The study of collaborative practice arrangements: where do we go from here?

In 2007 ASCO published their workforce study, Forecasting the Supply of and Demand for Oncologists, which gave ASCO its first look at the future of oncology care delivery in the United States. The view was bleak, with the supply and demand curves painting an austere picture of oncology by 2020. The study predicted a demand increase of 9.4 to 15.1 million oncologist visits. This increase would create a visit deficit that translates into a predicted shortage of between 2,550 and 4,080 oncologists by the end of this decade. To address such a significant shortfall in an already strained medical system will require a multifaceted approach. Substantially increasing the supply of oncologists would not be possible in the current medical system, so a transformation of oncology practice models emerged as the most likely strategy to address expected demands in oncology services. It has been suggested by many in the oncology community that expanded use of nurse practitioners and physician assistants, jointly known as nonphysician practitioners (NPPs), could effectively extend the supply of oncologist services, for both active oncology treatment and care for the growing number of cancer survivors. Better integration of NPPs could also improve practice quality and efficiency and, by better balancing workload and skills, may increase professional satisfaction for providers. ASCO’s first glimpse into this opportunity stemmed from a 2006 survey of oncologists. The survey reported that 56% of oncologists worked with NPPs and that oncologists who employed NPPs in their practices reported higher visit rates than those who did not. In addition, the majority of oncologists believed that NPPs benefited their practices by enhancing efficiency, improving patient care, and increasing physicians’ professional satisfaction. ASCO’s Workforce Advisory Group, a volunteer group tasked with creating and managing workforce initiatives to address the impending shortage, sought to study the use of NPPs in a more systematic fashion. The Advisory Group was concerned that the only ASCO report on the inclusion of NPPs was based on survey results from oncologists and that actual data on practice efficiency and satisfaction of all stakeholders, including oncologists, NPPs, and patients, were lacking. The Advisory Group wanted to be proactive in providing guidance for members’ practices, with the basic tenet that if collaborative practices that use NPPs could be modeled for efficiency and satisfaction, ASCO recommendations should be data driven and evidence based. To establish data on practices that use NPPs, ASCO partnered with Oncology Metrics, a division of Altos Solutions, in 2009 to conduct the ASCO Study of Collaborative Practice Arrangements. The aim of the study was to determine how using NPPs could benefit both oncology practices and patients, and to identify optimal arrangements for practices looking to make such expansions. From the outset, the study sought to evaluate the economics and satisfaction levels in community clinical practices rather than practices in academic centers. This was based on the assumption that academic practices have confounding factors that would influence NPP collaboration models and efficiency. This study used not only survey results, but also quantifiable, practice-derived data. The results of the study, published in Journal of Oncology Practice, provide compelling data from the perspective of professional satisfaction, patient satisfaction, and practice efficiency demonstrating that increased inclusion of NPPs in community-based practices will benefit all oncology care stakeholders. Several conclusions can be drawn from this study: Collaborative oncology practices are associated with a high degree of satisfaction for professionals and patients. Those practices in which an NPP is employed have both high physician and NPP satisfaction with their collaborative practice model. Critical to the practices is that patients know when they are being treated by an NPP rather than a physician, and, in addition, they are very satisfied with the care they receive in the collaborative practice. This study provides definitive proof that physician-NPP care teams are well accepted by patients with cancer, alleviating physician concerns that patients will react negatively to the introduction of NPPs into their care. Productivity of all professionals is enhanced when NPPs works with multiple physicians rather than just one oncologist. The concept of NPPs working with just one physician rather than multiple physicians would seem to be too subtle to affect practice activity. However, the study demonstrated that practices in which NPPs worked with all physicians had a 19% greater numbers of encounters per full-time equivalent physician in the 6-month observation period compared with practices that used a one-to-one NPP-physician arrangement. Though not included in the publication, the results were similar when productivity was assessed by either patient encounters or relative value units (Shuster S, personal communication, June 4, 2011). It is hard to envision another practice modification that affects practice productivity to such a degree. JOURNAL OF CLINICAL ONCOLOGY E D I T O R I A L S VOLUME 29 NUMBER 27 SEPTEMBER 2