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Journal of Oncology Practice, Vol 3, No 2 (March), 2007: pp. 79-86 © 2007 American Society of Clinical Oncology. DOI: 10.1200/JOP.0723601
Future Supply and Demand for Oncologists : Challenges to Assuring Access to Oncology Services
Purpose: To conduct a comprehensive analysis of supply of and demand for oncology services through 2020. This study was commissioned by the Board of Directors of ASCO. Methods: New data on physician supply gathered from surveys of practicing oncologists, oncology fellows, and fellowship program directors were analyzed, along with 2005 American Medical Association Masterfile data on practicing medical oncologists, hematologists/oncologists, and gynecologic oncologists, to determine the baseline capacity and to forecast visit capacity through 2020. Demand for visits was calculated by applying age-, sex-, and time-from-diagnosis-visit rate data from the National Cancer Institute's analysis of the 1998 to 2002 Surveillance, Epidemiology and End Results (SEER) database to the National Cancer Institute's cancer incidence and prevalence projections. The cancer incidence and prevalence projections were calculated by applying a 3-year average (2000–2002) of age- and sex-specific cancer rates from SEER to the US Census Bureau population projections released on March 2004. The baseline supply and demand forecasts assume no change in cancer care delivery and physician practice patterns. Alternate scenarios were constructed by changing assumptions in the baseline models. Results: Demand for oncology services is expected to rise rapidly, driven by the aging and growth of the population and improvements in cancer survival rates, at the same time the oncology workforce is aging and retiring in increasing numbers. Demand is expected to rise 48% between 2005 and 2020. The supply of services provided by oncologists during this time is expected to grow more slowly, approximately 14%, based on the current age distribution and practice patterns of oncologists and the number of oncology fellowship positions. This translates into a shortage of 9.4 to 15.0 million visits, or 2,550 to 4,080 oncologists—roughly one-quarter to one-third of the 2005 supply. The baseline projections do not include any alterations based on changes in practice patterns, service use, or cancer treatments. Various alternate scenarios were also developed to show how supply and demand might change under different assumptions. Conclusions: ASCO, policy makers, and the public have major challenges ahead of them to forestall likely shortages in the capacity to meet future demand for oncology services. A multifaceted strategy will be needed to ensure that Americans have access to oncology services in 2020, as no single action will fill the likely gap between supply and demand. Among the options to consider are increasing the number of oncology fellowship positions, increasing use of nonphysician clinicians, increasing the role of primary care physicians in the care of patients in remission, and redesigning service delivery. There is growing evidence that the nation is facing a physician shortage, largely driven by the aging of the population and a physician workforce that has not grown to meet the needs of the nation.1–4 The Census Bureau projects the number of Americans 65 years and older will double between 2000 and 2030.5 Oncologists care disproportionately for older patients; therefore, the aging of the population will likely increase the demand for oncology services. Age-related growth in cancer rates will also be accompanied by an increasing number of cancer survivors requiring ongoing monitoring and care from oncologists.6 New therapies will also influence the demand for services. All of this will come at a time when the oncologist workforce is aging and heading into retirement in increasing numbers.2 An ASCO study of the oncologist workforce conducted in the mid-1990s found that supply and demand were in equilibrium.7 The current analysis shows a similar balance in 2005, but projects that this balance will not be sustained into the future. Oncology will not be the only specialty facing future shortages. There has been a recent surge of reports highlighting future specialty shortages, most citing the aging of the population as a key factor leading to increased demand.8–21 This article presents a summary of the major findings of the Association of American Medical Colleges (AAMC) Center for Workforce Studies report to ASCO on the Oncology Workforce. A copy of the full report can be downloaded from ASCO's Web site (www.asco.org/workforce).
Data Collection In collaboration with the ASCO Workforce in Oncology Task Force, the AAMC Center for Workforce Studies conducted original data collection through surveys of practicing oncologists, oncology fellows, and oncology fellowship program directors. The Survey of Practicing Oncologists was administered in 2006 to a random sample of 4,000 oncologists (including physicians with a primary or secondary specialty of medical oncology, hematology/oncology, gynecologic oncology, and pediatric hematology/oncology) drawn from the American Medical Association (AMA) Masterfile, and received a 42% response rate. The survey included questions on current practice activities, work hours, visit rates, practice setting, use of nurse practitioners and physician assistants, and options for addressing future workforce shortages. The surveys of entering and exiting fellows were administered by e-mail using contact information provided by ASCO. The survey of exiting fellows was administered in June 2005 to 442 fellows completing training in 2005, and received a 50% response rate; there were questions included on post-training plans and factors influencing post-training activities. The survey of entering fellows was administered in May 2006 to 438 fellows entering training in 2006, and received a 62% response rate; it inquired about reasons for selecting oncology and future career expectations. The survey of oncology program directors was administered in 2005 to 242 directors using contact information provided by ASCO, and received a 67% response rate; it asked questions about the number of fellowship positions available, practice setting of recent graduates, and plans to expand fellowship positions. In addition, the Center analyzed existing data sources including the AMA Masterfile, a national database of physicians; cancer registry data from the National Cancer Institute's (NCI's) Surveillance, Epidemiology and End Results (SEER) database; US Census Bureau population projections; and board certification data from the American Board of Internal Medicine and the American Board of Gynecology. The supply-and-demand projections focus exclusively on medical oncologists, hematologists/oncologists, and gynecologic oncologists. Pediatric hematologists/oncologists were included in the data collection activities but were excluded from the modeling and scenarios, as national data on utilization were only available for the Medicare-eligible population.
Supply Forecasting
The forecasted counts of oncologists were then converted to visit capacity using the age-, sex-, and practice setting–specific visit estimates from the 2006 Survey of Practicing Oncologists. A conservative supply estimate was also calculated by removing outliers from the visit rate data. The baseline forecasts assume that the age-, sex-, and practice setting–specific visit rates, the new entrant rate and the departure from practice rates would not change over time.
Demand Forecasting The baseline model did not attempt to project alterations in demand caused by changes in practice patterns, service use, or cancer treatments. These factors are considered in alternate supply-and-demand scenarios.
Alternate Scenarios Alternate supply scenario assumptions included: (1) increasing the number of fellowship slots available; (2) productivity gains resulting from the increased use of nurse practitioners and physician assistants; (3) extending the physician supply through delays in physician retirement; (4) productivity increases; and (5) changing visit rates for the newest generation of physicians (ie, decreased productivity for oncologists 45 years or younger in 2005). Alternate demand scenario assumptions included: (1) a gradual increase in the percentage of incident cancer cases seen by an oncologist, combined with a gradual increase in the mean visit rates for this population; (2) patients 70 years and older adopting higher visit rates similar to those of patients younger than 70 years; (3) increased use of primary care physicians (PCPs) to monitor patients in remission; and (4) increased use of hospice for cancer patients in the last year of life.
Supply of Oncologist Visits Results from the practitioner survey provided the practice setting and visit rate data that formed the basis of the visit capacity estimates. Visit capacity varied significantly by oncologists' practice setting, age, and sex (Table 1). Practice setting is the greatest determinant of how many patient visits an oncologist is likely to have in a given week, with those in private practice conducting significantly more patient visits compared with those in academic and other settings. Oncologists 45 to 64 years of age see more patients per week than oncologists at the beginning of their careers, or those 65 years or older who are still active in medicine (Table 2). This productivity arc has also been documented in a workforce study of PCPs.23 Women generally have lower visit rates than men, though the variation is only significant in the private practice setting.
For the baseline supply model, the setting distribution remained constant, with 27% academic, 65% in private practice, and 8% in government or other settings. The sex and age distribution changed as new physicians entered and exited the workforce, with the percentage of female physicians projected to increase from 23% in 2005 to 39% in 2020 and the mean age decreasing from 50.4 to 47.8 years.
Demand for Oncologist Visits
Not all cancer patients will see an oncologist. The NCI analysis of visit rates provided age-, sex- and time-from-diagnosis visit rates that were then applied to NCI's cancer projections to calculate total annual demand for visits. Assuming there is no change in cancer incidence or utilization patterns between now and 2020, demand for visits is projected to increase from 41 million in 2005 to 61 million in 2020, yielding a 48% increase in overall demand for oncologist visits in 2020.
Baseline Supply and Demand Projections
While visit capacity is projected to increase by 14% between now and 2020, assuming there are no major changes in the utilization of services by cancer patients during the intervening years, demand is projected to increase 48%. Under the scenario of high supply and low demand, the shortage will be 9.5 million visits. Under the scenario of low supply and high demand, the shortage would be as much as 15.0 million visits. This translates into a shortage of 2,350 to 3,800 oncologists—roughly one-quarter to one-third the available 2005 supply.
Alternate Supply and Demand Scenarios
Demand for oncology services is expected to sharply increase throughout the next 15 years—a growth that will be driven by the aging of the population and the age-sensitive nature of cancer, as well as the increase in cancer survivors. Given concurrent aging of the oncology workforce, the current number of training positions and the time and resources needed to expand the supply, the nation is unlikely to be able to meet the future demand with the expected supply of oncologists. Some possible approaches to narrowing the anticipated gap between supply and demand are discussed in this section.
Increasing Fellowship Positions
Increasing the Role of PCPs
Productivity Gains
Increased Use of Nurse Practitioners and Physician Assistants However, it is unlikely that the numbers of NPs or PAs will be sufficient to bridge the gap between supply and demand for oncology services. First, other specialties will compete with oncology for nurse practitioners and physician assistants. Second, while the number of NPs and PAs has grown rapidly, it is unclear if they will be able to sustain this level of growth.37,38
Delaying Retirement of Existing Oncologists
Increased Use of Hospice
Potential for Even Greater Shortages Analysis of the NCI visit data reveals that the percentage of patients who saw an oncologist during the first 12 months postdiagnosis increased by 12% between 1998 and 2002, and the mean visit rates for those patients increased by 25%. This change may reflect the increasing number of treatment options available and the increasing complexity of cancer treatment protocols. Even with a more modest rate of growth, as modeled in the first demand scenario, the gap between supply and demand would nearly double. Given the growth in adjuvant therapies and the potential for new therapies to be introduced, it is likely that visit rates will continue to increase, though it is unclear at what pace this will occur. Demand for oncology services could also increase beyond baseline projections if patients 70 years and older have visit rates more comparable with those of younger patients. Baby boomers are already frequently receiving treatments that used to be rare in patients older than 50 years, and overall visit rates for patients ages 50 to 64 years grew by 26% between 1994 and 2001, though they have remained stable since that time.42,43
Limitations of the Data Unpredictability of future health care delivery. The enterprise of forecasting physician supply and demand is an important one.44,45 However, as has been observed by others, the reliability of this effort is questionable.46 The predictions seldom seem to come to fruition, as many found out at the end of the 1990s when the projected glut of physicians never appeared. However, a rapidly aging population, coupled with the sobering age-specific cancer incidence rates, requires an understanding of how demand for oncology services and the supply of oncologists will be related in the future. Cognizant of previous failed attempts to forecast physician supply and demand, we have employed a strategy of developing a number of alternate visions of the future to understand the potential trajectories of the supply and demand, rather than predict an absolute figure some 15 years into the future. This strategy also has the advantage of viewing the effects of potential policy decisions (eg, increasing the number of oncology fellowship positions available) on the relationship between supply and demand in the future. Medicare data for visit rates. Another limitation of the data was the set of statistics derived from the NCI's SEER database on oncologist visit rate and proportion of oncology cases that are treated by an oncologist. The visit data were limited to Medicare claims and thus only represent the experiences of oncology cases involving patients 65 years and older. These data were used to calculate the demand for oncologist visits among adults younger than 65 years as well; specifically, the visit data applied were for those between ages 65 and 70 years. This application could underestimate the true visit rates among the adult, population younger than 65 years, thus underestimating the demand for oncologists. Aggregated cancer rates. The cancer incidence and prevalence projections are not disease-specific and were developed based on aggregate age- and sex-specific cancer rates. This approach was selected due to data limitations and the uncertainty of future diagnosis, treatment, and survivorship for each cancer type. This limited our ability to reliably model possible decreases in cancer incidence such as the recent evidence of a reduction in breast cancer or possible decreases in cervical cancer that might result from the new cervical cancer vaccine. Similarly, the demand data did not support separate models for gynecologic oncology in the analysis. While supply and demand for gynecologic oncology might be different since it includes surgical cancer treatments, this work is intended to provide an aggregate analysis of demand for oncology services, and not to be oncology-specialty specific.
No single potential remedy will fully address the likely future shortage of oncologists. Furthermore, the expected gap between supply and demand in 2020 could be much larger than baseline projections suggest if younger physicians have lower lifetime productivity than their predecessors and/or if visit rates increase due to changing practice patterns or demand for services. There are opportunities to reduce the gap between projected supply and demand by increasing the number of oncology training slots and by increasing the use of other practitioners such as NPs or PAs, PCPs, and hospice care providers. However, none of these solutions alone can offset the projected shortages. ASCO, policy makers, and the public face major challenges ahead to forestall likely shortages in the capacity to meet demand for oncology services. The nation is facing a potential crisis, but action taken throughout the next several years can minimize the crisis and may even lead to more effective approaches to delivering high-quality oncology services. More will need to be done to assure that we make the best use of our limited supply of oncologists.
The authors indicated no potential conflict of interest.
This study was funded by the American Society of Clinical Oncology. Analysis was conducted by the AAMC Center for Workforce Studies, under the guidance of the ASCO Workforce in Oncology Task Force. The Center collects and analyzes data on the physician workforce in order to promote a supply and distribution of physicians that is consistent with the demands and needs of the US population. The Albany Center for Health Workforce Studies administered the survey of practicing oncologists and the statistical forecasting. We thank members of the ASCO Workforce in Oncology Task Force for their participation in this project. The Task Force included Michael Goldstein, MD, Chair, Beth Israel Deaconess Medical Center, Boston, Massachusetts; James L. Abbruzzese, MD, M.D. Anderson Cancer Center, Houston, Texas; Maria Quintos Baggstrom, MD, Washington University School of Medicine, St Louis, Missouri; Dean Bajorin, MD, Memorial Sloan-Kettering Cancer Center, New York, New York; Lodovico Balducci, MD, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida; Diane C. Bodurka, MD, M.D. Anderson Cancer Center, Houston, Texas; Jay L. Bosworth, MD, Long Island Radiation Therapy, Manhasset, New York; Craig Earle, MD, Dana-Farber Cancer Institute, Boston, Massachusetts; Peter D. Byeff, MD, Cancer Center of Central Connecticut, Southington, Connecticut; Peter Carroll, MD, University of California San Francisco Comprehensive Cancer Center, San Francisco; Hedy Lee Kindler, MD, University of Chicago, Chicago, Illinois; Richard A. Cooper, MD, University of Pennsylvania, Philadelphia, Pennsylvania; Nancy Renee Feldman, MD, University of California Los Angeles Medical Center, Sylmar, California; Dean H. Gesme, MD, Minnesota Hematology Oncology PA, Minneapolis, Minnesota; Robert J. Mayer, MD, Dana-Farber Cancer Institute, Boston, Massachusetts; Stephanie Lee, MD, MPH, Fred Hutchinson Cancer Research Center, Seattle, Washington; Lawrence S. Lessin, MD, Washington Cancer Institute, Washington, DC; Robert F. Ozols, MD, Fox Chase Cancer Center, Philadelphia, Pennsylvania; Lisa S. Rome, MD, Veterans Administration Connecticut Health Care System, Westport, Connecticut; David Mendelson, MD, Premier Oncology, Scottsdale, Arizona; Tracey O'Connor, MD, Roswell Park Cancer Institute, Buffalo, New York; Jennifer Schwartz, MD, FRCPC, Indiana University, Indianapolis, Indiana; Douglas J. Scothorn, MD, Mission Children's Clinic, Asheville, North Carolina; Visaharan Sivasubramaniam, MD, University of Kentucky, London, Kentucky; Samuel M. Silver, MD, PhD, FACP, University of Michigan, Ann Arbor, Michigan; Christopher Willett, MD, Duke University Medical Center, Durham, North Carolina; and Antonio C. Wolff, MD, FACP, Johns Hopkins Kimmel Cancer Center, Baltimore, Maryland. We thank Joan Warren, Angela Mariotto, and Martin Brown at the National Cancer Institute for providing the cancer incidence and prevalence projections and oncology visit rate data that formed the basis of our demand forecasts.
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Copyright © 2007 by the American Society of Clinical Oncology, Online ISSN: 1935-469X. Print ISSN: 1554-7477
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