Solutions to the Oncology Workforce Shortage

Although the data presented at this workshop suggest that there are current and worsening health care workforce shortages across a variety of health disciplines, these shortages are felt more strongly in cancer care than in other areas of health care, several presenters stressed. Dr. Benz stated that there is great importance in focusing on solutions to the shortage in the oncology workforce because of the high prevalence of cancer in the U.S. population; men have a 1-in-2 chance and women have a 1-in-3 chance of developing cancer during their lifetimes (ACS, 2008). Dr. Lichtveld added that “any investment that we make in cancer care without comprehensively addressing the cancer workforce will fail.” She recommended creating a cancer-specific effort at addressing these shortages. “If it is everywhere, it is nowhere, and often public health has suffered from that,” she said. “We need to be focused on cancer care and the cancer workforce and not on shortages across the board, no matter how tempting that is.” Alison Smith, a Director at C-Change, added that the solutions that are developed in the cancer community could serve as examples for the larger national health care workforce crisis.

A recurring theme during the workshop was that, within the cancer arena, there should be a systems-over-silos approach (i.e., an approach that crosses health care professions and covers the entire spectrum of cancer care). Dr. Lichtveld stressed the multidisciplinary nature of the impending cancer workforce crisis, with shortages felt for all types of health care



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Solutions to the Oncology Workforce Shortage A lthough the data presented at this workshop suggest that there are current and worsening health care workforce shortages across a variety of health disciplines, these shortages are felt more strongly in cancer care than in other areas of health care, several presenters stressed. Dr. Benz stated that there is great importance in focusing on solutions to the shortage in the oncology workforce because of the high prevalence of cancer in the U.S. population; men have a 1-in-2 chance and women have a 1-in-3 chance of developing cancer during their lifetimes (ACS, 2008). Dr. Lichtveld added that “any investment that we make in cancer care without comprehensively addressing the cancer workforce will fail.” She recommended creating a cancer-specific effort at addressing these short- ages. “If it is everywhere, it is nowhere, and often public health has suffered from that,” she said. “We need to be focused on cancer care and the cancer workforce and not on shortages across the board, no matter how tempting that is.” Alison Smith, a Director at C-Change, added that the solutions that are developed in the cancer community could serve as examples for the larger national health care workforce crisis. A recurring theme during the workshop was that, within the cancer arena, there should be a systems-over-silos approach (i.e., an approach that crosses health care professions and covers the entire spectrum of cancer care). Dr. Lichtveld stressed the multidisciplinary nature of the impend- ing cancer workforce crisis, with shortages felt for all types of health care 2

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2 ENSURING QUALITY CANCER CARE workers who provide cancer care. These shortages are also spread out across the continuum of care and across geographic boundaries. “We know that where we did discipline-specific recruitment and retention, although we had initial success, that success was not sustainable because this is a multi- disciplinary issue and the challenges are universal,” Dr. Lichtveld said. She also suggested, because the impending health care shortages create “a growing challenge not only in the quantity of the people, but also in the quality,” both the numbers and knowledge of health care workers should be strengthened. Many presenters suggested taking short-term actions to meet the immediate need for cancer care, such as improving efficiency, recruit- ment, and retention, as well as pursuing longer-term solutions that involve strengthening and filling the workforce pipeline. Speakers, such as Mr. Salsberg, Dr. Lichtveld, and Dr. Benz, noted that both approaches are necessary, as steps taken now to boost the numbers of cancer care workers are not likely to have an impact until years after the nation already experi- ences problems due to this shortage. This section of the workshop summary outlines the major solutions suggested by the various speakers to minimize the impact of the oncology workforce shortage on the quality of care. These included solutions focused on (1) new models of care, (2) recruitment and retention, (3) education and training, (4) research support, and (5) policy. NEW MODELS OF CARE SOLuTIONS Developing and using new models of care to help meet the demand for cancer care was explored extensively at the workshop. It is expected that cancer centers, especially those with academic affiliations, will play a large role in developing and demonstrating such new models of care, as these centers or their satellites train most cancer health care professionals, pointed out Dr. Benz. In addition, cancer centers are the hubs for research and have the resources to provide the specialized care required by many patients. They also serve many cancer survivors, a growing population that, as noted previously, is increasing the demand for cancer care. It is estimated that between 15 and 20 percent of cancer patients will encounter a cancer center at some point during their trajectory of care, according to Dr. Benz (NCI, 2007). However, a large number of cancer patients are seen in community private practice settings, so physicians practicing in these settings must also

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2 SOLUTIONS TO THE ONCOLOGY WORKFORCE SHORTAGE be engaged in creating and carrying out solutions to remedy the workforce shortage, several participants noted. What may work for a large cancer center may not be practical for a small community practice and thus “we had best be thinking about multiple options for solutions and not look for the single magic bullet,” said Mr. Thomas Kean, Executive Director of C-Change. Alternatively, the health care industry could try to develop new models of care that serve both cancer centers and community practices, as did Duke University Hospital, Mr. Sowers reported. Its cancer care center has set up numerous cancer clinics affiliated with the hospital in the nearby, more rural communities. These clinics are serviced by Duke University physicians, nurses, and a management staff, who travel to the satellite facilities on a regu- lar basis. “We keep the cancer patients in their community—chemotherapy and radiation therapy is delivered in their home hospitals—and they have the Duke brand providing the service back in their local communities.” To do this, Duke University sets up the policies, procedures, and standards of care followed by the local hospitals. Duke University also offers research or program development affilia- tions (for which it provides billing and clinical trial infrastructure support), continuing medical and nursing education, and assistance in setting up new cancer programs. “It really is an infrastructure beyond the walls of the cancer center—one that reaches out into the community and looks at how we can serve the community that we live in and influence what happens with cancer care,” Mr. Sowers said. Dr. Shulman added that Dana-Farber is also developing a community outreach program, which includes bringing specialized services to nearby communities, such as survivorship and pallia- tive care—services the communities do not have the resources or expertise to provide. “That gives us, as academic medical centers, a unique opportu- nity to develop not only models of care within an academic setting, but also models that might work out in the community,” he said. In addition, other methods for developing new models of care that could address an oncology workforce shortage include (1) improving efficiency; (2) increasing teamwork, especially in the areas of survivorship, palliative care, and family caregiving; and (3) developing a medical home. Each of these potential solutions is discussed in detail below. Improving Efficiency One way that implementing new models of care can address the oncology workforce shortage is by improving the efficiency of health care.

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2 ENSURING QUALITY CANCER CARE Mr. Salsberg offered several suggestions for making better use of the lim- ited number of oncologists, including making greater use of information technology and electronic medical records (EMRs). When a recent ASCO survey asked practicing oncologists what actions could help address the potential shortage of oncologists in the future, the top two suggestions given by most respondents were to increase efficiency by reducing paperwork and regulations, and by improving information technology (see Table 3) (AAMC, 2007). Expanded use of computer technology by patients could also reduce the workload of oncologists, pointed out Dr. Patricia Ganz, Professor of Health Services in the School of Public Health, and Professor of Medicine in the David Geffen School of Medicine at the University of California, Los Angeles. “We are on the verge of having a very empowered patient population—all those boomers who are going to be having excess demands are also very com- puter literate,” she said. “My patients e-mail me with questions that I pass on to the nurse practitioner I work with, and this limits the number of visits that people have to have, and puts less stress and demand on the workforce.” Dr. Bajorin agreed, and added that EMRs combined with patients who are computer literate “provide tremendous opportunity to engage patients.” TABLE 3 Oncologists’ Views on Addressing Workforce Shortage Significant Potential (Percent) Increase Reduction of paperwork and regulations 61 Improved IT such as electronic medical records 43 efficiency Increase/ Increased use of NPs/PAs 36 Train more clinical oncologists 34 extend Increased use of oncology nurses and CNS 32 oncology Create incentives to delay retirement 28 workforce Increase use Hospice and palliative care providers 26 Social workers, counselors, and patient educators 24 of related care Hospitalists 20 providers Pain and symptom management specialists 17 Primary care providers to care for patients in remission 15 SOURCE: Salsberg presentation (October 20, 2008) and 2006 Practitioner Survey, ASCO.

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2 SOLUTIONS TO THE ONCOLOGY WORKFORCE SHORTAGE He noted one initiative at the Memorial Sloan-Kettering Cancer Center that allows patients to access their lab results through an online portal, and to ask questions about their health by e-mail. Dr. Shulman also stressed the need to develop electronic systems that enable measurement of outcomes and provide decision support for better care, such as electronically based treatment plans and summaries that patients can share with all the practi- tioners who are involved in their care. However, Dr. Goldstein noted that there is a paucity of studies that document whether EMRs actually increase productivity. Although there is general agreement that EMRs improve legibility and documentation, and that they provide a good way to transfer records to physicians, they require a time-consuming learning curve to implement them properly, and the cost of purchasing an EMR system can be substantial. Although Dr. Goldstein indicated EMRs will eventually be instituted in most, if not all, practices, the best format and ways to integrate them into an oncology practice have not yet been established. To aid in the decision making involved in changing to EMRs, ASCO developed an oncology-specific handbook with informa- tion and resources about selecting and implementing EMRs. Teamwork Another strategy for bolstering the oncology workforce by changing the traditional models of care is to integrate and expand the role of physi- cian assistants (PAs) and nurse practitioners (NPs) within a collaborative/ team-based care model. Encouragingly, the number of new PAs entering practice each year has grown fivefold in the past 15 years (AAMC, 2008). The number of new advanced practice nurses is also growing rapidly—expanding from just under 6,000 nurses in 2002 to close to 7,000 in 2007. However, according to Mr. Salsberg, it is uncertain what the impact of increasing edu- cational requirements will have on the growth of NPs and PAs, and whether an increase in NPs and PAs will result in more of these health care workers providing oncology care. Neither PAs nor NPs practice only in primary care. They are spread throughout the health care system among many different health specialties, Mr. Salsberg noted. Dr. Goldstein pointed out that only a minority of PAs opt for internal medicine and oncology specialties (4.7 and 1.7 percent, respectively) (AAPA, 2008), and only 1 percent of NPs specialize in oncology (AAPA, 2004). An ASCO survey of practicing oncologists found that about half of the respondents currently work with an NP or PA and, of those who do,

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2 ENSURING QUALITY CANCER CARE they report that the use of these health professionals fostered higher patient visit rates. About two-thirds of those who work with an NP or PA believe it benefits the practice by improving patient care, efficiency, and physician sat- isfaction (AAMC, 2007). But Dr. Goldstein added that when he surveyed private practices about the role of PAs or NPs, he found a wide divergence of opinion on the usefulness of these professionals, which suggests “we’re not doing a good job yet in ascertaining and developing ways that NPs and PAs can be integrated into practices more effectively,” he said. He suggested documenting and sharing collaborative practice models and doing more outreach to nonphysician practitioner training programs. Dr. Goldstein noted that, as part of its strategic 5-year plan, ASCO will be starting pilot programs that will assess how oncologists can work most efficiently with NPs and PAs. Also, with support from the Susan G. Komen Foundation for the Cure, ASCO is seeking proposals for explor- ing new oncology practice models of care and their impact on efficiency, productivity, and patient and professional satisfaction. Mr. Salsberg sug- gested evaluating expanded roles for PAs and NPs within a collaborative care setting for “how far different professionals can go, in terms of their roles and their responsibilities.” Dr. Bajorin suggested that competitive grants be given to researchers studying innovative approaches to practice, including team care and part-time practice, as well as conducting and evaluating pilot programs to test such innovative models of service delivery. Mr. Salsberg pointed out, however, that unless there are payment reforms, there will be little incentive for such a team-based approach to cancer care. “I think PAs and NPs can do a whole lot of services, but if they are not paid and it’s going to cost the physician money to become more efficient, they are less likely to do it,” he said. He also pointed out that such expansive team care may not be feasible in a small individual practice. Dr. Goldstein concurred, noting that the starting salary for an NP in com- munity practice in the Boston area is about $80,000 a year plus benefits. In addition, almost no NPs are trained in oncology when they join practices. One large practice in Massachusetts has developed its own curriculum to train its own NPs, he said, but this requires about 6 months before the NPs are free to practice independently. “This is a tremendous use of resources and constitutes a major expense to the practice,” he said. Dr. Thomas J. Smith, Massey Endowed Professor for Palliative Care Research Medi- cal Director, Thomas Palliative Care Unit, VCU-Massey Cancer Center, expressed frustration that there is no agreed-upon reimbursement rate among insurance companies and Medicare for NP services. Medicare and

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2 SOLUTIONS TO THE ONCOLOGY WORKFORCE SHORTAGE commercial insurers reimburse NP services at different rates. Attempts to achieve consensus on a consistent rate have not been successful, he said. One discussant suggested that various state laws limiting the scope of practice for PAs and NPs might prove problematic, although Mr. Salsberg noted that the vast majority of states now permit PAs and NPs to prescribe drugs. From a policy perspective, Dr. Atul Grover, the Director of Govern- ment Relations at AAMC, pointed out that special interest groups tend to pressure Congress not to support initiatives that enable tasks typically done by doctors to be performed by nonphysicians. “We are going to have to really think long and hard about how to get to a point where we can stop worrying about the labels of individuals—their professions or professional societies—and get to a point where we put the patient back in the center of care,” he said. He also noted the importance of “getting the training right—of having people function to the maximum ability of their training, skill level, and competencies.” Several participants, including Dr. Benz, sug- gested ensuring that ancillary cancer care staff have some core competency in oncology. Dr. Lichtveld called for national benchmarks of quality as opposed to those provided by individual disciplines. Carol Schwartz, Senior Manager of Policy and Practice at the American Society of Hematology, noted the relatively untapped health care employee pool of exiting military medics. “I challenge you to try and figure out how to fit them in. Their education and training and experience does not crosswalk very well into different states’ scopes of practice. As a result, in most states they have to start at the beginning as a nursing assistant when they have been working very autonomously in the military at a much higher level.” This discourages them from pursing a health career, she claimed. Building on both the concept of team science and translational research, Dr. Mooney suggested more partnerships between nursing research scientists and physician scientists to broaden the clinical research being conducted in cancer and cancer centers. Dr. Bednash added that the National Institute of Nursing Research (NINR) is a major source of funding for pre- and post-doctoral studies in nursing. But NINR is severely under- funded. This shortage of money has limited NINR’s ability to produce the nursing workforce that can educate, do research, and be specialty-focused, she said. There was some discussion about using primary care providers to care for cancer patients in remission, to help relieve the workload burden of oncolo- gists. But this strategy was only supported by a small number of practicing oncologists in a recent ASCO survey (AAMC, 2007). Lack of support for

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0 ENSURING QUALITY CANCER CARE this option may reflect the difficulties of finding available primary care physi- cians. Nearly one in five Americans have inadequate or no access to primary care physicians because of a shortage of such physicians, not because they do not have health insurance (NACHC and RGC, 2007). “The primary care network is very oversubscribed,” said Dr. Shulman. “One of the chal- lenges I have is that many of my patients don’t have primary care physicians and I can’t bribe any of my primary care physician colleagues to take them into their practice, and so the care for them remains on us. It doesn’t look like there’s going to be a tremendous increase in the number of primary care doctors over the next decade to share the care of these patients, and we need to acknowledge that fact.” Survivorship Care A third method of producing new models of care is to change how survivorship care is administered. Currently, nearly 70 percent of oncologist office visits are for survivorship care (AAMC, 2007). However, Dr. Jacobs noted that there are no established guidelines for caring for adult cancer survivors. The development of such guidelines would help ensure that adult cancer survivors receive proper care not only from their oncologists, but also by the other providers who might be responsible for the cancer survivors’ post-cancer-treatment care. One survey of cancer survivors found that more than one-third rated the quality of information they received from their oncologists as fair to poor, including information about long-term side effects (McInnes et al., 2008). “Survivors tend to think that they are left in the medical twilight zone post-treatment,” said Dr. Jacobs. She reiterated IOM’s recommendation that “patients completing primary treatment should be provided with a comprehensive treatment summary and follow-up plan that explains the cancer type, treatments, and consequences, as well as the timing and content of follow-up care” (IOM, 2005). A treatment plan and summary could bolster the use of primary care physicians or nonphysician health care workers to provide cancer or survivorship care, pointed out Dr. Goldstein. However, Ms. Galassi pointed out that if survivorship care is shifted away from oncologists, into the primary care setting, then oncologists could be overburdened with acute care patients, which might foster burnout. But, Dr. Goldstein noted that the ASCO survey of oncologists found that death and dying were not major factors in leading physicians to retire, but rather it was frustration with the system and overwork (AAMC, 2007). “Oncologists

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1 SOLUTIONS TO THE ONCOLOGY WORKFORCE SHORTAGE expect to have dying patients. Frustration with the regulations, paperwork, and practice environment were driving more people out of practice than the patient population,” he said. Dr. Bajorin added that, if survivorship care was shifted from the oncologist to the primary care physician, there would still be a substantial difference between supply and demand. However, he still recommended training oncology fellows in collaboration with primary care providers, and the team use of NPs and PAs, as it is estimated that cancer will increase by 81 percent by 2020 (NCI, 2009). ASCO currently is developing customizable disease-specific chemo- therapy treatment plans and summaries (ASCO, 2008). These plans and summaries are meant to improve documentation and coordination of cancer treatment and survivorship care. They are intended to facilitate provider-to-provider and provider-to-patient communication. The tem- plates may be distributed to patients or providers as records of the care planned and received. Importantly, the treatment plans and summaries are not intended to replace detailed chart documentation, including complete patient histories or chemotherapy flow sheets. The treatment plans detail planned chemotherapy regimens, doses, cycles, durations, and the major side effects, while the treatment summaries describe the treatment delivered, the major toxicities, and the follow-up plan for care. Some ASCO treatment plans and summaries for specific cancers are already available on the ASCO website (ASCO, 2008). Dr. Jacobs recommended the survivorship care plan resource offered by Oncolink.1 She noted that patients seem to like using this plan, which can be created by patients for themselves or by their providers, and includes a large amount of educational information. “It’s very important that patients be empowered and given records of their treatment so that they become portable in the event of a natural disaster, or in the event that they are in a different part of the country or the world,” said Dr. Goldstein. “With these treatment plans and summaries, the medical pro- fessionals seeing the patients will have an adequate summary on which to base future interventions.” Even with the widespread use of treatment plans, there will still be several challenges involved in caring for cancer survivors, including their diverse needs that extend beyond their cancer care needs, and funding issues, Dr. Jacobs pointed out. Cancer survivors are a diverse group, often with a wide range of diseases or conditions besides cancer that need to 1See http://www.oncolink.com/oncolife.

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2 ENSURING QUALITY CANCER CARE be treated or monitored. Yet these non-cancer-related health needs are often not a priority for oncologists. One study found that 8 percent of cancer survivors only see their oncologist, whereas 68 percent see both their oncologist and primary care physician. Those who received all their care from a primary care physician were less likely to undergo cancer- related surveillance procedures but more likely to receive preventive health measures such as eye exams, flu vaccines, cholesterol screening, and bone density scans. Those who saw only an oncologist had the worst preventive care (Earle and Neville, 2004). Reimbursement for survivorship care does not cover the costs of pro- viding appropriate monitoring and support for the physical, social, and emotional effects in the short and long term course for the disease and treat- ment of cancer. In order to offer these services, institutions that do provide this care absorb the cost or must seek funding from other sources. Many community-level institutions and smaller-scale providers simply cannot afford to do so. As a result, survivorship care is not self-sustaining and must receive external support or income from other patients, Dr. Jacobs noted. She added that when survivorship care is done at a large institution, such as an academic cancer center, it will generate downstream revenue for that insti- tution because of the additional care provided by radiologists, cardiologists, and other specialists. Several survivorship clinics exist within cancer centers and academic institutions. The oldest are pediatric oncology follow-up clinics, some of which have been operational for over 20 years. These clinics serve survivors will all types of cancers and require significant resources to meet a wide range of needs. A few cancer centers run adult follow-up clinics akin to these pediatric models, but they currently reach a limited number of patients and are unlikely to ever meet the needs of a wide population of cancer survivors, especially considering how expensive they are to run, Dr. Jacobs said. Alternatively, some cancer centers, such as Memorial Sloan-Kettering,2 offer disease-specific survivorship clinics, many of which are run by NPs. “They are fairly successful,” said Dr. Jacobs, “but they are unreasonable at most institutions that don’t have the resources to back them up.” Instead, many oncology practices employ NPs to provide survivorship care. In these practices, the NPs follow the patients and do all of the long-term follow-up care. Another alternative used for survivorship care is a consultative service, in which an oncologist interested in providing survivorship care sets aside 2See http://www.mskcc.org/mskcc/html/64918.cfm.

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 SOLUTIONS TO THE ONCOLOGY WORKFORCE SHORTAGE one day a week, for example, to see cancer survivors about their long-term, cancer-related concerns. Dr. Jacobs is currently involved in a pilot program implementing an integrative care model of survivorship treatment at the University of Penn- sylvania. Survivorship care-focused visits are done by NPs in the participat- ing oncology practices, with the goal of ultimately transitioning patients to their primary care physicians for their cancer follow-up care. At these visits, a treatment summary and care plan is completed and discussed with the patient, and copies of the summary and care plan are made for the patient’s primary care physician or other subspecialists. The NP that does the follow- up care for the patient is also the same NP assigned to the patient’s case when he or she was undergoing treatment. Because survivorship clinics are so resource-intensive, Dr. Jacobs expects their use to be limited to certain cancer centers. “I’m not sure this is the way to go,” she said. “The broadest reaching survivorship care model is to develop treatment summaries and care plans for patients. Patients take control, to some extent, of the care that they need. They are informed of what they need, and we’re helping them inform the providers that are caring for them.” Partnership between private oncology practices and other local medical offices, hospitals, or cancer centers may be a more efficient and economical way to provide cancer patients with the full continuum of care they need, including psychosocial support, nutritional counseling, and palliative and end-of-life care, Dr. Goldstein suggested. Although, he noted, this option may not be available in rural and other underserved areas. More social workers in oncology care might also help relieve the burden of care on oncologists while improving patients’ well-being. Dr. Ferrell pointed out that, at the City of Hope National Medical Center in Los Angeles, “our medical oncologists say they are overwhelmed with the amount of time they are spending with social issues, psychological issues, anxiety and depression, and yet my institution has very few social workers. The fact that there are only 1,200 social workers who specialize in oncology is a glaring cry for our community to see what incentives and opportuni- ties can get them more involved in cancer care.” Ms. Rosalina Van Zanten from the Association of Oncology Social Work pointed out that, despite the higher level of education required for social workers, their salary is less than entry-level nurses with a bachelor’s degree, and she suggested that there needs to be more monetary and professional validation of health care social workers in order to increase the number of these professionals.

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 ENSURING QUALITY CANCER CARE adjust to a new way of providing cancer care, whether it be through collab- orative team efforts, more Internet-based practices, or any of the other new models proposed. Useful in that reeducation process will be the findings of several studies that have assessed what prompts physicians to change their way of practicing medicine, Dr. Mazmanian pointed out. One study found that printed educational materials and formal continuing medical education programs did not foster significant behavioral change (Davis et al., 1995). In contrast, the most effective interventions were mediated through phar- maceutical representatives, opinion leaders and patients, and by automatic reminders. Multiple interventions were more effective at eliciting change than single interventions. As a result, Dr. Mazmanian suggested taking a systems approach when trying to foster change in the health community, and conducting educational demonstration projects. In addition, Dr. Lichtveld, suggested that part of the culture change needs to include the development of cultural competencies. The workforce should be able to address the unique needs of minority patients. She pointed out that the number of African American patients, Hispanic patients, and other minority patients are increasing in this country, and she stated that cancer care should be tailored to serve such a diverse population (see Figure 10). “This is a requirement rather than a luxury to help address Percent of the Population 80 1990 70 2000 60 2025 (projected) 50 2050 (projected) 40 30 20 10 0 White, Not Black American Asian and Hispanic Hispanic Indian, Pacific Orgin (of any Eskimo, and Islander race) Aleut Race and National Origin FIGuRE 10 Rationale for cultural competence: Why do we have to be culturally competent? SOURCE: Lichtveld presentation (October 20, 2008). Data from the U.S. Census Bureau, Population Division on Housing and Household Economic Statistics Division. New figure 10

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 SOLUTIONS TO THE ONCOLOGY WORKFORCE SHORTAGE health disparities,” she said. Developing and adopting national standards for cultural competency, such as the standards the AAMC and the Association of Schools of Public Health (ASPH) are currently trying to develop, will help improve the quality of care. RESEARCH SuPPORT SOLuTIONS Advances in oncology care are closely related to the basic and clinical research done on cancer. However, cancer research has been hurt by a lack of funding in recent years, according to several participants. The NCI provides a number of Career Development Awards (CDAs) to support basic, transla- tional, and clinical research in oncology, as well as K12 institutional grants aimed at fostering physicians to collaborate with basic science researchers to promote translational therapeutic research. Dr. Wiest noted that “even during this time of a flat budget, the NCI has continued to support M.D.s and M.D./Ph.D.s to pursue academic research, both through the Career Development Awards and the loan repayment program. The success rate for physician scientists has remained relatively stable, and oncologists are actively engaged in research.” Dr. Wiest showed that the success rate for applicants being awarded CDAs is between 15 and 25 percent. This number has remained rela- tively flat since 2004, across both M.D.s, Ph.D.s and M.D.s/Ph.D.s (see Figure 11). When broken down by subspecialty, medical oncologists have acquired the most CDA and K12 grant funds, followed by surgical oncolo- gists, pathologists, and radiation oncologists (see Figure 12). The success rate for these specialties being awarded CDAs has varied over the past 4 years, as can be seen in Figure 13. Dr. Wiest suggested ways to improve NCI support of physician- scientists, including increasing the salary cap on CDAs from $75,000 to $100,000 and partnering with foundations and societies to supplement resources for subspecialty physicians in academic research. He also sug- gested considering redirecting dollars to CDA mechanisms that have had the biggest impact in promoting academic research among physician- scientists. In addition, it might be worthwhile to consider redirecting some of the funds used in the loan repayment program to support physician- scientists, Dr. Wiest said. Dr. Benz suggested that cancer centers, the NIH, foundations, and other sources of research training support need to work with one another to expand training opportunities for faculty across all disciplines related

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 ENSURING QUALITY CANCER CARE 50 30% MD Awarded PhD Awarded 45 MD/PhD Awarded MD Awarded 25% PhD Awarded 40 MD/PhD Awarded 35 20% Number of Awards Success Rate 30 25 15% 20 10% 15 10 5% 5 0 0% 2004 2005 2006 2007 2008 Year FIGuRE 11 Career Development Awards (CDAs) awarded by applicant degree. SOURCE: Wiest presentation (October 20, 2008) and the National Cancer Institute. $12.00 New Figure 11 Investment in Millions $10.00 $8.00 Med Onc Path $6.00 Rad Onc Surg $4.00 $2.00 $0.00 2004 2005 2006 2007 2008 Year FIGuRE 12 Cost by subspecialty. The cost reflects money accrued by each subspe- cialty through CDA and K12 grant funds. Med Onc = Medical Oncologists, Path = Pathologists, Rad Onc = Radiation Oncologists, Surg = Surgical Oncologists. SOURCE: Wiest presentation (October 20, 2008) and the National Cancer Institute. Figure 12 New

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 SOLUTIONS TO THE ONCOLOGY WORKFORCE SHORTAGE Medical Oncologists 35 50% Number of Applications/Awards 30 40% 25 Success Rate 30% 20 15 20% 10 10% 5 0 0% Radiation Oncologists 35 50% Number of Applications/Awards 30 40% 25 Success Rate 30% 20 15 20% 10 10% 5 0 0% Surgical Oncologists Number of Applications/Awards 35 50% 30 40% Success Rate 25 30% 20 15 20% 10 10% 5 0 0% Number of Applications/Awards Pathologists 35 50% 30 40% Success Rate 25 30% 20 15 20% 10 10% 5 0 0% 2004 2005 2006 2007 2008 Year Applied Success Rate Awarded FIGuRE 13 CDAs to subspecialists. The different oncology subspecialties have had various levels of success at achieving CDA awards over the past four years. SOURCE: Wiest presentation (October 20, 2008) and the National Cancer Institute.

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 ENSURING QUALITY CANCER CARE to oncology. Dr. Bajorin suggested continuing programs such as those of ASCO, which provide travel awards to residents so they can attend national meetings, as well as supporting a medical school student rotation program so that medical students can go to a major cancer center and participate in oncology care and oncology research. POLICy SOLuTIONS Two policy experts at the workshop discussed possible policy solutions to the crisis in the oncology workforce. One long-term solution that was offered to help counter impending oncology workforce shortages was to boost the numbers of physicians who receive GME, especially those that pursue internal medicine residencies and oncology fellowships. As Dr. Grover pointed out, “No matter how many M.D.s or D.O.s [Doctors of Osteopathic medicine] you produce or how many international graduates you bring from abroad, you are largely limited by the size of your graduate medical educational enter- prise, that is, the training of residents and fellows.” Because the government, through Medicare and other federal and state programs, provides the financial support for training residents and fellows, public policy that controls funding for these programs may indirectly affect both the numbers of physicians and the specialties they acquire, pointed out Dr. Grover. Medicare is the largest explicit payer for GME and directly offers financial compensation for residency education costs, including resident stipends and salaries. It also indirectly compensates for the higher patient care costs due to the presence of teaching programs in academic hos- pitals. Other government sources of support for GME include Medicaid; the Veterans Administration; Title VII, which supports primary care physi- cian training; and the Children’s Hospital Graduate Medical Education Program, which supports pediatric training. The Balanced Budget Act of 1997 limited the number of residencies and fellowships for which Medicare would pay, as part of a money-saving strategy by the federal government. This Act assumed the number of physicians currently being generated was sufficient to meet the nation’s needs, and, with a few exceptions, stipulated that additional residencies and fellowship positions beyond those established in 1996 would not be funded. In addition to this Act, CMS recently made its requirements for reimbursement more stringent, according to Dr. Grover. For example, it no longer reimburses for training at nonhospital sites, or for a number of other education or patient safety and quality-related activities. It also

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 SOLUTIONS TO THE ONCOLOGY WORKFORCE SHORTAGE has made it more difficult to acquire reimbursement for any resident time spent in research activities unless they relate to the clinical care of patients. The Bush administration and the Medicare Payment Advisory Com- mission (MedPAC), an independent Congressional agency, recently proposed limiting Medicare reimbursement to GME even further. These measures have not been passed, but some are still being considered. “As we are trying to grow, they’re still thinking about what to cut,” noted Dr. Grover, and “the pressure to cut is even more extreme now with the current state of the economy,” he added. Dr. Grover showed that the Balanced Budget Act combined with the influx of managed care, which emphasizes using gatekeeper primary care physicians to reduce the need for specialists, has led to the total number of residency positions remaining relatively stagnant since the mid-1990s (see Figure 14). “We’re at a point where we certainly aren’t able to grow at the rate or to the extent at which the population requires additional health care workers trained,” he said. “We are probably in deficit funding now, meaning that our institutions are taking on the full costs of training an additional 3,000 to 5,000 residents and fellows that Medicare doesn’t reimburse. I don’t think our institutions are going to be able to go much further without some help from the federal government,” Dr. Grover stressed. Senators Joe Biden, Harry Reid, and others tried to provide that financial help with a bill12 they introduced in 2007 that aimed to raise the Medicare GME funding caps in those states that are below the national average in terms of residents to population ratios. The bill, which was not passed during the 110th session of Congress, would have increased Medicare-funded slots by 1,222 residency positions, although there were concerns that the funding for this bill may have come from limiting the per capita amount of funding for all residency slots. Policy makers could also try to seek additional funding for GME from other government agencies or programs that provide health care funding, including the Veterans Administration and Title VII, Dr. Grover added. As for seeking policy solutions for the shortage of oncologists specifi- cally, Dr. Grover noted that since 2002 the number of oncology fellow- ships has increased more than the number of residencies that train primary 12U.S. Congress. House. Resident Physician Shortage Reduction Act of 200, HR 1093. 110th Cong., 1st. Sess. U.S. Congress. Senate. Resident Physician Shortage Reduction Act of 200, S 588. 110th Cong., 1st Sess.

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0 ENSURING QUALITY CANCER CARE 105,000 BBA Managed Care 100,000 95,000 Number of Residents 90,000 PEW and IOM & IOM COGME 85,000 80,000 75,000 70,000 PPS 65,000 60,000 1980 1984 1988 1992 1996 2000 2004 Year FIGuRE 14 Total Graduate Medical Education (GME) positions in all medical specialties, 1980-2004. This graph depicts the effect of the policy environment on growth in GME positions. In the 1980s when a prospective payment system (PPS) was in place, there was a steady increase in GME positions. In the 1990s when managed care was being utilized, the growth in GME positions slowed. Reports by COGME, PEW, and IOM in the 1990s emphasized the role of gatekeepers and primary care. When the Balanced Budget Act (BBA) of 1997 was passed, GME positions were already at a plateau. FIGURE 14 NEW NOTE: COGME = Council on Graduate Medical Education, Summary of the Fourth Report, Recommendation to Improe Access to Health Care Through Physician Workforce Reform, www.cogme.gov/rpt4.htm; IOM = Institute of Medicine. 1996. The Nation’s Physician Workforce: Options for Balancing Supply and Requirements. Washington, DC: National Academy Press; PEW = Critical Challenges: Executie Summary, Reitalizing the Health Professions for the Twenty-First Century, www.futurehealth.ucsf.edu/summaries/ challenges.html. SOURCE: Grover presentation (October 21, 2008) and the Association of American Medical Colleges. care physicians, for which there is a heightened perceived need to expand. “People are concerned about family medicine and general internal medi- cine, so when you look at the lack of problems that oncology has relative to other specialties in attracting people, it makes it less sympathetic,” Dr. Grover said. He added that, because oncologists have higher incomes than many other specialties, “it becomes very difficult to make a case for it and have people be sympathetic. Within health care, you have to be realistic

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1 SOLUTIONS TO THE ONCOLOGY WORKFORCE SHORTAGE about where oncology fits in with everybody else, given the overall lack of federal resources.” Dr. Kavita Patel, Deputy Staff Director for the Senate Health, Education, Labor and Pensions Committee, Health Subcommittee of Senator Edward M. Kennedy, agreed, noting that “we are dealing with intersecting forces and needs, and we are trying desperately to prioritize, and there is definitely a priority for primary care at this time for refinancing and aligning payment and incentives and workforce issues.” In her presentation, Dr. Patel discussed the recent landscape of federal and state initiatives intended to provide support for the education and train- ing of the general health care workforce, as well as the cancer workforce. Her first example, the Health Professions Education Partnerships Act of 1998,13 illustrated successfully enacted federal legislation that provides grants, contracts, and scholarships to support the education of underrepresented minorities interested in the health professions. She also highlighted some examples of legislation that did not pass Congress, including the National Cancer Act,14 which was introduced in 2002, 2003, and 2007 and included provisions to promote the growth of the cancer workforce through grants, scholarships, fellowships, loans, and loan repayment mechanisms. An addi- tional bill not passed by Congress was the Quality of Care for Individuals with Cancer Act,15 introduced in 2002 and 2004, which included provi- sions to establish grants to support cancer curriculum development, pro- grams to promote an adequate and diverse cancer workforce, and a plan to assist health care workers in professions facing the most severe shortages. Dr. Patel also discussed two examples of state legislation addressing health care workforce issues. Massachusetts enacted legislation16 in 2008 that created a loan forgiveness program for physicians and nurses who agree to practice primary care in medically underserved areas, as well as providing tuition incentives for University of Massachusetts medical students who agree to practice primary care in the state for 4 years. As part of the state’s 13Health Professions Education Partnerships Act of 1, P.L. 105-392, 105th Cong., 2d Sess. (November 13, 1998). 14U.S. Congress. Senate. National Cancer Act of 2002, S 1976. 107th Cong., 2d Sess.; U.S. Congress. Senate. National Cancer Act of 200, S 1101. 108th Cong., 1st Sess.; U.S. Congress. Senate. National Cancer Act of 200, S 1056. 110th Cong., 1st Sess. 15U.S. Congress. Senate. Quality of Care for Indiiduals with Cancer Act, S 2965. 107th Cong., 2d Sess.; U.S. Congress. Senate. Quality of Care for Indiiduals with Cancer Act, S 2771. 108th Cong., 2d Sess. 16The Commonwealth of Massachusetts General Court. Senate. Bill to promote cost con- tainment, transparency and efficiency in the deliery of quality health care, SB 2863. 185th Sess.

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2 ENSURING QUALITY CANCER CARE overall health care reform efforts, Minnesota also passed legislation17 in 2008 that requires the commissioner of health to study and recommend changes necessary to health professional licensure and regulation so that advanced practice RNs, PAs, and other licensed health care professionals are fully utilized. In addition to Dr. Patel’s survey of recent workforce legislation, she also discussed the comprehensive cancer legislation that Senators Kennedy and Hutchison are currently developing.18 The legislation is aimed at the entire continuum and spectrum of cancer care, including workforce issues. In crafting the legislation, one of the issues that they are trying to confront is determining which agencies the legislation should target. According to Dr. Patel, they have debated whether the legislation should designate multiple agencies responsible for programs that foster quality cancer care or increase the oncology health care workforce. “We talk sometimes about having a ‘cancer czar’ or some coordinator of cancer programs,” she said. But both Drs. Patel and Grover pointed out that any current efforts to devise legislation that fosters a growth in the oncology workforce may be dwarfed by both the new administration’s focus on making major health care reforms and an economy on the downturn that cannot support major funding for new programs and initiatives. However, Dr. Patel noted that the change in administration offers new opportunities. “We are going to be dealing with new agencies and agency heads and new high-level nonpolitical appointees, so this may be the time to make sure that those people hear that cancer care must be a priority,” she said. Ms. Smith added that attempts to acquire funding for programs that will help alleviate the shortage of oncol- ogy health care workers should be couched in language that stresses their long-term economic benefits. “We could say, ‘by funding a more elegant model for delivering care, we could offset hospitalization, or by funding educational programs, we might offset unemployment,’” she said. Ms. Bruinooge raised the issue of whether Medicare funding for GME could be used for collaborative cancer care, much of which takes place outside hospital settings. Dr. Grover concurred, noting that “with the new administration coming in, we will have the opportunity to say there’s a lot that can be done from a regulatory side to train people for the 21st century 17Minnesota State Legislature. Senate. SF 3780. 85th Sess. 18U.S. Congress. Senate. 21st Century Cancer ALERT (Access to Life-Saing Early Detec- tion, Research, and Treatment) Act of 200, S. 717. 111th Cong., 1st Sess.

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 SOLUTIONS TO THE ONCOLOGY WORKFORCE SHORTAGE and not the 18th century. It would be helpful if Congress gave CMS that extra leeway to encourage the development of new arenas of training, new models of collaborative, interdisciplinary care.” However, Dr. Grover warned that training in new models of care will be a waste of time if there are not opportunities to employ those new models in real-world settings. He suggested a strategy that attempts to transform the practice of medicine to fit training activities in the new models of care. He added that a major barrier to developing new models of care is a payment system that is based on capitation. “Health care is not widgets,” he said. “We shouldn’t get rewarded for doing more and get paid according to vol- ume.” Ms. Smith suggested a pay-for-performance reimbursement system that rewards better care, a concept which Dr. Grover noted is just starting to be explored by policy makers. Dr. Patel cautioned that pay-for-performance is “an answer in certain areas for certain conditions, but it’s not going to get us to that comprehensive change.” Dr. Patel also noted that “we are going to have to marry what we do in training with what we do on the private side and so sometimes I think that CMS is not necessarily the vehicle of change.” She noted that there are over 230 demonstration projects within CMS, and it is unclear how useful they are. “These demonstration programs are usually underfunded and though you might get results from it, you don’t have the sample size to actually show anything that is going to convince policy makers,” she said. Instead, she sug- gested organizations, such as the AAMC, support demonstration projects in real time to inform those at the federal level what innovative and creative programs should be supported with public funds. “Show people what you know works even if it is examples from 20 institutions—that’s a lot more data than we have in many cases about anything,” Dr. Patel said. Both Drs. Patel and Grover stressed the importance of thinking out- side the box of oncology and building on the work of other related fields. Dr. Patel suggested using what can be done within the cancer arena as a model for what can be done in all health care and vice versa. For example, the coordination of care required for adequate cancer survivorship care can be a useful model for the care of patients with other medical problems, she pointed out. “We need to think of how we can build on each other’s energies and passions and the money spent on doing these things,” she said. Ms. Schwartz suggested building synergy by supporting other organization efforts related to oncology, such as the National Priorities Partnership, which recently released a document that stresses making palliative care a health care priority.

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 ENSURING QUALITY CANCER CARE Dr. Grover concurred but commended IOM’s effort to bring together different professions within the cancer care umbrella with a unified purpose of determining what cancer patients need. He suggested that all these fac- tions voicing a unified message will impress policy makers more than frac- tious efforts. Dr. Shulman added, “We’re only going to make progress if we band together with physicians, nurses, social workers, physician assistants, and all the other groups. If we’re all squabbling and have different ideas about how to divide up the pie and who’s in charge and who gets reim- bursed for what, then we’ll be nibbling at change and won’t foster the bold changes that are needed.” Dr. Bednash agreed and urged physicians to join with nurses in lobbying for more support for the clinical training of nurses and their reimbursement in a collaborative care setting. She also suggested that the numerous consumer advocacy groups for various types of cancers join this unified effort to address oncology workforce issues. Ms. Smith added that the cancer survivor community should be tapped to advocate for oncology health care needs. Mr. Salsberg suggested learning from what was done to promote efforts to address the shortage of primary care providers. Studies documenting the shortages of primary care providers led to public media campaigns and lobbying efforts in Congress, he noted. “There were a number of alliances and principle statements coming out that increased awareness on the part of the public about the shortages of primary care physicians,” he said. He also noted the speed and creativity of the government efforts that are under way to address the current economic crisis. “It does seem that this country seems to respond more quickly to crisis so maybe we need a public relations effort to really help our leaders understand that this is a crisis that needs urgent attention,” he said.