1. Use of NPs/PAs in the Oncology Setting ARM Workforce Interest Group Clese Erikson Senior Research Associate June 2, 2007

2. Oncology Workforce Study Funded by the American Society of Clinical Oncology Authors: Clese Erikson, M.P.Aff Edward Salsberg, MPA Gaetano Forte Suanna Bruinooge Michael Goldstein, MD

3. Survey Methodology Survey sent to a random sample of 4,000 oncologists identified from the AMA Masterfile as having a primary or secondary specialty of:  Medical oncology  Hematology/oncology  Pediatric hematology/oncology  Gynecologic oncology Initial mailing, thank you post-card, follow-up mailing to non-respondents 92-items, 19 related to use of NPs/PAs Results weighted using standard procedures

4. Overall Response Rate 42.5%

5. Current professional activities NPercent Active full-time in oncology128077.6% Active part-time in oncology1489.0% Still in fellowship training as of 9/30/200560.4% Active in medicine, but not oncology985.9% Inactive in medicine at the present time382.3% Retired from medicine724.4% Missing90.5% Total1651100%

6. Specialty N% Medical oncology31722% Hematology/oncology80055% Pediatric hematology/oncology15811% Gynecologic oncology695% None of the above987% Radiation oncology20% Surgical oncology23% Other57% Total Active Clinical Oncologists = 1,344

7. Demographics RespondentsMasterfile Gender Female26%24% Male74%76% Age <355%3% 35-4427%26% 45-5438%34% 55-6423%27% 65 and over7%10% Medical Education US MGs76%71% IMGS24%29%

8. NPs/PAs likely to provide any of the following services to your patients? TRADITIONAL ACTIVITIES Provide patient education and counseling Manage patients during treatment visits Provide pain and symptom management Address emergent care Provide follow-up care for patients in remission Provide non-cancer related primary care for patients in active treatment Provide end of life/hospice care Perform research related activities Take night or weekend call Conduct hospital rounds ADVANCED ACTIVITIES Assist with new patient consults Order routine chemotherapy Perform invasive procedures (eg, bone marrow, spinal tap)

9. Percent of Oncologists whose NPs/PAs ‘usually’ or ‘always’ Provide patient ed/counseling61% Provide pain and symptom mgmt46% Manage patients during visits43% F/U care for pts in remission43% Address emergent care30% Order routine chemotherapy25% Assist w/ new pt consults23% Provide end of life/hospice care22% Conduct hospital rounds22% Primary care for pts in active treatment20% Perform invasive procedures19% Perform research activities13% Take night or weekend call 7%

10. 56% of oncologists work with NPs/PAs in some capacity

11. Use of NPs/PAs does not vary significantly by gender

12. Likelihood of working with NPs/PAs decreases with age

13. 72% of academics work with NPs/PAs compared to 46% of private practice oncologists

14. NP/PA contribution valued

15. Variation in productivity by reported level of NP/PA activity Academic Setting Variation not statistically significant

16. Relationship breaks down when you look by gender and setting

17. Options for Addressing Shortages (2006 Practitioner Survey) % Sig Potential Increase Efficiency Reduction of paperwork and regulations 61% Improved IT such as EMRs 43% Increase / extend oncology workforce Increased use of NPs/PAs 36% Train more clinical oncologists 34% Increased use of oncology nurses and CNS 32% Create incentives to delay retirement 28% Increase use of related care providers Hospice and palliative care providers 26% Social workers, counselors and patient educators 24% Hospitalists 20% Pain and symptom management specialists 17% Primary care providers to care for patients in remission 15%

18. Those who currently use NPs/PAs more likely to see increased use as a solution to oncologist shortages

19. Supply Scenarios– Increased usage of NPs/PAs BASELINE - 56% currently use NPs/PAs but only 26% at advanced capacity MIN – 85% use NPs/PAs minimally (4% increase in visits per week for private practice; no increase academic) MAX– 85% use NPs/PAs for advanced activities (10% increase for both settings)

20. NP scenarios show potential to increase visit capacity by.4 million to 3.2 million visits

21. Results from Survey of Physicians Under 50

22. Only 44% of physicians under 50 work with NPs/PAs

23. Percent work with NP/PA varies by specialty category Primary Care – FP, GP, IM, and Peds Medical, Surgical, and Facility Based – Physician Characteristics and Distribution Categories

24. Clear differences of opinion regarding benefits of using NPs/PAs among those who work with them and those who don’t

25. Conclusions Oncologists that work with NPs/PAs consistently agree that this improves efficiency and quality without increasing their workload Inconclusive that use of NPs/PAs actually improves visit capacity Increased use of NPs/PAs could have potential to help address shortages but other solutions will be needed Those who do not work with NPs/PAs are less inclined to see the value of their contribution