frequently, practices were owned by either one physician or multiple physicians, as opposed to a hospital, health system, or a group of organizations (physicians, hospitals, health systems). Almost two thirds of respondents indicated participation in clinical trials. Table 1 summarizes key characteristics of responding practices.
For the purposes of this study, support services were broken into six categories as shown. The survey instrument included a detailed list of potential services that were included in each category. For instance, the support service called “Care Coordination” included 10 potential functions or tasks. Respondents were asked to indicate the support services offered by their practices during calendar year 2005 from the comprehensive list, which had been developed earlier in phase I of the study. Responses were analyzed to determine the extent to which the listed services were provided in oncology practices in conjunction with chemotherapy services throughout the country. Although the survey response rate was somewhat low, this effort did yield useful findings. A summary of the services within each category of support that respondents indicated were provided is presented in Table 2.
This study also examined several other trends related to the effect on time and cost spent on support services in oncology practices, including the number of full-time oncologists per practice, number of locations, payer mix, and clinical trials participation. Following are several key findings from the study.
Finally, the survey did collect general data on time spent by administrative and clinical staff members on each level of support service. Those data are not presented here because significant variations in the reported times suggested the need to further validate the responses.
Practices were asked how often the average patient was offered or provided with each support service, and to report this as an average percentage of the visits made by that patient. Responses are categorized by the median percentage of time support services and are offered in Table 3. There were fewer responses to this question because it was not specifically asked on the initial, lengthier version of the survey.
The vast majority of financial counseling services were provided by administrative staff as were more than half of the care coordination services. The remaining services were primarily provided by clinical staff other than nurse practitioners and medical oncologists.
This study offers an important perspective on the nature of chemotherapy support services as well as the types of support services being offered and provided by oncology practices across the United States. ASCO and AOHA can build on these data to better inform decision making about coverage and reimbursement for these services and to support recognition of the full range of cancer care services by the Centers for Medicare & Medicaid Services, as well as other payers.