[gdpawel]

John L. Marshall, M.D.
For Medscape Oncology

I have been hearing a lot about the shift from buy-and-bill to having different outcomes and metrics. Our entire system of medical oncology, whether it is in private practice or hospital-based, has been founded on drug sales. That has been our procedure or our angle, if you will, to make some money to fund our practices, hire our staff, and so on. Of course, there is a real issue that this is going to go away. As the margin has decreased on buy-and-bill, we are certainly scrambling to look for other ways to run our practices.

Another element is that we are going to stop being judged or incentivized based on consumerism. We are going to shift over to something called outcomes. How are we doing? How are our patients doing? And by whose standards are we going to measure this? Am I going to be judged the same way that you guys are going to be judged? I only see gastrointestinal cancers, but I tend to see very sick patients, so my overall outcomes are terrible, right? Many of my patients die because they are in bad shape. They come to see us for new or different approaches, so I don't often see the "easy" patients with early-stage disease. Therefore, maybe my outcomes are going to be worse. Maybe my consumption is going to be higher and I am therefore going to be judged differently, maybe more harshly than others. How are we going to do this outcomes measure?

Clearly, we are going to need electronic medical records. We are going to need to benchmark our performances against others that are out there. We work in a pretty big institution here, with some decent infrastructure support. How would you do this in a 2- or 3-person practice?

On the other side, we are seeing a ton of increased pressure to have private practices be bought by institutions or merge into institutions and become employed. This is just one more angle to the pressure of getting people to become employed: You are going to need outcomes measures. Can you do that in your own practice? How will you do that under a private practice model?

Here in the Washington, DC, area, there is pressure for more and more oncologists to be employed. Fewer and fewer private practices are out there, and the only ones standing, frankly, are either the very weakest ones or the very strongest ones that have been able to manage this transition. I am not sure what it is going to look like, but I do understand that the pressure is out there as our financial model is shifting, as our outcomes and our incentives are shifting.