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Projected Supply of and Demand for Oncologists and Radiation Oncologists Through 2025: An Aging, Better-Insured Population Will Result in Shortage

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The American Society of Clinical Oncology (ASCO) published a study in 2007 that anticipated a shortage of oncologists by 2020. This study aims to update and better assess the market for chemotherapy and radiation therapy and the impact of health reform on capacity of and demand for oncologists and radiation oncologists. The supply of oncologists and radiation oncologists, by age, sex, and specialty, was projected through 2025 with an input-output model. The Medical Expenditure Panel Survey, commercial claims, and Medicare claims were analyzed to determine patterns of use by patient characteristics such as age, sex, health insurance coverage, cancer site, physician specialty, and service type. Patterns of use were then applied to the projected prevalence of cancer, using data from the SEER Program of the National Cancer Institute. Beginning in 2012, 16,347 oncologists and radiation oncologists were active and supplying 15,190 full-time equivalents (FTEs) of patient care. Without consideration of the Affordable Care Act (ACA), overall demand for oncologist services is projected to grow 40% (21,255 FTEs), whereas supply may grow only 25% (18,997 FTEs), generating a shortage of 2,258 FTEs in 2025. When fully implemented, the ACA could increase the demand for oncologists and radiation oncologists by 500,000 visits per year, increasing the shortage to 2,393 FTEs in 2025. Anticipated shortages are largely consistent with the projections of the ASCO 2007 workforce study but somewhat more delayed. The ACA may modestly exacerbate the shortage. Unless oncologist productivity can be enhanced, the anticipated shortage will strain the ability to provide quality cancer care.
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Original Contribution
Projected Supply of and Demand for Oncologists and
Radiation Oncologists Through 2025: An Aging,
Better-Insured Population Will Result in Shortage
By Wenya Yang, MPA, MA, James H. Williams, Paul F. Hogan, MS,
Suanna S. Bruinooge, Gladys I. Rodriguez, MD, Michael P. Kosty, MD, FACP, FASCO,
Dean F. Bajorin, MD, FASCO, Amy Hanley, Ashley Muchow, Naya McMillan, DrPH,
and Michael Goldstein, MD, FASCO
The Lewin Group, Falls Church; American Society of Clinical Oncology, Alexandria, VA; South Texas Oncology and
Hematology, San Antonio, TX; Scripps Clinic, La Jolla, CA; Memorial Sloan-Kettering Cancer Center, New York, NY; and Beth
Israel Deaconess Medical Center, Boston, MA
Abstract
Purpose: The American Society of Clinical Oncology (ASCO)
published a study in 2007 that anticipated a shortage of oncol-
ogists by 2020. This study aims to update and better assess the
market for chemotherapy and radiation therapy and the impact
of health reform on capacity of and demand for oncologists and
radiation oncologists.
Methods: The supply of oncologists and radiation oncolo-
gists, by age, sex, and specialty, was projected through 2025
with an input-output model. The Medical Expenditure Panel Sur-
vey, commercial claims, and Medicare claims were analyzed to
determine patterns of use by patient characteristics such as age,
sex, health insurance coverage, cancer site, physician specialty,
and service type. Patterns of use were then applied to the pro-
jected prevalence of cancer, using data from the SEER Program
of the National Cancer Institute.
Results: Beginning in 2012, 16,347 oncologists and radiation
oncologists were active and supplying 15,190 full-time equiva-
lents (FTEs) of patient care. Without consideration of the Afford-
able Care Act (ACA), overall demand for oncologist services is
projected to grow 40% (21,255 FTEs), whereas supply may grow
only 25% (18,997 FTEs), generating a shortage of 2,258 FTEs in
2025. When fully implemented, the ACA could increase the de-
mand for oncologists and radiation oncologists by 500,000 visits
per year, increasing the shortage to 2,393 FTEs in 2025.
Conclusion: Anticipated shortages are largely consistent with
the projections of the ASCO 2007 workforce study but some-
what more delayed. The ACA may modestly exacerbate the
shortage. Unless oncologist productivity can be enhanced, the
anticipated shortage will strain the ability to provide quality can-
cer care.
Introduction
In 2007, a study commissioned by the American Society of
Clinical Oncology (ASCO) estimated a 14% increase in supply
of services provided by oncologists and radiation oncologists
and a 48% increase in demand for such services by 2020, re-
sulting in a shortage when comparing the base supply-and-
demand scenarios.
1
The projections under the base scenarios
were created by applying the then-current cancer prevalence
rates and Medicare use pattern to the expected US population
through 2020. (In the 2007 ASCO study, the youngest age
group in the National Cancer Institute [NCI] visit analysis (65
to 69 years) was used as the use pattern for all patients with
cancer age 70 years.) Although the ASCO study did not
cover radiation oncologists, a study published in 2010 pro-
jected that by 2020, the demand for radiation therapy would
grow 10 times faster than the supply of radiation oncologists.
2
Many factors influence the supply of and demand for oncol-
ogy services, including changes in the incidence and prevalence
of cancers, population demographics, insurance status and type,
and changes in physician retirement rates and productivity.
Since the publication of the 2007 oncologist supply-and-de-
mand projections, the NCI has updated its cancer prevalence
projections based on more recent SEER data. Another signifi-
cant driver of the demand for oncologists and radiation oncol-
ogists will be the implementation of the Affordable Care Act
(ACA). The ACA is anticipated to have a profound impact on
public and private health plan enrollment and use of oncologist
services. This study provides an update of the projected supply
of and demand for oncologists and radiation oncologists
through 2025, simulating the impact of the ACA health cover-
age expansion.
Methods
ASCO contracted with The Lewin Group to develop an oncol-
ogist supply-and-demand model that projects the supply of and
demand for oncologist services over time (2012 to 2025) by
physician specialty: radiation oncology and a composite of on-
cology (including hematology/oncology, hematology, medical
oncology, gynecologic oncology, and pediatric hematology/on-
cology), hereafter referred to as oncologists. Future demand for
oncologist services is projected by patient characteristics (eg, age
[65 and 65 years], sex, type of health insurance coverage,
Health Policy
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cancer site, and service type [chemotherapy/radiation therapy v
other]).
We calculated two commonly used measures to track oncol-
ogist and radiation oncologist active supply: one, the number of
oncologists and radiation oncologists actively engaged in pa-
tient care activities, and two, a full-time equivalent (FTE) on-
cologist to account for variation in provider engagement in
clinical care. For both the supply-and-demand computations,
we adopted an empirical definition of an FTE oncologist/radi-
ation oncologist. We defined an FTE as the expected number of
patient visits that an average oncologist or radiation oncologist
engaged full time in clinical care would provide in a year. We
used the base year, 2012, to define an FTE in terms of annual
patient visits by dividing specialty-specific demand by the num-
ber of physicians primarily providing clinical care in each spe-
cialty, adjusting for physicians providing clinical care on a part-
time basis.
Supply Analysis
We estimated the total supply of oncologists and radiation on-
cologists by specialty at the beginning of base year 2012. In each
subsequent year, we projected the supply of oncologists and
radiation oncologists with an input-output or inventory model.
Beginning with the 2012 count of active physicians, we applied
age- and sex-specific probabilities of leaving the workforce an-
nually because of retirement or death. New physicians, having
completed their appropriate education, residency, and fellow-
ship training, would enter the workforce by age-, specialty-, and
sex-specific probability each year. We projected supply into
2025 under a baseline scenario and four alternative scenarios.
Current Supply
To derive the number of clinically active oncologists and radi-
ation oncologists in the 2012 base year, we extracted health
provider data from Provider360, an OptumInsight database
that contains demographic, geographic, and clinical character-
istics on more than 3 million health providers.
3
We used 2 years of productivity estimates from Medical
Group Management Association (MGMA) Physician Com-
pensation and Production Survey to observe variation in the
productivity of oncologists and radiation oncologists by years of
experience, sex, specialty, and full- versus part-time clinical care
(including administrators, researchers, and teachers; excluding
nonpatient care and unclassified).
4,5
For example, we found
that hematologist-oncologists with 18 years of experience
provided 120% more visits than hematologist-oncologists with
1 to 2 years of experience. The data also showed that male
hematologist-oncologists delivered 17% more visits than their
female colleagues, whereas male gynecologic oncologists deliv-
ered 6% fewer visits than their female colleagues.
To estimate the proportion of oncologists and radiation on-
cologists who provided clinical care only part of the time, we
linked the American Medical Association (AMA) Physician
Masterfile
6
with Provider360 to identify physicians who self-
designated as primarily providing direct patient care or primar-
ily providing other services (eg, teaching).
Projected Future Supply
After calculating the current supply of oncologists and radi-
ation oncologists by specialty in year 2012, we projected the
future supply of these physicians based on the following
scenarios:
Baseline supply. Beginning with the current workforce of on-
cologists and radiation oncologists in January 2012, we aged the
workforce by applying age- and sex-specific joint probability of
retirement and mortality annually. We applied mortality rates
from national vital statistics
7
and historical rates of retirement
for internal medicine physicians
8
to the projection of oncolo-
gists and radiation oncologists. All oncologic specialists were set
to leave the workforce by age 75 years. Residents and fellows
completing all accredited training programs in 2012 and 2013
entered the workforce. Projections of graduating residents and
fellows from 2014 to 2016 were based on recent matched data
from the National Residency Match Program, adjusted to ac-
count for residents historically matched outside the process who
go on to complete Accreditation Council for Graduate Medical
Education training.
9,10
The flow of new entrants was constant
over time after 2016. We subtracted graduating residents and
fellows who left the country or entered primarily nonclinical
careers.
11
Change in oncology fellowship slots. We estimated a one-time,
permanent 10% increase in fellowship positions in 2013 and
project specialty–specific fellowship positions, assuming that
positions would be matched at historical rates (2008 to 2012).
This scenario may be unlikely to happen because of the signif-
icant challenge of securing additional funding for the increase
in positions. We also estimated the impact of a one-time 10%
decrease in fellowship positions in 2013.
Change from historical retirement rates. We assessed the impact
of a 10% increase and 10% decrease in the proportion of phy-
sicians, by age and sex, who remained in clinical practice each
year.
Demand Analysis
The national market demand for oncologist and radiation
oncologist services can be defined as the mix of services that
society is willing to pay for based on population epidemiologic
needs, economic constraints such as household income, level of
health insurance coverage, and price of services, and availability
of advanced treatments. Population needs for oncologist and
radiation oncologist services are highly correlated with demo-
graphics and prevalence of cancer. Projected increases in popula-
tion, especially growth in the elderly population with cancer
diagnoses, suggest growth in demand for oncologist services. Level
of use of oncologist services by patient age group, sex, health insur-
ance coverage, cancer site, physician specialty, and service type were
applied to the combined projected prevalence of cancer and likeli-
hood of holding various health insurances, with and without the
ACA.
Yang et alYang et al
40 JOURNAL OF ONCOLOGY PRACTICE •VOL. 10, ISSUE 1Copyright © 2014 by American Society of Clinical Oncology
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Copyright © 2014 American Society of Clinical Oncology. All rights reserved.
Estimates and Projections of Cancer Prevalence
As an update of previous work, cancer prevalence for 17 cancer
sites (Data Supplement) was estimated by the NCI using more
recent SEER data that included patients diagnosed from 1975
through 2008.
12
Patients with cancer were classified by the site
of their first diagnosis. The cancer prevalence projection meth-
ods have been described elsewhere.
12,13
The base prevalence
projection assumed that future incidence and survival rates were
constant and based on the average rates from the most recent
data period, 2006 through 2008, for each cancer site by age
group and sex.
Current Demand
We calculated the probability of a patient with cancer seeing an
oncologist once in a year versus two or more times in a year and
calculated the average annual per-patient oncologist and radia-
tion oncologist visits. We identified visits related to chemother-
apy or radiation therapy based on diagnosis, procedure, and
national drug codes (Data Supplement). For oncologists and
radiation oncologists, we classified any visit where chemother-
apy or radiation therapy was not administered as an “other”
visit. An examination of the services provided during these
other visits revealed that across cancer sites, up to 50% of these
other visits were for patient evaluation and management. A
majority of services provided by radiation oncologists were re-
lated to radiation therapy, with a small proportion of other
visits.
To calculate the use rates for privately insured patients with
cancer, we used the OptumInsight medical claims database,
which contains historical medical and pharmacy claims for ap-
proximately 25 million geographically diverse covered lives per
year. For patients with cancer age 65 years, we used the
Medicare medical claims 5% sample data. For patients with
cancer age 65 years who were covered by other public insur-
ance or uninsured, we used data from the Medical Expenditure
Panel Survey outpatient and physician files (2006 to 2010 for
larger sample size) to estimate the difference between use of
privately insured patients and use of those with public insurance
(eg, Medicaid) or with no insurance.
14
In a regression analysis
(Data Supplement), we found a statistically significant rate of
use for other visits only when comparing uninsured with pri-
vately insured patients, but not when comparing publicly with
privately insured patients. Consequently, we only applied the
rate ratio of the uninsured as compared with the privately in-
sured for other visits to the use patterns of other visits from the
privately insured to estimate use by the uninsured. We assumed
that those with public insurance would use the same level of
oncologist and radiation oncologist services as those with pri-
vate insurance.
To estimate health insurance coverage of the population by
age and sex before and after the ACA, we used estimates from
the health benefits simulation model, a microsimulation model
of the US health care system designed to provide estimates at
the national, state, and county levels of changes in coverage and
health spending.
15
We benchmarked total insured Americans
to Congressional Budget Office February 2013 estimates,
which anticipate a gradual uptick in health insurance coverage
until full ACA implementation in 2017.
16
The February 2013
health insurance coverage estimates take into account states that
decided to partially expand or not expand Medicaid programs
at that point in time. Large geographic disparities of health
insurance coverage currently exist across the country and may
change after health reform as states implement the ACA.
17
Projected Future Demand
The demand for oncologists and radiation oncologists was pro-
jected under the following scenarios:
Baseline demand. The baseline total demand for FTE physi-
cians engaged in clinical care was projected based on NCI base
prevalence projections, assuming the probability of seeing an
oncologist or radiation oncologist and the per-patient use pat-
terns remained the same as in the base year of 2012. Under this
scenario, future population distribution by insurance coverage
(private, public, Medicare, and uninsured) was assumed to re-
main constant as observed in year 2012.
Health reform. We projected the changes in health insurance
coverage by age and sex from 2014 to 2017 (with anticipated
full implementation of the ACA) and assumed that future
health insurance distribution would remain the same as in year
2017. Using the probability of seeing an oncologist or radiation
oncologist and use patterns of oncologist and radiation oncol-
ogist services as in the base year of 2012, we estimated total
national demand for FTE oncologists and radiation oncologists
engaged in clinical care under the ACA until 2025.
Results
Supply Analysis
We found that approximately 16,347 oncologists and radiation
oncologists were clinically active and filing medical claims for
patients with cancer diagnoses in 2012. Among these, there
were 13,070 oncologists and 3,277 radiation oncologists.
We found that 16% of oncologists and 5% of radiation
oncologists provided clinical care on a part-time basis. These
oncologists and radiation oncologists engaged in part-time
clinical care delivered 48% of the patient care visits that their
peers in full-time patient care provided. This finding is con-
sistent with those of prior surveys showing academic oncol-
ogists, on average, spent 48.3% of their time on clinical
activities.
18
As a result of lower clinical productivity, we
estimated by experience and sex the number of oncologists
and radiation oncologists providing FTE patient care in the
beginning of 2012 to be 15,190, including 12,000 oncolo-
gists and 3,190 radiation oncologists.
The total supply of oncologists and radiation oncologists
(counting those engaged in full- and part-time clinical care) is
projected to increase by 29% to 21,066 in 2025. The number of
physicians delivering an FTE number of clinical care visits is
expected to rise by 25% to 18,997 in the same year (Figs 1A to
1C). This slower growth in oncologists and radiation oncolo-
Projected Supply of and Demand for Oncologists Through 2025Projected Supply of and Demand for Oncologists Through 2025
JANUARY 2014 • jop.ascopubs.org 41Copyright © 2014 by American Society of Clinical Oncology
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Copyright © 2014 American Society of Clinical Oncology. All rights reserved.
gists who provide an FTE of clinical care indicates that the
oncologist and radiation oncologist workforce as a whole will
deliver fewer patient care visits over the next decade. This de-
crease is mainly the result of the retirement of physicians who
deliver (on average) larger numbers of patient visits and of
changes in physicians’ demographic characteristics.
Demand Analysis
Under the ACA, an estimated 25 million Americans could gain
public and private health insurance as of 2017, leaving approx-
imately 30 million still uninsured.
16
Although the ACA makes
health insurance available to millions of Americans in 2014,
implementing the law will take time. To estimate market de-
mand for oncologists and radiation oncologists, we applied in-
surance-specific use rates to the cancer populations with the
respective insurance coverage. We assumed that those who were
newly insured and age 65 years would use oncologist and
radiation oncologist services at the same rate as currently cov-
ered Americans with the same types of insurance. Assuming
these same use patterns and full implementation of the ACA,
the newly insured will increase demand for clinical oncologists
and radiation oncologists by 500,000 visits in 2025 alone. As a
result, 2 million visits that would have been demanded by un-
insured populations without the ACA will instead come from
the private and public insurance markets, and demand will
therefore rise to 1.1 million and 1.4 million visits in 2025,
respectively (Appendix Fig A1, online only).
From 2012 to 2025, the overall market demand for oncol-
ogy services is expected to rise 40%, under the baseline, to 83.4
million oncology visits. In that period, more than 11 million
elderly Americans will become Medicare recipients, a popula-
tion that we estimate will increase demand from 39 to 61 mil-
lion oncology visits. In comparison, Americans age 65 years
will increase overall demand by 2 million visits to a total of 22
million visits in 2025. The proportion of chemotherapy (31%
to 32%) or radiation therapy visits (84% to 85%) provided by
each specialty will remain steady over time from 2012 to 2025
(Fig 2).
While controlling for age, sex, health insurance coverage,
cancer site, physician specialty, and service type, we projected
demand assuming that patterns of patient use would remain
constant from 2012 to 2025. Under the baseline, we project
that an additional 1,521 oncologists and 737 radiation oncol-
ogists engaged in FTE clinical care, a total of 2,258 clinical care
FTEs, will be needed across the United States by 2025 (Figs 3A
to 3C). In 2025, Americans newly insured under the ACA will
increase the demand by an additional 130 oncologists and five
42.4
59.8
17.2
23.6 0.5
2025
2012
No. of Visits (millions)
80
90
100
70
60
50
40
30
20
10
0
Oncologists
Radiation oncologists
Health reform
Figure 2. Baseline demand and health reform demand by oncologist
and radiation oncologist visits.
A
B
C
2012
2013
2014
2015
2016
2017
2018
FTEs
FTEs
FTEs
2019
2020
2021
2022
2023
2024
2025
Oncs/Rad Oncs (thousands)
Year
22
21
20
19
18
17
16
15
14
13
2012
2013
2014
2015
2016
2017
2018
2019
2020
2021
2022
2023
2024
2025
Oncs (thousands)
Year
18
17
16
15
14
13
12
11
10
2013
2014
2015
2016
2017
2018
2019
2020
2021
2022
2023
2024
2025
Rad Oncs (thousands)
Year
3.9
3.7
3.5
3.3
3.1
2.9
2.7
2.5
2012
10% growth in fellowship slots
Retirement rates 10% lower
Baseline supply FTE
Retirement rates 10% higher
10% decrease in fellowship slots
Rad onc count
10% growth in fellowship slots
Retirement rates 10% lower
Baseline supply FTE
Retirement rates 10% higher
10% decrease in fellowship slots
Onc count
10% growth in fellowship slots
Retirement rates 10% lower
Baseline supply FTE
Retirement rates 10% higher
10% decrease in fellowship slots
Total onc and rad onc count
Figure 1. Projections of oncologist supply by scenario. (A) total oncol-
ogists (Oncs) and radiation oncologists (Rad Oncs); (B) oncologists; (C)
radiation oncologists. FTE, full-time equivalent.
Yang et alYang et al
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Copyright © 2014 American Society of Clinical Oncology. All rights reserved.
radiation oncologists engaged in FTE clinical care, resulting in
a total shortfall of 2,393 clinical care FTEs.
Discussion
This study was initiated to better assess the current market for
oncologist and radiation oncologist services and forecast the
supply of and demand for oncologists and radiation oncologists
in the future, with and without the impact of the ACA. At the
national level, overall demand for oncologists and radiation
oncologists is expected to grow 40%, whereas the FTE clinical
care oncologist and radiation oncologist supply may grow by
only 25% by 2025 under the baseline projection, resulting in a
market shortage of 2,258 additional FTE clinical care oncolo-
gists and radiation oncologists in 2025. With the full imple-
mentation of the ACA, this shortfall increases to 2,393 clinical
care FTEs.
This study contributes empirical evidence on differentiated
patterns of use by the privately insured, publically insured, and
uninsured. Among patients with cancer age 65 years, we
found that uninsured patients demanded approximately 50%
fewer other visits (ie, non–chemotherapy/radiation therapy–
related visits) provided by oncologists and radiation oncologists
than privately insured patients. A distinction was also made
between patient use of chemotherapy, radiation therapy, and
other oncology-related visits. Although we estimated that the
demand for chemotherapy and radiation therapy may increase
by 37% and 35%, respectively, the proportion of specialty-
specific demand made up by chemotherapy or radiation therapy
will remain stable.
On the supply side, the prior 2007 study found that 32% of
oncologists and radiation oncologists worked in the academic
setting, providing 48% fewer clinical services than their peers in
private practice. Our analysis of AMA Physician Masterfile and
OptumInsight data estimated the proportion of part-time clin-
ical care oncologists and radiation oncologists to be 16% and
5%, respectively. We estimated that 1,000 more clinical FTE
oncologists will be needed by 2020 alone, which is lower than
the earlier estimated shortages of 2,550 to 4,080 FTEs.
1
The
estimated shortage in the Erikson et al study was smaller be-
cause the study estimated Medicare-equivalent demand for
people age 65 years and classified oncologists and radiation
oncologists engaged in part-time clinical care more broadly (eg,
all academics).
Our study is limited in that it provides a narrow perspective
on the market for oncologists and radiation oncologists, while
excluding markets for other clinicians who may see patients
with cancer. For example, we could not accurately assess the
current involvement of advanced-practice providers (ie, nurse
practitioners and physician assistants) in cancer treatment, be-
cause it is common to file claims under the oncologist or radi-
ation oncologist when provided incident to the physician.
Because of the limited evidence often drawn from small samples
of oncologists on the variations of productivity, we used 2 years
of data from the MGMA to assess the potential productivity
changes in the future based on projected changes in oncologist
demographics. Future research should focus on more precise
productivity estimates and benchmarks. Our study also as-
sumed a constant pattern and level of involvement by other
specialists, such as surgical oncologists, urologists, and primary
care physicians; however, their involvement in cancer care may
change over time. Although we used health claims data from
both Medicare and a large national private health plan, new
requirements under the ACA will lead to different insurance
A
B
C
2012
2013
2014
2015
2016
2017
2018
2019
2020
2021
2022
2023
2024
2025
FTE Oncologists (thousands)
22
21
20
19
18
17
16
15
14
2012
2013
2014
2015
2016
2017
2018
2019
2020
2021
2022
2023
2024
2025
FTE Oncologists (thousands)
18
17
16
15
14
13
12
11
2013
2014
2015
2016
2017
2018
2019
2020
2021
2022
2023
2024
2025
FTE Oncologists (thousands)
4.5
3.7
3.9
4.1
4.3
3.5
3.3
3.1
2.9
2.7
2.5
2012
Oncology demand
Oncology supply
Health reform
Oncology demand
Oncology supply
Health reform
Oncology demand
Oncology supply
Health reform
Year
Year
Year
15.6 16.0
16.4
16.9
17.3
17.8
18.2
18.7
19.2
19.7
20.2
20.7
21.3
15.2 15.3 15.5 15.7 16.0 16.3 16.6 16.9 17.3 17.6 18.0 18.3 18.6 19.0
16.1
16.5
17.0
17.4
17.9
18.4
18.9
19.4
19.8
20.3
20.9
21.4
12.3 12.7 13.0
13.3
13.7
14.1
14.4
14.8
15.2
15.6
16.0
16.5
16.9
12.0 12.1 12.3 12.5 12.8 13.0 13.3 13.6 13.9 14.2 14.5 14.8 15.1 15.4
12.7
13.1
13.5
13.8
14.2
14.6
15.0
15.4
15.8
16.2
16.6
17.0
3.2 3.3 3.4 3.4 3.5 3.6 3.7 3.8 3.9 4.0 4.1 4.2
4.3
4.4
3.2 3.2 3.2 3.2 3.2 3.3 3.3 3.4 3.4 3.5 3.5 3.5 3.6 3.6
Figure 3. Baseline supply and demand scenarios through 2025. (A)
total oncologists; (B) oncologists; (C) radiation oncologists. FTE, full-
time equivalent.
Projected Supply of and Demand for Oncologists Through 2025Projected Supply of and Demand for Oncologists Through 2025
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Copyright © 2014 American Society of Clinical Oncology. All rights reserved.
products in the future and may cause patients to change the way
they demand care. The AMA Masterfile and OptumInsight
Provider360 are exhaustive databases of US physicians, but
some designations of primary specialty may be incorrectly re-
ported, and primary career activity may not be up to date,
rendering inaccurate productivity for clinicians switching ca-
reer roles in cancer care.
Because the employer mandate to provide health insurance
is delayed until 2015, complete implementation of the ACA
may not be achieved by 2017 as expected. If the implementa-
tion of the ACA faces more obstacles, access to health insurance
may take longer than previously expected. Although near-term
implementation is in question, in the long-term, the ACA is
estimated to generate additional market demand of 500,000
visits or 135 clinical FTE oncologists and radiation oncologists
per year. Market demand will vary by region, because popula-
tions of uninsured are geographically concentrated, and states
address health reform in many different ways. A forthcoming
study by the American Cancer Society, ASCO, and the Amer-
ican Society for Radiation Oncology will examine the geo-
graphic variation of oncology demand and location of
oncologists and radiation oncologists. At the start of 2013, se-
questration lowered Medicare payments by 2%, and the pay-
ment cut is expected to last for several years. This may lead
many oncologists and radiation oncologists to send Medicare
patients elsewhere for chemotherapy and turn down patients
lacking supplemental insurance.
19
Finally, research is mixed on
whether there is pent-up demand for health services, but there is
no evidence to suggest that newly insured patients with cancer
would demand more oncologist services than the currently in-
sured population.
Market projections in our study assumed constant pat-
terns of use and provider delivery, but recent developments
are likely to affect how care is provided. Through health
reform, hundreds of accountable care organizations (ACO)
have been formed, some implementing clinical pathways to
standardize oncology treatment, which are expected to stan-
dardize care and may enhance physician productivity and
reduce costs.
20
A survey conducted in 2011 found that 65%
of the health plans and health systems forming ACOs indi-
cated that oncology services were closely aligned or already
employed by the organizations, and another 30% had loose
affiliations with oncology providers.
21
Disease-specific
ACOs for oncology care would particularly focus on stan-
dardizing care pathways, using an integrated care approach,
and improving counseling of patients on how to manage the
course of disease. All these factors will likely affect care de-
livery patterns and hence the supply of and demand for
oncologist and radiation oncologist services.
Under any scenario presented here, market demand is ex-
pected to exceed supply of oncologists and radiation oncolo-
gists. Unless productivity can be enhanced in the near future,
additional oncology fellowship positions will be needed for on-
cology. To close the gap observed in our baseline supply-and-
demand projections by 2025, entering residency and fellowship
classes from 2014 to 2022 would have to increase by 210 for
oncology and 120 for radiation oncology. Because it is unlikely
that the US health system will expand physician training pro-
grams so dramatically on such a short time horizon, strategies to
improve the productivity of oncologists and radiation oncolo-
gists should be considered and evaluated to mitigate the short-
fall. Productivity effects of ACOs, patient-centered medical
homes, and team-based care models should be assessed specifi-
cally for the delivery of oncology services to understand how
these new models are changing the delivery of oncology care. As
office-based practices become more integrated with institu-
tions, oncologists and radiation oncologists may take on more
responsibility for integration of care, leaving less time for pa-
tient visits. For example, emergency physicians working in ac-
ademic settings have been found to spend more time on indirect
care and care coordination than their counterparts in commu-
nity hospitals.
22
Despite longer average work weeks for aca-
demic oncologists (56.3 hours) compared with those in private
practice (53.1 hours), the average academic spends 10% of that
time on administrative tasks, compared with just 4% of that
time by peers in private practice.
1
More collaborative and coordinated care by oncologists, ra-
diation oncologists, and advanced-practice providers may in-
crease productivity. A prior study found that oncology practices
that incorporated advanced-practice providers saw significantly
more new patients per FTE physician than practices not work-
ing with advanced-practice providers.
23
Oncology-specific
training for advanced-practice providers who trained outside of
oncology could also help increase the number and type of ser-
vices clinicians are able to provide together. This scenario may
be the most likely strategy to increase supply because the fund-
ing to increase fellowship training slots is uncertain.
Previous studies of the market for oncologists and radiation
oncologists estimated larger shortages, but we estimate that a
significant shortage may still occur unless productivity and sup-
portive clinical staff increase. Although more administrative
duties may come with ACOs, oncologists and radiation oncol-
ogists should prioritize cancer-specific standardized care path-
ways to make care coordination more fruitful. Oncology-
specific training for advanced-practice providers who are
trained outside the field of oncology and training for oncolo-
gists to enhance team-based care could increase the number of
patients oncology sites are able to serve.
Acknowledgment
Supported by Susan G. Komen for the Cure and the American Society
of Clinical Oncology (ASCO). Study design and statistical analysis was
performed under contract at The Lewin Group and in collaboration with
the ASCO Workforce Advisory Group (WAG). Presented in part at a
Capitol Hill briefing on October 24, 2013. We gratefully acknowledge
the important data and analysis contributed by Angela Mariotto, PhD,
acting branch chief of the Data Modeling Branch of the Surveillance
Research Program within the Division of Cancer Control and Population
Sciences at the National Cancer Institute. These data were an invalu-
able resource for the demand projections, and we appreciate Dr Mari-
otto’s expertise and efforts. We also thank the WAG members who
helped to make this project possible and M. Kelsey Kirkwood and
Deborah Kamin, PhD, of ASCO for their contributions to the study.
Yang et alYang et al
44 JOURNAL OF ONCOLOGY PRACTICE •VOL. 10, ISSUE 1Copyright © 2014 by American Society of Clinical Oncology
Information downloaded from jop.ascopubs.org and provided by at ASCO on January 17, 2014 from 206.205.123.242
Copyright © 2014 American Society of Clinical Oncology. All rights reserved.
Authors’ Disclosures of Potential Conflicts of Interest
Although all authors completed the disclosure declaration, the following
author(s) and/or an author’s immediate family member(s) indicated a
financial or other interest that is relevant to the subject matter under
consideration in this article. Certain relationships marked with a “U” are
those for which no compensation was received; those relationships
marked with a “C” were compensated. For a detailed description of the
disclosure categories, or for more information about ASCO’s conflict of
interest policy, please refer to the Author Disclosure Declaration and the
Disclosures of Potential Conflicts of Interest section in Information for
Contributors.
Employment or Leadership Position: Wenya Yang, The Lewin
Group (C); James H. Williams, The Lewin Group (C); Paul F. Hogan, The
Lewin Group (C); Suanna S. Bruinooge, American Society of Clinical
Oncology (C); Amy Hanley, American Society of Clinical Oncology (C);
Naya McMillan, The Lewin Group (C) Consultant or Advisory Role:
None Stock Ownership: James H. Williams, UnitedHealth Group;
Paul F. Hogan, United Health Group; Ashley Muchow, United Health
Group Honoraria: None Research Funding: None Expert Testi-
mony: None Patents, Royalties, and Licenses: None Other Re-
muneration: None
Author Contributions
Conception and design: Wenya Yang, Paul F. Hogan, Suanna S.
Bruinooge, Michael P. Kosty, Amy Hanley, Ashley Muchow
Administrative support: Suanna S. Bruinooge, Amy Hanley
Collection and assembly of data: Wenya Yang, James H. Williams,
Suanna S. Bruinooge, Ashley Muchow, Naya McMillan
Data analysis and interpretation: Wenya Yang, James H. Williams,
Paul F. Hogan, Suanna S. Bruinooge, Gladys I. Rodriguez, Michael P.
Kosty, Dean F. Bajorin, Amy Hanley, Ashley Muchow, Michael A. Gold-
stein
Manuscript writing: All authors
Final approval of manuscript: All authors
Corresponding author: Suanna S. Bruinooge, American Society of Clin-
ical Oncology, 2318 Mill Rd, Suite 800, Alexandria, VA 22305; e-mail:
workforce@asco.org.
DOI: 10.1200/JOP.2013.001319
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Projected Supply of and Demand for Oncologists Through 2025Projected Supply of and Demand for Oncologists Through 2025
JANUARY 2014 • jop.ascopubs.org 45Copyright © 2014 by American Society of Clinical Oncology
Information downloaded from jop.ascopubs.org and provided by at ASCO on January 17, 2014 from 206.205.123.242
Copyright © 2014 American Society of Clinical Oncology. All rights reserved.
Appendix
Members of the American Society of Clinical Oncology Workforce Advisory Group: Michael Goldstein, MD (cochair), Beth Israel
Deaconess Medical Center, Boston, MA; Dean F. Bajorin, MD (cochair), Memorial Sloan-Kettering Cancer Center, New York, NY;
Michael P. Kosty, MD, Scripps Clinic, La Jolla, CA; R. Steven Paulson, MD, Baylor Charles A. Sammons Cancer Center, Dallas, TX;
Kathleen W. Beekman, MD, Ann Arbor Hematology Oncology Associates, Chelsea, MI; Patrick A. Grusenmeyer, ScD, Helen F.
Graham Cancer Center, Newark, DE; Gladys I. Rodriguez, MD, South Texas Oncology Hematology, San Antonio, TX; and
Stephanie F. Williams, MD, Spectrum Health Systems, Grand Rapids, MI.
2012
2013
2014
2015
2016
2017
2018
2019
2020
2021
2022
2023
2024
2025
No. of Visits (millions)
16
14
12
10
8
6
2
4
0
Privately insured
Publicly insured (non-Medicare)
Uninsured
Year
Shift up in demand from privately insured population
Shift up in demand from publicly insured population
Shift down in demand from uninsured population
Figure A1. Market demand by insurance type (visits).
Yang et alYang et al
JOURNAL OF ONCOLOGY PRACTICE •VOL. 10, ISSUE 1Copyright © 2014 by American Society of Clinical Oncology
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Copyright © 2014 American Society of Clinical Oncology. All rights reserved.
... The time to treatment among Medicaid patients trended toward a decrease following ME. The increased time to treatment we observed may be less dependent on insurance status and more associated with a national trend of growing cancer prevalence within an aging population, increasing complexity of care, and a shrinking provider pool [26,27]. ...
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Male Lister hooded rats were raised from weaning either alone (isolation reared) or in groups of five (socially reared controls). At 5 months of age, bilateral guide cannulae were implanted within the nucleus accumbens, and experiments began. The effect of isolation rearing upon the reinforcing efficacy of the intravenous self-administration of cocaine (experiment 1), or the bilateral intra-accumbens self-administration ofd-amphetamine (experiment 2) was assessed. Self-administration was made contingent upon the acquisition of a novel lever-pressing response. Two identical levers were available within each operant chamber. Responding on one lever resulted in the delivery of drug (experiment 1: cocaine, 1.5 mg/kg per infusion; experiment 2:d-amphetamine, 0.25 g/side), responding on the second, control lever was recorded but had no programmed consequences. Animals were not primed with noncontingent infusions at any time. For experiment 1, animals received intra-accumbens infusions of the D1 dopamine receptor antagonist SCH-23390, or the D2 dopamine receptor antagonist sulpiride over two test sessions. Within each session, animals received a cumulative series of doses of each dopamine receptor antagonist. A validation group received doses of each antagonist according to more conventional methods (one dose per session). In either case, intra-accumbens infusions of SCH-23390 or sulpiride enhanced the rate of the self-administration of cocaine in socially reared controls. However, isolation rearing impaired this response to intra-accumbens infusions of the dopamine receptor antagonists. Experiment 2a examined the acquisition of the intra-accumbens self-administration ofd-amphetamine. Socially reared controls acquired readily a selective response upon the drug lever. However, isolation reared animals acquired a selective response at a greatly retarded rate. In experiment 2b, a fulld-amphetamine dose-response function was examined. Isolation rearing impaired the response to a range of doses ofd-amphetamine. In experiment 2c, the infusate (1 gd-amphetamine per infusion) was adulterated with either SCH-23390 or sulpiride. Adulteration with either dopamine receptor antagonist enhanced the rate of response by socially reared controls. Isolation rearing impaired this response to SCH-23390, and blocked the response to sulpiride. These data are discussed in relation to the functioning of cortico-limbicstriatal systems, with particular reference to the mesoaccumbens dopamine projection.
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Male Lister hooded rats were raised from weaning either alone (isolation reared) or in groups of five (socially reared controls). At 5 months of age, experiments began. Experiment 1 examined the effect of isolation rearing upon the locomotor response to a novel environment, and the locomotor stimulant effect of an injection of cocaine (10 mg/kg). Isolation reared animals were more active in a novel environment, and were more responsive to the locomotor stimulant action of cocaine. In succeeding experiments, the effects of isolation rearing on the reinforcing efficacy of intravenous cocaine were assessed. Animals were never primed with noncontinugent infusions of cocaine at any time during these experiments. In experiment 2, the effect of isolation rearing upon the acquisition of the intravenous self-administration of cocaine was examined. Two levers were present in the operant chambers. Depression of one lever resulted in the intravenous delivery of a 1.5 mg/kg infusion of cocaine, responses on the second, control lever were recorded but had no programmed consequences. Isolation reared animals acquired a selective response on the drug lever at a slower rate than socially reared controls. In experiment 3, a full cocaine dose-response function was examined. Isolation rearing shifted the cocaine dose-response function to the right. In addition, isolation rearing impaired the selectivity of the response on the drug lever at lower doses of cocaine. In experiment 4, the effect of isolation rearing upon the response to a conditioned reinforcer associated previously with cocaine delivery was observed. In the absence of cocaine, the contingent presentation of the conditioned reinforcer enhanced selectively the rate of response by socially reared controls. However, isolation reared animals were unresponsive to this manipulation. These data are discussed with reference to dysfunctional cortico-limbic-striatal systems, and their interactions with the mesoaccumbens dopamine projection.
Article
Rats were reared from weaning either in isolation or in social groups for 10 weeks and were then tested for the acquisition of schedule-induced polydipsia (SIP). Isolation-reared rats were impaired in the development of this behaviour when compared to socially-reared controls. This reduction in drinking was specific to this test situation. Home cage water consumption and drinking in the SIP test chamber without a schedule of food delivery were unaltered and home cage drinking following water deprivation was significantly higher in the isolates. Housing adult rats in isolation did not impair SIP. The locomotor hyperactivity induced by isolation was also specific to rearing conditions. The inverse relationship between water consumption on the last day of testing and plasma corticosterone levels observed in both the socially-reared and socially-housed rats was absent in both the isolation-reared and isolation-housed rats.
Article
Rats reared from weaning in social isolation made more lever presses than controls on an alternating two-lever DRL schedule of reinforcement, and obtained fewer rewards. Isolates showed an increased tendency both to anticipate reward on the correct lever, and to perseverate on the lever which last gave reward, but their anticipatory deficit was relatively more marked. It is suggested that isolates act as if under an effectively higher level of food motivation. Measurement of home-cage food intake showed that the normal day-time depression of food intake was less marked in isolates than in socially-grouped animals.
Article
The generality of a postulated inhibitory deficit in isolated rats was tested by comparing their persistence under extinction and satiation procedures with socially reared animals. At the end of training, socially reared animals ran faster than isolates in the terminal component of a complex behavioural chain, but at the same speed in earlier components. During both extinction and satiation, however, isolates ran faster than the social controls in the middle component of the chain. Group differences in running speed in the terminal component were reduced both in extinction and satiation. The relationship between these findings and the disinhibitory effects of certain brain lesions is discussed.