Adapting to Changes in Practice-Based Hematology

It is not news that the practice of hematology today looks much different than it did in 1958 when the American Society of Hematology was established. As 2014 draws to a close, practicing hematologists are finishing their first year having been faced with new board certification requirements, reimbursement policies, and the launch of the Patient Protection and Affordable Care Act health exchanges.

Faced with this changing landscape, and in an effort to be proactive and strategically focus the future initiatives of ASH’s Committee on Practice (COP), a planning task force was charged with examining the current COP activities, identifying and prioritizing the major issues affecting the practice of hematology, and providing specific recommendations to the COP for short- and long-term priorities. As part of that process, the COP initiated a research survey designed to gather a current and comprehensive understanding of its practice-based clinical community of members and their needs.

“We decided to do this survey because of the challenges we felt are facing practicing hematologists,” said Steven Allen, MD, chair of the ASH Committee on Practice and associate chief of hematology at the North Shore-LIJ Cancer Institute. “The practice environment has changed tremendously over the past few years, and we felt it was important to determine what the current demographics of practicing hematologists are, and what issues they are facing so that ASH could align its programs and policies to meet the needs of the practicing hematology community.”

Recently, ASH Clinical News spoke with Dr. Allen and other practice-based hematologists about the current state of their practices, the results of the ASH COP survey, and whether or not they feel the survey results accurately reflect the current state of practice-based hematology in the United States. What follows are some of the findings from the survey.

Many Hematologists Are Starting Down the Road to Retirement

In 2013, a Survey of Practice-Based Hematology was sent to 5,081 physicians, who represented U.S. ASH members classified as practice-based/clinical physicians who see patients for at least 40 percent of their work week. The total number of physicians surveyed represented 36 percent of ASH’s entire membership.

Seventy-six percent of respondents to the online survey were adult hematologists, and 18 percent were pediatric hematologists. For this analysis, 6 percent of respondents who self-identified as “retired” or “no longer in practice” were removed.

The typical, or median, respondent to the survey completed his or her fellowship 18 years ago, in 1996. Overall, the proportion of respondents completing fellowship within each four-year increment since 1980 was consistent.

According to Dr. Allen, one of the most surprising findings of the practice survey was that one in four respondents (24%) indicated that they are considering retiring in the next five years.

“This indicates that in the near future there is going to be a manpower crisis in hematology, and the demands on the remaining practitioners and the patient loads are going to increase,” Dr. Allen said.

Judith Kleinerman, MD, a practicing hematologist with Steward Medical Group Medical Specialists of Taunton, in Massachusetts, is among the group of physicians actively thinking about retirement. Dr. Kleinerman falls into the median age group of the respondents of this survey, having finished her fellowship in 1996. Until two years ago, Dr. Kleinerman worked with a partner in a two-person, private hematology/oncology practice; however, the practice is now owned by a larger medical group.

“I do think about slowing down in a couple of years and, ultimately, retiring in five to six years,” Dr. Kleinerman said. “Doctors work unusually long, hard, and stressful hours and start to feel the need to slow down and enjoy life.”

The Problems with Recruitment: Expectations Versus Reality

With a number of hematologists considering retirement, it’s no surprise that 42 percent of respondents reported that they were actively recruiting new physicians to their groups, with the likelihood of recruitment correlating to the size of the practice (FIGURE).

Eighty-three percent of respondents would only consider recruiting a physician who was board-certified or eligible in hematology by the American Board of Internal Medicine and/or board-certified or eligible in hematology-oncology by the American Board of Pediatrics.

However, recruiting qualified candidates may be easier said than done. Although Dr. Kleinerman said her retirement is likely still a few years away, her business partner, an oncologist, is looking to retire now, and they are finding it difficult to find his replacement.

“In our practice, my partner and I have been working every other weekend for years — nobody is going to accept a job like that,” Dr. Kleinerman said. “People coming out of training now have different expectations in terms of personal time.”

Dr. Kleinerman said that she and her partner have asked their affiliated hospital for assistance, even going so far as to take a pay cut to finance their search, but are having little luck.

Kenneth Adler, MD, is a practicing hematologist at Regional Cancer Care Associates in New Jersey, one of the largest oncology physician networks in the country. Dr. Adler said that his practice has recently hired two physicians, but that he was beginning to notice an interesting trend among applicants.

“We received about 30 to 40 applications for each position – our practice is in a desirable place to live and raise a family. However, only a few of the applicants were graduates from American medical schools,” Dr. Adler noted. “American graduates are graduating with debt and seem to not be choosing to go into cognitive specialties like hematology, but rather gravitating to procedure-based specialties.”

Drs. Adler and Allen both agreed that something needs to be done to try to engage more medical students in the field of hematology, and ASH has definitely made that one of its short- and long-term goals, Dr. Allen said.

“Even among those who go into hematology/oncology fellowship, many trainees tend toward solid tumors and shy away from hematology because it is a challenging and difficult field,” Dr. Allen said. “ASH needs to emphasize the satisfaction that can be achieved by taking care of patients with these fascinating and challenging conditions.” 

Landscape of Mergers

As chair of ASH’s COP, Dr. Allen said he had noticed a new trend emerging even among the COP members in recent years: More members are affiliating with a hospital or with a non-hospital large physician group. The results of the recent survey seem to confirm this trend on a national basis.

Results indicated that:

  • 47 percent of respondents work for a practice owned by an academic medical center
  • 25 percent worked for a community-based private practice not owned by a hospital or larger entity
  • 19 percent worked for a hospital-based practice at a non-academic medical center
  • 9 percent worked for a practice owned by a large, non-hospital entity

More than half of the hematologists who had practices other than community-based private practices indicated that their practice is affiliated with a larger practice, hospital, academic medical center, or health-care system. That number is only expected to increase: 18 percent of respondents from community-based private practices indicated that their practice is planning to merge with or be acquired by a larger practice, hospital, academic medical center, or health-care system in the next three years.

Dr. Adler pointed out that with the average survey respondent having completed training 17 years ago, this survey may have failed to capture younger trainees, or that such a high number of respondents from academic centers may indicate that these hematologists had more time to respond to the survey than those in private or community-based practices.

However, similar to the trends seen in the survey, both Dr. Adler’s and Dr. Kleinerman’s practices have merged with larger entities in recent years.

In Dr. Adler’s case, the hematology practice that he and a partner started in northern New Jersey in 1978 enjoyed several years of success, growing to include 12 hematologists/oncologists. Eventually, though, the practice could no longer financially sustain itself. Dr. Adler’s practice became a part of Regional Cancer Care Associates – a group that spans the length of New Jersey from Hackensack to Cape May.

“We were busy, but reimbursement plummeted, overhead went up, and revenues dropped,” Dr. Adler said of the decision to merge.

Dr. Kleinerman’s small private practice was located in a medical office building associated with a small, private, nonprofit hospital nearby. However, two years ago, she and her partner’s practice was bought by Steward Medical Group, an employed physician group that is part of Steward Health Care System, a community-based accountable care organization formed with an investment from Cerberus Capital Management.

“I had built a pretty large hematology practice, but we could not afford to run our practice anymore,” Dr. Kleinerman said, echoing the reasons Dr. Adler gave for choosing to partner with a larger organization.

Increasing Demands, Decreasing Reimbursement             

The survey also asked respondents, in an open-ended fashion, to identify some of the major issues affecting their practices. So, what keeps hematologists up at night? The most common issues are:

  • reimbursement (25%)
  • staffing (23%)
  • insurance issues (15%)
  • increasing costs (13%)
  • electronic medical/health records or documentation issues (12%)

In addition, respondents reported spending an average of 29.8 percent – or a little less than one-third of their time – on patient care-related issues that are not billable.

“I think this is an accurate reflection of what goes on in a real practice,” Dr. Allen said. “A large percentage of one’s time is spent doing work that is not reimbursable.”

Dr. Kleinerman explained that hematology can be a challenging and intimidating specialty, and that she often spends a lot of time explaining and reassuring patients or their family members about their conditions. In addition to communicating with patients, Dr. Adler explained that many of these conditions also require discussion or consultation with other physicians or specialists.

According to Dr. Adler, hematologists have been working for years to try to get reimbursement for their cognitive work with little success.

Hematologists are also faced with some of the same time-consuming challenges facing other medical specialties. Although Dr. Adler has been involved with the development of many hematology quality measures and is a supporter of the Affordable Care Act, he is also concerned that time spent entering data into electronic health records and forms for quality measures is “sucking the life out of  physicians.”

Dr. Kleinerman echoed these sentiments, adding that the practice of medicine today is not necessarily what physicians signed up for 20 or 30 years ago.

“Physicians are not able to take care of patients in the same way,” Dr. Kleinerman said. “Physicians are ordered to document, see a lot of patients, and move fast.”

Hematology, though, does not lend itself well to this type of practice. “Our patients are very sick, very complicated patients who require a lot of thought and time to assess,” Dr. Allen said. “We have to call insurance companies to convince them to give permission for treatment, fill out disability forms, or return calls to patients or their families — and, unlike attorneys, we do not bill for this time.”

Weighing the Benefits

Working within a larger group may help to alleviate some of the non-reimbursable issues many hematologists may deal with in smaller private practices, but every silver lining has a cloud, so to speak.

Prior to joining the larger Regional Cancer Care Associates, Dr. Adler said his smaller 12-person group was able to negotiate decent prices with insurance providers or drug companies, but they simply did not have the same kind of negotiating power as local hospitals or larger groups.

Billing is another area where the larger group practice setting affords some benefit, Dr. Adler noted. Rather than being completed through 20 offices spread around the state, billing is now completed with one Medicare provider number through one central office. This simplified approach reduces each practice’s overhead.

Dr. Kleinerman has seen similar benefits and is relieved to no longer be dealing with the management of day-to-day finances of the practice. In her two-physician practice, there was constant concern about taking care of the staff, and, as reimbursement dwindled, the practice was forced to stop giving pay increases. As part of Steward Medical Group, Dr. Kleinerman earns a higher salary and no longer has the added pressure of worrying about providing for her staff. In addition, the larger group provides her with support services — for example, help with coding and reimbursement that she did not previously have access to.

There are drawbacks as well, Dr. Kleinerman said. As a small practice, she and her partner made all of the rules and had more flexibility in patient care and scheduling. The decision to merge with a larger group made financial sense for the practice, but it has also come with an adjustment period, she said.

ASH Addressing Change

“Clearly, the whole structure of hematology practice is changing. The Society needs to be aware of that so it can address the problems people face in making that transition and working in that environment,” Dr. Allen said.

To ensure that ASH’s efforts are aligned with the needs of practicing hematologists, the survey also asked respondents what the most valuable product or service would be that ASH could provide in the next three years to help their practice. Among the most commonly mentioned items were: education (13%), guidelines/pocket guides/standards of care (11%), and advocacy/lobbying/political action/support (10%).

According to Dr. Allen, the ASH COP is actively discussing the survey results and working to identify short- and long-term goals in addressing them.

In the short-term, ASH is planning a lunch session, titled “ASH Practice Partnership Lunch: Whither the Practice of Hematology in an Era of Mergers?”, at the 2014 annual meeting in San Francisco on Sunday, December 7, at 11:15 a.m. This session will focus on the challenges associated with mergers between traditional community-based private practices and larger health-care systems.

ASH is also working to address some of the workforce issues highlighted by the survey results. In addition to trying to attract more young physicians to the field of hematology, ASH is continuing to actively work with oncologists who occasionally perform hematology consultations. Throughout the year, ASH will also hold numerous educational meetings and refresher courses teaching physicians about benign hematology – including at the American Society of Clinical Oncology’s annual meeting – to help improve the level of hematology care provided around the country.

“People realize subconsciously that it is important for all members of the Society to see how much the practice of hematology has evolved and changed in the past few years,” Dr. Adler said. “There has been a rapid evolution — most practices are not small, community-based practices anymore. That changes how we function as a specialty and which challenges we face. ASH needs to keep that in mind and continue to help its members adapt.” — By Leah Lawrence


SIDEBAR
The practice landscape may be changing, but there is always one constant: ASH is here to help you meet these challenges. The Society is dedicated to meeting the needs of its clinical community, below are some of the efforts currently underway:

  • ASH Practice Partnership (APP): The APP is a network of selected group of practices that share information about practice issues in their locations
  • ASH Practice Partnership Lunch at this year’s Annual Meeting: The topic of this year’s presentation is “Whither the Practice of Hematology in an Era of Mergers?” (Sunday, December 7, 11:15 a.m.), and will feature remarks from Alice Gosfield, Esq., and Andrew Pecora, MD, an attorney and physician who have been involved with mergers. Led by chair Steven Allen, MD, this session will focus on the challenges associated with mergers between traditional community-based private practices and larger health-care systems.
  • Drug Resources Webpage: ASH has developed a webpage focused on improving access to high-cost drugs, including names and contacts for patient assistance programs, sample appeal letters for high-cost hematologic drugs, and up-to-date information on hematologic drug shortages.
  • ASH Resources for Clinicians: The Society has created materials covering changing practice and workforces issues that impact hematologists, such as the transition to the ICD-10 diagnosis system, the Medicare Physician Quality Reporting system, and the Sunshine Act data release. Access these resources at hematology.org/Clinicians.
  • New Payment Models: ASH is currently developing policy on the role of new payment models for hematologic illness including both malignant and non-malignant disease.

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