Mission to Treat Rural Poor Is Challenged by Merger Pressure

Gladys Rodriguez, MD

For Gladys Rodriguez, MD, a practicing oncologist for 24 years, the daily schedule is filled with calls to payers and hours spent at the computer typing up electronic health records. Years ago, she recalls, she had a lot more time to spend with patients.

“There are days that I have to call 10 different insurance companies to get approvals. Ten years ago, I never had to go through that,” Rodriguez, an employee of the START Center for Cancer Care in San Antonio, Texas, told Oncology Business Management. “It’s not only me. It’s everybody here. My nurse and my nurse assistant probably spend half of their time on the phone.”

START is a bustling, multi-location practice that has many of the problems identified as typical of oncology practices these days by the American Society of Clinical Oncology (ASCO) in its recent report, “The State of Cancer Care in America, 2015.” Mountains of administrative work, negotiations with payers, and difficulty recruiting adequately trained staff are common issues for the Texas clinic.

In addition, members of the practice sit down regularly to consider the pressures of the marketplace and how to remain independent, Rodriguez says. START employs 12 medical oncologists, 4 radiation oncologists, 4 phase 1 researchers, 9 general surgeons, and 2 gynecologist oncology surgeons.

START’s practice area is the city of San Antonio—which has 1.4 million inhabitants—along with the surrounding metro district and a rural expanse that extends at least 3 hours by car from the city center, encompassing Laredo and the West Texas—Mexico border town of Eagle Pass. San Antonio is growing rapidly, but many of its residents are economically disadvantaged, and the practice works with a large population of Medicare, Medicaid, and underinsured patients. Many patients traveling long distances have no transportation of their own and depend on area groups and towns to chip in for bus service to bring them to START.

Roughly half of Rodriguez’s patients are Hispanic, and 1% are undocumented. Some come from as far away as Mexico. “There are some programs in San Antonio that provide care for breast cancer patients even if they are undocumented, and we see a lot of those patients,” Rodriguez says.

START has a robust clinical trials program with about 40 drugs in phase 1 testing. The trials program allows patients to receive treatment that may not be available at other practices, broadening the availability of new treatments and options for care, while pro bono activities and patient foundations help to fund medications and care for indigent patients. Rodriguez says that one of the reasons START physicians prize their independence is that a larger, acquiring organization might not allow them as much latitude in treating their patients as they currently enjoy.

But oncology practices throughout Texas always seem to be in talks with acquirers, and the danger is that a practice which currently poses no sizable threat to START’s operations could become an adversary through a merger. An alternate scenario—and one no less worrying—is that a large health organization will, rather than take over a local practice, “just hire people from the outside and start their own program,” Rodriguez says.

Many independent practices throughout the country are reacting to these pressures by raising the white flag. ASCO reported that 7% of respondents to its annual survey indicated a likelihood that their practices would close; and the Berkeley Research Group has reported that, based on its own survey, 33% of community oncology practices are in serious acquisition talks with hospitals, or in merger talks with other practices.

Table 1. How Oncologists Spend Their Time

aSource: Shanafelt T,Gradishar W, Kosty M, Satele D, Chew H, Horn L. Burnout and career satisfaction among US oncologists. J Clin Oncol. 2014;32(7):678-686,http://jco.ascopubs.org/content/32/7/678.full.pdf+html. Published March 1, 2014. Accessed April 22, 2015.

“The solo practitioners are fading away, not because people don’t like to be by themselves,” Rodriguez says. “It’s just that because of the cost of medications, the infrastructure you have to provide, the chemotherapy in your office, because of all the reporting you have to do, it’s almost impossible to meet all of those requirements and still be able to provide the care. And because of that, the number of people who will be able to go to a rural place and try to practice by themselves is very limited.”

When it comes to female oncologists, the START practice is well in step with the times. ASCO noted in its report that 30% of oncologists and 48% of oncology fellows are women. Five of START’s 12 medical oncologists are female, a ratio that has held steady for much of Rodriguez’s tenure with the clinic, and that ratio extends elsewhere in the city.

It was the high proportion of women at the University of Texas Health Science Center in San Antonio that encouraged Rodriguez to accept a fellowship position there when she was starting out. She knew she’d be able to find mentors and would be less likely to encounter the attitude that women would be any less dedicated to the work than men. “The reason I stayed in San Antonio was that I felt that I didn’t have to break any barriers,” she says.

Physicians at the practice also exceed national averages on minority composition. There are 6 Latinos—4 of the 12 medical oncologists and 2 of the 4 radiation oncologists. Nationwide, the average of Latino oncologists in general is less than 4%. START has one African American oncologist, specializing in gynecology. Nationally, African American oncologists make up 2.3% of the population. One medical oncologist at START is Asian Indian.

A Patient-Doctor Relationship Becomes a Friendship

When you add up the long hours and all the administrative frustrations, it is no wonder that Rodriguez says there are days when she feels a sense of burnout. But there are also rewarding moments when she is reminded of why she became a physician. She cites the case of a 21-year-old Mexican woman who came to her with a case of chronic myelogenous leukemia (CML) and who faced very limited options for treatment, among them interferon and the scary prospect of a transplant. “She was terrified,” Rodriquez recalls. Fortunately, the woman qualified for a trial for interferon plus imatinib (Gleevec), a tyrosine-kinase inhibitor, which beat the cancer into remission. “She’s now 37 years old,” Rodriguez says. “She had a baby. She is still disease-free and never had a transplant.”

In the intervening years, their relationship has grown far beyond that of patient-doctor: “She’s one of the first patients I saw in private practice, and so she saw me pregnant with my daughter and she has followed my family through all of these years. She still comes to see me.”

The advances of modern medicine have led to many more similarly wonderful achievements that couldn’t have been dreamed of years ago, and which make modern practice fulfilling despite all, Rodriguez says. Still, at 55, she is in the portion of the oncologist population for whom retirement is looming. It’s not a date that she looks forward to. The deciding factor will be whether she is able to keep up with the deluge of fresh information as multiple fields of cancer care explode with new developments.

“I remember a patient many years ago when I was young who came to see me because her doctor didn’t know about a new drug that she had read about in the newspaper and felt that he wasn’t up-to-date,” Rodriguez says. Reaching such a stage—being unable to advise patients of their true options—is, she says, her “greatest fear.”

For now, though, older doctors are an asset in a profession where the younger generation does not appear to have the same work ethic, Rodriguez says. In part, she blames softer hours in residency programs that were modified to prevent serious errors caused by overwork and fatigue. “Their expectation of what they have to do at work and how to be effective is kind of different,” she says of young physicians. “We have one older doctor in our group who sees almost twice the number of patients as the other doctors, and we realized that to replace him, whenever he decides he’s going to retire, is going to take two or three people. He starts at 5 o’clock in the morning and he’s the last to leave at 8 o’clock at night, and almost nobody these days wants to do that.”

Whether it’s the workload, or the preference among doctors for working in urban settings, or other reasons, it is difficult for the San Antonio practice to find the right employees, Rodriguez says. START has several open positions and has done a lot of interviewing. “Recruiting the right person for a practice requires interviewing many physicians,” she says. “Not only do we have to compete with other groups and institutions, but also with larger cities and physician preferences.”