Hospital-Based or Community-Based Practice, We All Care for Patients with Cancer

The majority of cancer care is well known to be delivered in the community setting. We also are starting to learn that there may be cost differences based on site of service. What does that really mean to a patient with cancer, a physician, a practice administrator, and a payer or employer? The real answer is…it depends.

The cancer community has at its heart a desire to serve patients and to beat cancer as often as possible, as well as to assist patients through the journey if cure is not an option. The men and women who choose to serve patients with cancer are special in their own right—no matter where they are employed, you will find specialized knowledge, expert training, warmth, compassion, and even love for their patients.

The Challenge

We are being challenged every day to prove quality and value. Of note, the very medical decisions and treatment choices made by physicians for their individual patients are being challenged and held up to some interpretation of evidence-based standards, or the thought that it may be time to change the current model for physician diagnostics and treatments. Is there a quality difference related to the site of care—hospital based versus private practice? We do not yet know. All we do know is that the cost, and possibly the length of treatment, varies, based on recent studies by Milliman (with US Oncology)1 and by Avalere Health (with Com - munity Oncology Alliance and the National Association of Managed Care Physicians).2

Many questions remain to be answered about the depth of service elements, the consistency of the service and care, and even the scope of care across the continuum. Until those differences are known, it is impossible to delve into defining which approach is more appropriate or has greater value, let alone assessing the value given for the cost spent.

Another reality is that because of the very nature of hospital–payer contracting, identifying specific cost differences may not lead to any significant change: hospital contracting is on a more unilateral basis, across the entire spectrum of inpatient and outpatient care, and individual rates may be less flexible or have less importance, be cause contracting is not as focused on a specialty-specific basis.

Although we do need to be cognizant of information that could lead to better policy decisions on all sides, and studies like the 2 cited here contribute to the greater body of knowledge,1,2 it may be useful to reconsider the focus and intensity of the hospital-versus-community discussion. The problem is that the more we battle among ourselves—challenging one type of physician care setting against another—the more we leave ourselves open to other delivery models and oversight coming in from another direction.

Our reality is that Medicare reimbursement, and the extent to which private payers mirror its rates, make it incredibly difficult, if not impossible, for most private oncology practices to stand alone. That is not a trend that will be easily stopped; indeed, in some states almost all oncologists are already hospital based.

Identifying Standards of Care

Instead of battling internally over which site is better or worse, our focus may be better spent on identifying the medical and operational standards that would be expected of any site delivering quality cancer care. This would enable those who care for patients with cancer (hospital based and private practice based) to draw the line in the sand as a challenge to other potential delivery models under consideration (eg, possible infusion clinics in retail pharmacy settings, in corporate complexes, or in free-standing commercial settings).

Some of these discussions regarding standards and expectations are al - ready under way. The National Comprehensive Cancer Network (NCCN) and National Business Group on Health have a substantial project in progress that defines expectations for cancer benefit design for employers and health plans. The Community Oncology Alliance, the McKesson/US Oncology Network, and at least 2 other major projects, are seeking to shape and define the oncology medical home concept. The American Society of Clinical Oncology has identified specific quality measures in its Quality Oncology Practice Initiative (QOPI) project and is now certifying QOPI-engaged practices.

However, most of these projects are specific to the individual project–Suggestions for categories of cancer program delivery standards may begin with expectations for monitoring and documentation in accreditation and certification programs, such as those managed by the Joint Commission and the American College of Surgeons Commission on Cancer, as well as the Oncology Nursing Society, and various laboratory and imaging oversight bodies.focused end goals and do not address the breadth of oncology care delivery, regardless of site of care. Some goals will be difficult to establish on a unilateral basis but will be essential as we move forward.

Suggestions for categories of cancer program delivery standards may begin with expectations for monitoring and documentation in accreditation and certification programs, such as those managed by the Joint Commission and the American College of Surgeons Commission on Cancer, as well as the Oncology Nursing Society, and various laboratory and imaging oversight bodies.

The USP 797 Standards for chemotherapy mixing environments will be just as important, regardless of site. The National Association of Managed Care Physicians has a membership of medical directors that crosses health plans, employers, and providers; it may offer a good start to a cross-stakeholder discussion, especially with outreach and affiliation with other key, yet diverse, oncology perspectives.

Appropriate universal standards that we, as the community of oncology, can address will include not just clinical expectations (eg, all or specific levels of evidence from nationally accepted guidelines, such as produced by the NCCN), but also operational (ie, staffing, expertise, regulatory compliance) and service (ie, patient satisfaction, all types of patient assessments and counseling, financial transparency and counseling, and multidisciplinary patient assessment and support).

Moving Beyond Site of Care

It is also important not to focus on such questions and standards internally, or locally. We have already seen that “if you build it, they will come” is not a concept that has worked well for some practices that have led the curve in terms of creating content and standards but are now having difficulty finding health plans willing to pay for what they have developed.

This will become a national discussion that of necessity will engage many stakeholders. We are making progress, and do have some discussions under way, none of which yet addresses the totality of what we may need, but may provide useful building blocks for discussion over the next few years.

Whether you are in a hospitalbased practice, in private practice, or are considering a change from one to the other, patients with cancer and those who pay for their care have a right to certain standard levels of expectations—clinical, operational, and service related.

We are not likely to be able to affect how the hospital or the private practice situation shapes out in different communities—there are many other variables that shape that future—but we can work together to shape expectations and assessment of appropriate care, regardless of site.


  1. Fitch K, Pyenson B. Site of service cost differences for Medicare patients receiving chemotherapy. Milliman, Inc. October 19, 2011. Accessed May 3, 2012.
  2. Avalere Health. Total cost of cancer care by site of service: physician office versus outpatient hospital. Avalere Health, LLC. March 2012. Accessed May 4, 2012.

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