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  • Writer's pictureICOP

The War on Small Businesses

Innovative Community Oncology Practices “ICOP” was established in 2021 as an association of small and medium-sized community oncology practices with the aim of promoting our survival in the face of mergers and acquisitions. Although we have no political agenda, policies in all their forms and shapes do affect our mission and survival. Hence addressing those political matters is at the core of the ICOP mission.

It is no secret that since the 1970s when Stark Laws were implemented, small community medical practices were the main target. The essence of Stark zooms on preventing independent practices from working together to their benefit and the benefit of the patients and society. As it stands now, several independent practices can’t collaborate in negotiating payment terms with payers and can’t collectively build an imaging center or any other commercial entity unless they merge in one group under one unified Tax I.D. number, which would compromise their cherished American way of independence. So why is it crucial for the policymakers to insist on this policy? Let’s talk about who is behind this.

The American Hospital Association saw the risk of physicians working together in competing with hospitals. Forming an imaging center, which would naturally provide more accessible and lower-cost services, would force hospitals to be more efficient at a lower and competitive cost. Hospitals enjoy a non-competitive atmosphere. Add to that the fact that hospitals realized that doctors, by nature and training, aim at the independence that allows them to be more efficient in providing services to patients in a timely fashion. They are a great example of the American way of innovation through an agile efficient business operation. Innovation flourishes when there is competition.

Policymakers generally align with the Dream of hospitals, even though large institutions are the essence of monopoly controlling the marketplace. To achieve that Dream, the hospitals, through their massive budget financed by their high cost of service and non-taxed status, can and do contribute large sums of money to political campaigns as active lobbyists. The alliance between politicians and hospitals has been to the detriment of small practices and on a larger scale to all small businesses. This became more obvious during the Covid pandemic, where large businesses were allowed by the government to stay open while small ones were forced by rules to close their doors. Many small businesses were forced out of the competitive environment while the Wal-Marts of the world not only stayed open, they flourished.

Despite mounting evidence that community oncology provides more accessible, better-personalized care at a much lower cost, there seems to be little or no effort by policymakers and even payers to take advantage of this crystal clear observation. Congress seems at all times eager to pass new laws, but they rarely, if ever, reverse or delete laws enacted centuries ago. Some of the laws contradict old ones, but no one seem to care to notice. If policymakers and the insurance industry are for better quality and lower cost, why is it that no one, none of them, has hinted to revisit Stark laws? As they say, “follow the money stupid.” At any political fundraiser, I have attended, and I have hosted and participated in dozens of them, there would be less than a handful of physicians, yet hospitals are represented by several with generous checks in their hands. Elected politicians are humans, they aspire to re-election over and over, and money seems to win most elections, local or national. Hospitals come with large checks, several from each. Doctors see patients hoping that the honest elected officials do their best to help patients and society.

In excess of 60% of community oncology practices have either closed their doors or been acquired by large hospitals and academic centers. Reversing that would be a challenge unless positive, meaningful measures are taken. Insurance companies, assuming they care about quality, access, and cost- that is a big assumption since payers profit on margin; the higher the cost, the larger their revenues- must change their payment system to equalize revenues for the same services wherever services are rendered (Payment Parity). Unless policymakers see the light and act, the future of community oncology and other specialties is in peril.

Is it good for the healthcare consumer to have rules whereby hospitals get paid higher fees for the same services that can be provided by independent practices? Is it because, as some insurance executives have said,” hospitals have higher overhead.” Isn’t that subsidizing and promoting inefficiency to the detriment of our patients?

Unless elected officials and policymakers see the light and act for the best interest of those who put them in power, independent medical practices are in jeopardy. The question is, how do we make elected officials do what is right? In the old days, elected members of Congress had jobs; they were farmers, merchants, active members of the armed forces. They spent three months a year in Washington DC enacting laws. Then they went home to make a living. Now being a politician is how they make money- and lots of it. It has become a business and an endless career. I might be hallucinating by suggesting that term limits are the answer so that elected officials do what is good for their constituents and the country, but that is an illusion. It is hard to imagine career politicians stripping themselves of laws that protect their professional life and deep pockets.

What is left of community oncology needs to coalesce as in what ICOP does, to be innovative and create a voice that is loud and clear. I have not lost hope, and we should not. Our task is not more difficult than that of Martin Luther King Jr., who had a dream that came true against all the odds. We can do it as community oncologists, and we can have the Dream. In America, nothing is impossible. It is the land of the free and innovation. Join Innovative Community Oncology by visiting or email Carrie Smith,

Nash Gabrail MD

Gabrail Cancer Center

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