By Luke Nordquist, MD, FACP.  The typical community oncologist in the U.S. is spending progressively more time each day providing services that are necessary in order to provide quality care that each patient with cancer expects and deserves. These services require more time to complete and a larger number of staff than a typical physician’s office. In many ways, outpatient oncology offices resemble more of an acute care center than a standard physician’s office. According to Journal of Oncology Practice benchmark data, it is not unusual for an oncology office to employ eight to 10 personnel per physician. In a practice such as my own, which focuses heavily on clinical trials, the numbers of staff necessary can even be higher.

Unfortunately, many of these vital services are non-reimbursable and at the expense of the oncology practice. Since the creation of outpatient oncology services, by far the greatest overhead expense and source of revenue has been infusion drugs. Oncology infusion drugs have also become the biggest and easiest target when it comes to reform and saving health care dollars. With declining reimbursement for infusion drugs, the non-reimbursable services, and in reality, the community oncology practices themselves, are placed in jeopardy.

However, this is not a new concern. A 1988 excerpt from the Federal Register cautioned about underpayment for oncology professional services: “Current Medicare Part B payment rules for physicians’ services, however, may fail to compensate adequately for these services because the usual reasonable charge methodology may not fully recognize the overhead costs involved in these procedures.” This left me wondering if higher powers in charge of reforming today’s cancer care truly understand what sets oncology practices apart from other types of physician offices. Do they understand the laundry list of essential but non-revenue generating services that oncologists provide on a daily basis? To be honest, if I was asked what those services include, would I be able to rattle off the laundry list of services that my staff and I provide at our office? I decided to informally survey my employees and created a list that by no means is complete but does give one a sense of why oncology offices seem to be buzzing:

Common Non-Reimbursed Oncology Services:

• Development of complex treatment plans and schedules
• Discussion regarding evidence or rationale for a specific treatment and other options
• Discussion with patient about possible clinical trials
• Discussion and education for a patient regarding the treatment plan and schedule
• Discussion with the patient regarding possible treatment toxicities
• Communicating with a patient’s family regarding treatment options, prognosis, etc.
• Communication with other physicians/multidisciplinary tumor boards
• Dose and schedule modifications for treatment toxicities
• Modification of treatment if not covered by insurance or funding not available
• After-hours phone interventions for disease and treatment toxicities
• Psychosocial counseling of the patient and family/caregiver
• End-of-life discussion
• Survivorship care and education
• Health maintenance: smoking cessation, cancer screening, dietary
• Genetic counseling for patient and family
• Providing “Medical Home” services for acute issues to avoid hospitalizations
• Mixing and preparation of infusion drugs
• Obtaining prior authorizations for treatments/procedures
• Appealing denials for prior authorizations
• Billing complex treatments
• Appealing denials for payments and underpayments for services/treatments provided
• Finding alternative funding sources for patient’s treatments, travel, etc.
• Completing disability, FMLA, DMV, and other forms
• Scheduling imaging, lab, physician referrals, homecare services, transfusions, etc.
• Clinical trial eligibility, enrollment, data collection and entry, oversight and regulation of data

It is not uncommon, during a typical oncology office visit, to have to address not only the cancer and treatment toxicities but other potentially related issues such as blood sugars, sleep, pain, and abnormal labs. In addition, given that oncology care often requires frequent clinic visits for treatment and the close patient–cancer clinic relationship that develops, most oncologists would attest that it is not uncommon to assume at least part of the role of primary care for a patient during the time the patient is on active treatment. Oncologists often find themselves giving advice or treating a non-cancer related illness such as a urine infection or skin rash.

Oncologists are as generous as any other field of medicine when it comes to putting patients first, even at the cost of their personal time and resources. However, in today’s environment, which includes a world of “prove your quality to maintain your existence,” it is time that oncology is recognized and compensated fairly for all we provide and not just for administration of infusion drugs. When CMS developed the average wholesale price payment program years ago, it was recognized that the infusion drug margin would also cover the many non-reimbursed services.

More recently, policy makers have lost sight of this and erroneously see the drug margin as only oncology overcompensation. We are in desperate need of a mechanism in the reimbursement system to be compensated fairly for the services provided such as a “cancer management” fee, which has been suggested by some experts in the field.