Cancer Care Trends: ACCC’s 2013 Survey of Community Oncology

Washington, DC—The preliminary results of the 2013 Cancer Trends Survey conducted by the Association of Community Cancer Centers (ACCC) were reported at the 2013 ACCC annual meeting by Ron Schlief, RPh, MBA, and Bruce Edelen, of Oncology Reimbursement Management in Carmel, IN. Survey results show that not all the stars are where they used to be. “In a nutshell,” Mr Edelen said, “it’s not status quo in the marketplace anymore—it’s changing.”

He hoped that this initial reporting would give ACCC members a solid footing, providing enough perspective so that they can benchmark their programs against others, in the following vital areas related to cancer care:

  • Marketplace consolidation
  • Patients’ ability to afford care
  • How to establish metrics to measure quality of care—a major component of healthcare reform
  • The realities of accountable care organizations (ACOs)
  • The phenomenon of white bagging. White bagging is the practice of having patient-specific medications or supplies delivered directly to the practice setting (ie, outpatient infusion center, physician office, hospital) for use by a specific patient.

A total of 98 cancer care programs and institutions completed the ACCC survey, including 66% community-based cancer programs, 14% outpatient cancer centers, and 5% university-based programs. The vast majority (94%) of respondents were not-for-profit institutions.

Overall Financial Health

When asked about the overall financial health of cancer centers, “More than 80% of you who filled out the survey said, ‘I either feel good or very good about my financial status right now,’” Mr Edelen told ACCC attendees. He then suggested that this positive stance is likely attributable to a given program’s ability to manage costs, and may reflect the health of the cancer service line in comparison with other hospital service lines.

Whereas 75% of respondents said that they had enough data on which to base an opinion about overall financial health, respondents “are also saying that they lack the ability to track profit and loss specifically,” observed Mr Edelen, noting that cancer centers do not specifically know what their denial rates are, what the collectibles are, and what exactly was billed out or collected. “Many [community cancer centers] are expressing a desire to get better at this,” Mr Edelen said.

Cost management remains a top concern, as was reflected in last year’s survey. “Essentially, what we heard was that there are only so many strategies you can come up with in order to reduce costs. And there is only so much you can do before you start cutting into the bone that will start to impact your revenues,” Mr Schlief said.

One strategy around revenue production is the increase in the use of technology. “Technology is being a strategy for increasing my revenues throughout the hospital,” Mr Edelen cited survey responses. Investment in technology is increasing in cancer centers.

The Core Issues
Consolidation and Mergers/Acquisitions

The survey posed the question, “Over the past year have you acquired, merged, or somehow affiliated yourself with another cancer program?” Of the respondents, 25% said that they had. Furthermore, a response to a follow-up question regarding acquisitions of physician practices within the ACCC members’ marketplace showed that 45% of centers and institutions indicated that this is indeed occurring.

“Not surprisingly,” Mr Edelen commented, “sixty percent of you thought this trend would be ongoing; so, the question is, what does this mean for the patient?”

Mr Schlief pondered the implications of shifting sites of care from the employees’ perspective. “For each specialty that is employed, or practicing within a hospital, what kind of employment contract are those employees operating under? Are they operating under an employee contract, or is it a professional service contract, or are they private practice, or is it some type of joint venture?” Mr Schlief asked. Each facet will have an impact on the way a bottom line is calculated.

Cost of Care and the Uninsured

“In general,” said Mr Schlief, “what we’re seeing here is that more and more of you have concerns about the uninsured walking into your centers.” Respondents indicated that roughly 66% of current payments are coming from the public sector, “and once you tack on the uninsured, you’re looking at almost 70% of your business coming from other than the commercial payer.”

Based on the survey results, this proportion continues to increase as the number of commercial payers continues to decline. As Mr Schlief noted, “This is not a good picture.” He further observed that this seemed at odds with the overall sentiment that was expressed earlier that most centers were doing pretty well.

As for Medicare, 33% of respondents indicated that this sector of their payer population was increasing, whereas 50% said that the proportion was the same compared with 2011.

Quality-of-Care Metrics

Interest in quality-of-care metrics was strong, with 90% of respondents indicating that they were pursuing Commission on Cancer accreditation (there are no trend data about this, because it was the first year this topic was explored).

“What we heard back loud and clear from hospitals is that virtually every hospital is doing multiple things to try and approach how they measure quality,” Mr Schlief said.

“Then the PQRS [Physician Quality Reporting System] with Medicare, certainly there’s an incentive to participate. But what we’ve heard from members is that the incentive is so small—to actually do that for additional reimbursement….What’s driving this trend, I think, is more the hospital at large,” Mr Edelen commented.

When the question of “Would you be interested in collaborating with others as you go on this journey down quality metrics?” was asked, the answer was that nearly all (99%) respondents said that, yes, they would like to participate in peer-to-peer groups to better understand quality initiatives. “As we delved into this with follow-up interviews, we saw that the devil’s in the details in terms of how you collaborate, and how you do it in such a way that’s going to be beneficial to all those that are participating,” Mr Edelen suggested.


Accountable Care Organizations are certainly at the top of respondents’ minds,” said Mr Schlief. Everyone is talking about it, yet the data in this survey show that most cancer centers and institutions are not actually doing anything about it: 50% of respondents said that they intended to participate in an ACO, but only 13% actually do at this point. “Hospitals are looking at it, and certainly the cancer programs within those hospitals are trying to figure out what some of their first steps and forays into experimenting in this will be,” Mr Edelen said.

In general, there is a sense that cancer centers are waiting before they make the investment in an ACO, because they are uncertain what that investment will look like. As was expressed by a presenter at the 2012 ACCC meeting, “ACOs are like unicorns—everyone knows what they’re supposed to look like, but no one has ever actually seen one.”

White Bagging

"We tend to associate white bagging more with a community practice—a practice that doesn’t have as much clout,” said Mr Edelen. However, 25% of respondents indicated that white bagging is allowed at their institutions. This percentage represents a growth from 2011, where only 16% of members indicated that white bagging was permitted. “I think we can expect this upward trend to continue, as payers try and take providers more and more out of the profitability associated with the absolute purchase of chemotherapy,” Mr Schlief noted.

In a follow-up interview concerning this topic, one administrator discussed the relationship that his institution had with a specialty pharmacy, as a way of securing additional business. As Mr Schlief explained, “They were a 340B institution that used the specialty pharmacy to actually capture that business, and they kind of shared in the savings.”

And finally, as it relates to the issue of white bagging, the question “Do you have outpatient pharmacies on site that can administer oral cancer therapies and deliver on the prescriptions that your oncologists are writing?” was asked. Of the respondents, 30% indicated that they did.

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